Hesi Level 2 Practice Questions

What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. Vesicular breath sounds decrease B. Bronchodilators stimulate coughing C. Cough remains unproductive D. Wheezing becomes louder

Answer : Wheezing becomes louder. In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder (A) as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields (C) and is not an indicator of improvement during asthma treatment. Bronchodilators do not stimulate coughing (D).

A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? A. "Have you lost weight recently?" B. "At what time do you take your medication?" C. "Are you eating foods rich in potassium?" D. "What dose of medication are you taking?"

Answer: "At what time do you take your medication?" The nurse needs to first determine at what time of day the client takes the Lasix (D). Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia. The actual dose of medication (A) is of less importance than the time taken. (B) is not related to the insomnia. (C) is valuable information about the effect of the diuretic, but is not likely to be related to insomnia.

The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? A. "Having our children brush with fluoride toothpaste is not effective." B. "Excessive amounts of fluoride will make teeth turn brittle and yellow." C. "Use of fluoride in water is mostly effective during initial tooth formation." D. "Dental caries can be prevented through fluoridation of public water."

Answer: "Dental caries can be prevented through fluoridation of public water." Dental caries can be prevented through fluoridation of public water (D). Large amounts of fluoride (A) produces yellow and discolored teeth, not brittle teeth. (B) is effective for young teeth. Fluoride is effective throughout the life span, not just during initial tooth formation (C).

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? A. "I hear how miserable you are, but things will get better soon." B. "Let's talk about what is right with your life." C. "How can I help?" D. "Things probably aren't as bad as they seem right now."

Answer: "How can I help?" Offering self shows empathy and caring (C), and is the best of the choices provided. Combining the first part of (C) with (B) would be the best response, but this is not a fill-in-the-blank or an essay test! Choose the best of those choices provided and move on. (D) dismisses the client, things are bad as far as this client is concerned. (A) avoids the client's problems and promotes denial. "I hear how miserable you are" is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence--"but things will get better" which is offering false reassurance.

A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? A. "How can I help answer your questions?" B. "The healthcare provider should be here on Monday morning." C. "What concerns do you have at this time?" D. "Let me call and leave a message for your healthcare provider."

Answer: "Let me call and leave a message for your healthcare provider." It is best for the nurse to call the healthcare provider (D) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. The nurse can also implement offer to assist the client (A and C), but the highest priority intervention is contacting the healthcare provider.

A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents? A. "You can hold the baby with the oxygen blowing in the baby's face since the level is very close to room air." B. "Studies have shown that handling a sick newborn is not good for the baby and upsets the parents." C. "Since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen." D. "The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her."

Answer: "The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her." The baby is at 35% which is much more than room air (21%) and at this time the baby should not be moved from under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant (B). Holding sick babies benefits the infant and the parents (A). The first consideration now has to be the infant's oxygenation. The nurse should not take the baby out from under the hood without a prescription from the healthcare provider, as this could severely compromise the infant (C). A P02 of 35% cannot be readily achieved with "blow by" oxygen (D).

An infant weighs 7 lb at birth. How much should the nurse expect the infant to weigh at age 6-months? A. 12 lb. B. 17 lb. C. 14 lb. D. 21 lb

Answer: 14 lb. Infancy growth spurts double the birthweight by 4 to 6 months and triple it by one year. Twelve pounds (A) represents a lower-than-expected weight. A weight of 17 (C) or 21 (D) pounds is greater than expected.

Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? A. 2 pounds weight gain. B. Hematuria. C. 3+ bacteria in urine. D. Steady, dull flank pain.

Answer: 3+ bacteria in urine. Urinary tract infections (UTI) for a client with PKD require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease, so bacteria in the urine (C) is the most significant finding at this time. (A) is an expected finding from the rupture of the cysts. (B) does not provide a time frame to determine if the weight gain is a significant fluid fluctuation, which is determined within a 24-hour time frame. Although kidney pain can also be abrupt, episodic, and colicky related to bleeding into the cysts, (D) is more likely an early symptom in PKD.

The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)? A. 18 to 24 months of age. B. 11 to 12 years of age. C. 13 to 18 years of age. D. 4 to 6 years of age.

Answer: 4 to 6 years of age. The second booster of the measles, mumps, rubella (MMR) vaccine is recommended by the CDC for routine immunization at 4 to 6 years of age (D), which is commonly required prior to entrance into elementary school. Those who have not previously received the second dose should complete the schedule by 11 to 12 years of age (A and B). The MMR may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and both doses are administered beginning at or after 12 months of age (C).

Which client should the nurse identify as the highest risk for the onset of stress-related problems? A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, "I think I'm in control of my destiny." B. A woman who is graduating from college, getting married in one month, and states, "I'm anticipating the changes these events will make in my life." C. A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." D. A client who is passed over for promotion, quits a job to start a new business, and states, "This is just one of a series of challenges I've faced in my life."

Answer: A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness (D) is at the highest risk for a stress-related health problem. (A, B, and C) describe persons who are coping with change using healthy strategies, such as perceiving change as challenging, expressing commitment to change, and believing they have control over their life paths.

A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? A. The dosage of the diuretic will be decreased. B. The dosage of the diuretic will be increased. C. A potassium supplement will be prescribed. D. The diuretic will be discontinued.

Answer: A potassium supplement will be prescribed This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level (C). (A, B, and D) are not recommended actions for restoring a normal serum potassium level.

A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply.) A. Age. B. History of abuse. C. Pregnancy. D. Drug addiction. E. School dropout. F. Homelessness. G. Unmarried.

Answer: A, B, C, D, F Health risk factors for this client include (A, C, D, E and F). Each factor should be considered individually. The client, as an adolescent mother, is at high risk for nutritional deficits, anemia, gestational diabetes and hypertension, which also impact the fetus' risk for small for gestational age, fetal anomalies, and fetal demise. (B and G) may impact the client's social adaptation, but do not directly constitute health risk factors.

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A. Accused of diversion. B. Accused of unprofessional conduct. C. Reported for stealing. D.Reported for a HIPAA violation.

Answer: Accused of diversion. Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome.

The primary nurse receives the 0700 shift report for 4 clients on a medical unit. When prioritizing care, which action should the nurse implement first? A. Flush the lumen of a client's triple lumen central venous catheter with saline. B. Review the potassium levels of a client who receives a daily loop diuretic. C. Administer insulin per sliding scale to a client with a capillary glucose of 285. D. Assess the lung sounds of a client with pneumonia who is ready to go home.

Answer: Administer insulin per sliding scale to a client with a capillary glucose of 285. The nurse should first administer the insulin per scaling scale (A) to the client with hyperglycemia to prevent further elevation of the serum glucose levels. (B and C) are of less immediacy and can be delayed until the higher priority interventions are completed. The client's potassium level should be checked before administering a loop diuretic (D), but this can be done after administering the sliding scale insulin.

All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child? A. Assessing fontanels. B. Weighing diapers. C. Observing mucous membranes for moisture. D. Checking skin turgor.

Answer: Assessing fontanels. All of these interventions evaluate fluid status in infants. But, how old is this child? Posterior fontanel closes at 2 months and anterior fontanel closes by 18 months of age (B)! Remember normal growth and development!

Based on the blood culture and sensitivity results, the healthcare provider prescribes an IV aminoglycoside antibiotic and discontinues the current prescription for another broad spectrum antibiