Fundamentals and Comprehensive A Exam

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A."How will this affect your present sexual activity?" B."How active is your current sex life?" C."How has your sex life changed as you have become older?" D."Tell me about your sexual needs as an older adult."

ans: A "How will this affect your present sexual activity?" Rationale:Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? A.50 mg/dL B.80 mg/dL C.110 mg/dL D.140 mg/dL

ans: A 50 mg/dL Rationale:The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a low level, such as 50 mg/dL, requires the most immediate intervention to prevent loss of consciousness. Normal (such as 80 mg/dL) and slightly elevated levels, such as 110 or 140 mg/dL, do not require immediate intervention.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A.Mode of transmission B.Portal of entry C.Reservoir D.Portal of exit

ans: A Mode of transmission Rationale:The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry.

The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A.A client who is 2 days postoperative with a right total knee replacement B.A client who is scheduled for a sigmoid colostomy surgery today C.A client who has a surgical abdominal wound with dehiscence D.A client who is 1 day postoperative following a right-sided mastectomy

ans: A A client who is 2 days postoperative with a right total knee replacement Rationale:Option A is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. Option B will require a high level of nursing care when returned from surgery. Option C means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. Option D requires extensive teaching and should be assigned to a more experienced nurse.

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A.A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B.Pneumonia, with a sputum culture of gram-negative bacteria C.Urinary tract infection, with positive blood cultures D.Culture of a diabetic foot ulcer shows gram-positive cocci

ans: A A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) Rationale:The client with colonized MRSA is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy, which makes recovery very difficult. Positive blood cultures indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer at high risk for poor healing and bone infection.

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A.Encourage staff to participate in online in-service education. B.Assign staff to make sure that all equipment is thoroughly cleaned. C.Ask which staff members would like to go home for the remainder of the day. D.Notify the supervisor that the staff needs additional assignments.

ans: A Encourage staff to participate in online in-service education. Rationale:Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census. Option B is not the responsibility of the nursing staff. Option C is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary.

After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A.Ensure that the client receives breakfast within 30 minutes. B.Remind the client to have a midmorning snack at 1000. C.Discuss the importance of a midafternoon snack with the client. D.Explain that the client's capillary glucose will be checked at 1130.

ans: A Ensure that the client receives breakfast within 30 minutes. Rationale:Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction. Options B, C, and D are also important nursing actions but are of less immediacy than option A.

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A.Failure to collect all urine specimens during the period of the study will invalidate the test. B.Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C.Dialysis is started when the GFR is lower than 5 mL/min. D.Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

ans: A Failure to collect all urine specimens during the period of the study will invalidate the test. Rationale:Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results will be inaccurate. As renal function decreases, the creatinine level will decrease in the urine. Dialysis is usually started when the GFR is 12 mL/min. There is no need to record the frequency and amount of each voiding during the time span of urine collection.

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A.Help the client dangle his legs. B.Apply compression stockings. C.Assist with passive leg exercises. D.Ambulate three times a day

ans: A Help the client dangle his legs. Rationale:The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling, which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. Option B is indicated for venous insufficiency and indicated for bed rest. Ambulation is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A.Low serum albumin level B.Low serum transferrin level C.High hemoglobin level D.High cholesterol level

ans: A Low serum albumin level Rationale:Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A.Maintain standard precautions. B.Initiate contact isolation measures. C.Insert an indwelling urinary catheter. D.Instruct client in the use of adult diapers.

ans: A Maintain standard precautions. Rationale:The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A.Oral hygiene should be performed before the medication. B.Antifungal medications are available in tablet, suppository, and liquid forms. C.Candida albicans is the organism that causes the white lesions in the mouth. D.The dietary intake of dairy and spicy foods should be limited.

ans: A Oral hygiene should be performed before the medication. Rationale:HIV infection causes depression of cell-mediated immunity that allows an overgrowth of C. albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Nystatin. Options B and C provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but option A allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A.Pulse characteristics B.Open airway C.Entrance and exit wounds D.Cervical spine injury

ans: A Pulse characteristics Rationale:Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

Which client is most likely to be at risk for spiritual distress? A.Roman Catholic woman considering an abortion B.Jewish man considering hospice care for his wife C.Seventh-Day Adventist who needs a blood transfusion D.Muslim man who needs a total knee replacement

ans: A Roman catholic woman considering an abortion Rationale:In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A.Team 1: RN team leader, PN; team 2: PN team leader, UAP B.Team 1: RN team leader, UAP; team 2: PN team leader, PN C.Team 1: PN team leader, PN; team 2: RN team leader, UAP D.Team 1: PN team leader, UAP; team 2: RN team leader, PN

ans: A Team 1: RN team leader, PN; team 2: PN team leader, UAP Rationale:Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN. Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. Options B, C, and D do not use the expertise of the nursing staff for the high-risk clients.

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A.The color of the dialysate outflow is opaque yellow. B.The dialysate outflow is greater than the inflow. C.The inflow dialysate feels warm to the touch. D.The inflow dialysate contains potassium chloride.

ans: A The color of the dialysate outflow is opaque yellow. Rationale:Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider. Options B and C are desired. Option D is commonly done to prevent hypokalemia.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A.Stay with the client while the client is standing. B.Record the findings on the graphic sheet in the chart. C.Keep the blood pressure cuff on the same arm. D.Record changes in the client's pulse rate.

ans: A stay with the client while the client is standing Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A.Place the client in a side-lying position. B.Pull the auricle upward and outward. C.Hold the dropper 6 cm above the ear canal. D.Place a cotton ball into the inner canal. E.Pull the auricle down and back.

ans: A,B Place the client in a side-lying position. Pull the auricle upward and outward. Rationale:The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indica-tion(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A.Hourly urine output B.Bladder distention C.Urinary incontinence D.Intraoperative bladder decompression E.Urine sample for culture

ans: A,B,D Hourly urine output Bladder distention Intraoperative bladder decompression Rationale:Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A.Monitor maternal vital signs for hemorrhage. B.Instruct the woman to report any contractions. C.Ensure that the woman has a full bladder prior to beginning. D.Monitor fetal heart rate for 1 hour after the procedure. E.Place the client in a side-lying position.

ans: A,B,D Monitor maternal vital signs for hemorrhage. Instruct the woman to report any contractions. Monitor fetal heart rate for 1 hour after the procedure. Rationale:These are safe measures to implement during an amniocentesis to monitor for and prevent complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The woman should be placed in a supine position with her hands across her chest (E).

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A.Confusion B.Peripheral edema C.Crackles in the lungs D.Dyspnea E.Distended neck veins

ans: A,C,D Confusion Crackles in the lungs Dyspnea Rationale:Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion. Options B and E are associated with right-sided heart failure.

Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treat-ments for dehydration in a 36-month-old child? (Select all that apply.) A.Record wet diapers. B.Assess for sunken fontanels C.Examine skin turgor. D.Observe mucous membranes. E.Record dietary intake

ans: A,C,D,E Record wet diapers. Examine skin turgor. Observe mucous membranes. Record dietary intake Rationale:All these interventions can be used to evaluate fluid status in children and are helpful assessment functions (A, C, D, E), but the age of the child makes a fontanel check impractical (B). The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age.

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A.Shave the area where the TENS will be placed. B.Obtain small needles for insertion. C.Place the TENS unit directly over or near the site of pain. D.Explain to the client that drowsiness may occur immediately after using TENS. E.Describe the use of TENS for postoperative procedures such as dressing changes.

ans: A,C,E Shave the area where the TENS will be placed. .Place the TENS unit directly over or near the site of pain Describe the use of TENS for postoperative procedures such as dressing changes. Rationale:The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) A.Use lanolin to moisturize the tops and bottoms of the feet. B.Soak the feet in warm water for at least 1 hour daily. C.Wash feet daily and dry well, particularly between the toes. D.Use over-the-counter products to remove corns and calluses. E.Wear leather shoes that fit properly.

ans: A,C,E Use lanolin to moisturize the tops and bottoms of the feet. Wash feet daily and dry well, particularly between the toes. Wear leather shoes that fit properly. Rationale:Options A, C, and E are therapeutic interventions for foot care in the diabetic client. Options B and D are contraindicated and could cause foot infection or injury.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A.Place the client in a high Fowler position. B.Help the client assume a left side-lying position. C.Measure the tube from the tip of the nose to the umbilicus. D.Instruct the client to swallow after the tube has passed the pharynx. E.Assist the client in extending the neck back so the tube may enter the larynx.

ans: A,D Place the client in a high Fowler position. Instruct the client to swallow after the tube has passed the pharynx. Rationale:(A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.) A.Report lithium level of 2.0 mEq/L to the primary health care provider. B.Encourage competitive physical activities as part of the client's therapy. C.Provide an environment with increased stimuli to engage the client. D.Maintain consistent salt levels in the diet when client is taking lithium. E.Assess the client's nutritional and hydration status.

ans: A,D,E Report lithium level of 2.0 mEq/L to the primary health care provider. Maintain consistent salt levels in the diet when client is taking lithium. Assess the client's nutritional and hydration status. Rationale:A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli is therapeutic for the manic phase (C).

The nurse administers levothyroxine to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) A.Increase in T3 and T4 B.Decrease in heart rate C.Increase in TSH D.Decrease in urine output E.Decrease in periorbital edema

ans: A,E Increase in T3 and T4 Decrease in periorbital edema Rationale:Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-stimulating hormone (TSH) are not therapeutic results from taking levothyroxine (B and C). Levothyroxine does not affect urine output (D).

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A."I will avoid coughing, sneezing, and forceful nose blowing." B."Swimming can begin on the tenth postoperative day." C."Any mild discomfort can be managed with acetaminophen." D."Drainage from my ears is expected after the surgery."

ans: B "Swimming can begin on the tenth postoperative day." Rationale:The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims or allows water to enter the external ear. Options A, C, and D reflect correct responses.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A.Make the client comfortable and allow the client to sleep. B.Assess the client's neurologic status. C.Notify the surgeon about the comment. D.Ask the client's family to co-sign the operative permit.

ans: B Assess the client's neurologic status. Rationale:This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? A.Assign the PNs to perform am care and assist with feeding the clients. B.Assign the UAPs to take vital signs and obtain daily weights. C.Assign the RNs to answer the call lights and administer all medications. D.Assign the PNs to assist health care providers on rounds and perform glucometer checks.

ans: B Assign the UAPs to take vital signs and obtain daily weights. Rationale:A UAP can take vital signs and daily weights on stable clients. UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN. All team members can answer call lights, and PNs can administer some of the medications, so assigning the RN these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds, and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? A.Assess skeletal pins for infection. B.Assist the client with toileting. C.Establish thrombus prevention care. D.Evaluate pain management plan

ans: B Assist the client with toileting. Rationale:The PN can implement nursing care, such as option B. The PN assists the RN in the development of a teaching plan and reinforces information to the client according to the plan. Options A, C, and D are outside the scope of PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing to the plan of care under the supervision of the RN.

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A.3+ protein in the urine B.Blood urea nitrogen > 25 mg/dL C.Blood pH > 7.45 D.Urine output, 2500 mL/day

ans: B Blood urea nitrogen > 25 mg/dL Rationale:Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria, an expected finding. Metabolic acidosis is the potential complication, not alkalosis. During the diuretic phase of acute renal failure, there can be a normal output volume (≈2000 mL/day), which can result from IV fluid hydration.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A.Steak, baked beans, and a salad B.Broiled fish, green beans, and an apple C.Pork chops, macaroni and cheese, and grapes D.Avocado salad, milk, and angel food cake

ans: B Broiled fish, green beans, and an apple Rationale:Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A.Apply a warm compress proximal to the site. B.Check for kinks in the tubing and raise the IV pole. C.Adjust the tape that stabilizes the needle. D.Flush with normal saline and recount the drop rate.

ans: B Check for kinks in the tubing and raise the IV pole. Rationale:The nurse should first check the tubing and height of the bag on the IV pole, which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive actions should be implemented first.

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A.Inspect the dressing over the puncture site and under the client for bleeding. B.Take the vital signs to determine the client's response for a potential blood loss. C.Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D.Assess the client's pain level to determine the need for analgesic medication.

ans: B Take the vital signs to determine the client's response for a potential blood loss. Rationale:After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure. Although options A, C, and D should be implemented after the procedure, the first action is to obtain a baseline assessment.

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as ebola and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take? A.Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B.Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C.Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D.Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear.

ans: B Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. Rationale:Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients. Option A is too authoritarian and does not permit education to play a role in reducing fears. Option C is likely to be intrusive to the family member. Arbitrary staffing without education does not reduce staff fears, even with the provision of peer counseling.

The nurse is preparing to administer dalteparin subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A.Tachypnea B.Guaiac-positive stool C.Multiple small abdominal bruises D.Dependent pitting edema

ans: B Guaiac-positive stool Rationale:Dalteparin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding such as guaiac-positive stool while receiving an anticoagulant, the medication should be held and coagulation studies completed. Option A is not an indication to hold the medication unless accompanied by signs of bleeding. Option C is an expected result. Option D is related to fluid volume, rather than anticoagulant therapy.

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? Rationale:During the transition from oliguria to the diuretic phase of A.Diabetes insipidus B.Hypotension C.Hyperkalemia D.Uremia

ans: B Hypotension Acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension. Option A is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not option C. Option D is characteristic of chronic renal failure with multiple body system involvement.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A.Assign an unlicensed assistive personnel to transport the client via a wheelchair. B.Remind the client to walk carefully down the stairs until reaching a lower floor. C.Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D.Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

ans: B Remind the client to walk carefully down the stairs until reaching a lower floor. Rationale:During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A.Left brachial vein B.Right cephalic vein C.Dorsal side of the right wrist D.Right upper extremity

ans: B Right cephalic vein Rationale:The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A.Complete an incident report. B.Select another sterile needle. C.Disinfect the needle with an alcohol swab. D.Notify the supervisor of the department immediately.

ans: B Select another sterile needle. Rationale:After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A.Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B.Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C.Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D.Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.

ans: B Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. Rationale:His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her.

A male client with Parkinson disease is prescribed the antiparkinsonian agent amantadine HCl. Which action should the nurse take? A.Encourage foods high in vitamin B6 such as meat or liver. B.Teach client to change positions slowly. C.Instruct client to take at the same time as prescribed beta blocker. D.Notify client that development of a rash is a common side effect.

ans: B Teach client to change positions slowly. Rationale:Amantadine can cause postural hypotension, so sudden position changes should be avoided. Options A and C are contraindicated with this drug, and option D is a sign of a possible allergic reaction, not a common side effect.

he nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A.The cuff wraps around the girth of the leg. B.The UAP auscultates the popliteal pulse with the cuff on the lower leg. C.The client is placed in a prone position. D.The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

ans: B The UAP auscultates the popliteal pulse with the cuff on the lower leg. When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A.Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B.With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C.Assist the client to a standing position by gently lifting upward, underneath the axillae. D.Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

ans: B With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. Rationale:Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall.

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? A.Flex the hips and knees and align the knees with the client's knees for safety. B.Allow the client to sit on the side of the bed for a few minutes before transferring. C.Place the client's weight-bearing or strong leg forward and the weak foot back. D.Grasp the transfer belt at the client's sides to provide movement of the client.

ans: B Allow the client to sit on the side of the bed for a few minutes before transferring. Rationale:A client who has been immobile may be weak and dizzy and develop orthostatic hypotension (a drop in blood pressure on rising), so allowing the client to sit for a few minutes before transferring from the bedside to the wheelchair provides time for the client to gain equilibrium and allows dependent blood in the lower extremities to return to the heart. Next, positioning the legs under the client's center of gravity reduces back strain and stabilizes the client to stand. To ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a transfer belt provides a secure hold to prevent sudden falls.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections? A."I know you are capable of giving yourself the insulin." B."Giving yourself the injection seems to make you nervous." C."When I watched you give yourself the injection, you did it correctly." D."Tell me what you want me to do to help you give yourself the injection at home."

ans: C "When I watched you give yourself the injection, you did it correctly." Rationale:The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse.

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? A.A client with an admitting diagnosis of menorrhagia who is now 24 hours' post-vaginal hysterectomy B.A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C.A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D.A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet

ans: C A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) Rationale:Option C requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one-on-one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic, and careful assessment is essential. Options A, B, and D could all be cared for by a PN under the supervision of the RN.

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A.Americans with Disabilities Act of 1990 B.ANA Code of Ethics with Interpretative Statements C.ANA's Scope and Standards of Nursing Practice D.Patient's Bill of Rights of 1990

ans: C ANA's Scope and Standards of Nursing Practice Rationale:The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A.Hyperexcitability of reflexes B.Hyperextension of the head and back C.Inability to flex the chin to the chest D.Lateral facial paralysis

ans: C Inability to flex the chin to the chest Rationale:Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest. Although options A, B, and D may occur in meningitis, option A describes exaggerated spinal nerve reflex responses, option B describes opisthotonus, and option D may be related to cranial nerve pathology of the trigeminal nerve.

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A.Dilute each of the medications with sterile water prior to administration. B.Mix the medications in one syringe before opening the feeding tube. C.Administer water between the doses of the two liquid medications. D.Withdraw any fluid from the tube before instilling each medication.

ans: C Administer water between the doses of the two liquid medications. Rationale:Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication.

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A.Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B.Notify the health care provider and request a prescription for a large-volume enema. C.Assess the client's medical record to determine the client's normal bowel pattern. D.Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

ans: C Assess the client's medical record to determine the client's normal bowel pattern. This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Option A, B, or D may then be implemented, if warranted.

A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A.Pain scale B.Vital signs C.Breath sounds D.Level of consciousness

ans: C Breath sounds Rationale:Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds. Options A, B, and D are important assessment data but are not specifically related to insertion of a central venous catheter.

A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A.Orange juice has vitamin C that deters bacterial growth. B.Apple juice is the most useful in acidifying the urine. C.Cranberry juice stops pathogens' adherence to the bladder. D.Grapefruit juice increases absorption of most antibiotics.

ans: C Cranberry juice stops pathogens' adherence to the bladder. Rationale:Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs.

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A.Review the chart for a signed consent for hospitalization. B.Get the health care provider's permission to give the medication. C.Do not give the medication and document the reason. D.Complete an incident report and notify the parents.

ans: C Do not give the medication and document the reason Rationale:The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A.Perform cough and deep breathing exercises hourly. B.Turn from side to side in bed at least every 2 hours. C.Dorsiflex and plantarflex the feet 10 times each hour. D.Drink approximately 4 ounces of water every hour.

ans: C Dorsiflex and plantarflex the feet 10 times each hour. Rationale:To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? A.Allow the client to discuss the seriousness of the illness. B.Ensure that the client is provided with information about medications. C.Encourage as much independence in decision making as possible. D.Include the client in planning the course of treatment.

ans: C Encourage as much independence in decision making as possible. Rationale:Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible helps reduce stress experienced with repeated hospitalization. Options A, B, and D are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand and participate in the hospitalized plan of care.

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A.Encourage the client to turn from side to side every 2 hours. B.Elevate the foot of the client's bed at least 6 inches. C.Encourage the client to ambulate every 3 hours. D.Teach the client how to perform leg exercises while in bed.

ans: C Encourage the client to ambulate every 3 hours. Rationale:Ambulation is the best way to increase peripheral vascular activity. Options A, B, and D will increase peripheral vascular activity but are not as effective as ambulation.

Upon assessing a newborn male, the nurse finds the urethral meatus opens on ventral side of penis behind the glans. The nurse would recognize this finding is consistent with which finding? A.Cryptorchidism B.Priapism C.Hypospadias D.Episapdias

ans: C Hypospadias Rationale:In hypospadias, there is a congenital defect of urethral meatus in males and the urethra opens on ven-tral side of penis behind the glans. Answer A, B, and D are consistent with other conditions.

The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? A.Perform range-of-motion exercises on the lower extremities every 4 hours. B.Place a small firm pillow under the upper back to flex the lumbar spine gently. C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees. D.Position in reverse Trendelenburg with the feet firmly against the foot of the bed.

ans: C Rest in bed with the head of the bed elevated 20 degrees and flex the knees. Rationale:Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles. Range-of-motion exercises can result in paravertebral muscle spasms and increased pain. Bending the knees, rather than option B, reduces stress on the lower back. Option D places stress on the lower back and increases the client's pain.

When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A.Remind the child to clean his genital area. B.Defer perineal care because of the child's age. C.Retract the foreskin gently to cleanse the penis. D.Ask the parents why the child is not circumcised.

ans: C Retract the foreskin gently to cleanse the penis. Rationale:The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive.

A five year old is in Bryant's traction for intervention for a fractured femur. Which finding by the nurse would require intervention? A.The parents are at the bedside reading a book with the child. B.The child's hips are in 90-degree flexion. C.The child's hips are gently resting on the bed. D.The child is consuming 120 mL of grape juice.

ans: C The child's hips are gently resting on the bed Rationale:The In Bryant's traction, the buttocks should be elevated off the bed not resting on the mattress. Drinking grape juice with a volume of 120 mL is acceptable and the family should be incorporated into the child's plan of care.

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A.Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B.Apply ice packs to edematous or tender joints to reduce pain and swelling. C.Warm the child with an electric blanket prior to getting the child out of bed. D.Immobilize swollen joints during acute exacerbations until function returns.

ans: C Warm the child with an electric blanket prior to getting the child out of bed. Rationale:Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. Option A on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness. Option D is contraindicated, because joints should be exercised, not immobilized.

The nurse should encourage a laboring client to begin pushing at which point? A.When the cervix is completely effaced B.When the client describes the need to have a bowel movement C.When the cervix is completely dilated D.When the anterior or posterior lip of the cervix is palpable

ans: C When the cervix is completely dilated Rationale:Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm. If pushing begins before the cervix is completely dilated, the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson reflex).

Two days after swallowing 30 tablets of alprazolam, a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A.Direct the client to sign a liability release form. B.Restrict the client's ability to leave the unit. C.Explain the benefits of remaining in the hospital. D.Instruct the client to take medications as prescribed. E.Provide the client with names of local support groups. F.Notify the health care provider of the client's intention.

ans: C,D,F Explain the benefits of remaining in the hospital. Instruct the client to take medications as prescribed. Notify the health care provider of the client's intention. Rationale:To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A."What makes you think we did anything to your baby?" B."Are you or any of your blood relatives of Asian descent?" C."Those are stork bites and will go away in about 2 years." D."Those are Mongolian spots and will gradually fade in 1 or 2 years."

ans: D "Those are Mongolian spots and will gradually fade in 1 or 2 years." Rationale:Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African descent or dark-skinned babies. Option A is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African descent, option B does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the face or head and neck area.

Which client is best to assign to a graduate PN who is being oriented to a renal unit? A.A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt B.A client who is receiving continuous ambulatory peritoneal dialysis C.A client with continuous bladder irrigation for hematuria D.A client with renal calculi whose urine needs to be strained

ans: D A client with renal calculi whose urine needs to be strained Rationale:The client with renal calculi (kidney stones) is the most stable client for a PN who is being oriented. Straining urine and the administration of pain medication are tasks that can be safely performed with minimal risk of problems. Options A, B, and C require careful assessment from an experienced nurse because of the potential for significant complications.

A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A.A primigravida who is 8 cm dilated after 14 hours of labor B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation C.A client being induced for fetal demise at 20 weeks' gestation D.A multiparous client who is dilated 5 cm and 50% effaced

ans: D A multiparous client who is dilated 5 cm and 50% effaced Rationale:The new nurse should be assigned the least complicated client to gain experience and confidence, as well as protect client safety. Of the clients available for assignment, option D is progressing well and is the least complicated. Options A, B, and C have actual or potential complications and should be assigned to a more experienced nurse.

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A.Ask the UAP to check for the advanced directive while the nurse completes the assessment. B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C.Check the medical record for the advanced directive and then complete the client assessment. D.Call for the charge nurse to check the advanced directive while continuing to assess the client.

ans: D Call for the charge nurse to check the advanced directive while continuing to assess the client. Rationale:Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status. Options A and B are tasks that must be completed by a nurse and cannot be delegated to the UAP. Option C is contraindicated.

A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A.Review the plan and the steps in performing the procedure with another nurse. B.Look up the specific procedure in a medical-surgical nursing text on the unit. C.Discuss the client's prescribed procedure with an available health care provider. D.Consult the agency's policies and procedures manual and follow the guidelines.

ans: D Consult the agency's policies and procedures manual and follow the guidelines. Rationale:The agency's policies and procedures manual should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. Options A and B may be resources, but client care should be implemented according to the agency's published policies and procedures. Option C is not practical.

The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A.Prepare to evacuate the unit, starting with the bedridden clients. B.UAPs should report to the emergency center to handle transports. C.The licensed staff should begin counting wheelchairs and IV poles on the unit. D.Continue with current assignments until more instructions are received.

ans: D Continue with current assignments until more instructions are received. Rationale:When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received. Evacuation is typically a response of last resort that begins with clients who are most able to ambulate. Option B is premature and is likely to increase the chaos if incoming casualties are anticipated. Option C is poor utilization of personnel.

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A."Is your son's short stature a social embarrassment to him or the family?" B.What types of foods do both your children eat now and what did they eat when they were infants?" C."Did any significant trauma occur with the birth of your son?" D."Did your daughter also start her menstrual period at 12 years of age?"

ans: D Did your daughter also start her menstrual period at 12 years of age?" Rationale:Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins. Option A is not appropriate at this time. The mother is worried that something is wrong with her son physically. Option B has less to do with stature than growth and development. Option C is not related to growth hormone deficiencies, which are idiopathic (without known causes).

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? A."Let's play some dominoes for a few minutes." B."I don't think the violence means the world is ending." C."The news makes you have upsetting thoughts." D."Listening to the news seems to be frightening you

ans: D Listening to the news seems to be frightening you Rationale:A client's delusional statements are best addressed by identifying the feeling associated with the delusion. Option A may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief system. The client is unlikely to understand the relationship between the news and the thoughts experienced.

The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? A.Remove the client's nail polish and dentures. B.Assist the client to the restroom to void. C.Obtain the client's height and weight. D.Offer the client emotional support.

ans: D Offer the client emotional support. Rationale:By using therapeutic techniques to offer support, the nurse can determine any client concerns that need to be addressed. Options A, B, and C are all actions that can be performed by the UAP under the supervision of the nurse.

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A.The respiratory settings on the ventilator B.Only the client's spontaneous respirations C.The ventilator-assisted respirations minus the client's independent breaths D.The ventilator setting for respiratory rate and the client-initiated respirations

ans: D The ventilator setting for respiratory rate and the client-initiated respirations Rationale:The nurse should count the client's respirations and document both the respiratory rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on option A. Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A.White blood cell count B.Albumin C.Calcium D.Sodium

ans: D sodium Rationale:Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A.The client will experience increased tolerance to the drug's effects and may need a higher dose. B.The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C.The medication will be more highly protein-bound, increasing the duration of action. D.The therapeutic index will be increased, placing the client at greater risk for toxicity.

ans:B The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. Rationale:Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results? A.Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B.Assess the client for pain and administer pain medication as prescribed. C.Encourage the client to take short shallow breaths for 5 minutes. D.Prepare to administer sodium bicarbonate IV over 30 minutes.

ans:D Prepare to administer sodium bicarbonate IV over 30 minutes. Rationale:These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A.Encourage the client to use a nicotine patch. B.Reassure the client that it is almost time for another break. C.Have the client leave the unit with another staff member. D.Review the schedule of outdoor breaks with the client.

ans:D Review the schedule of outdoor breaks with the client. Rationale:The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules.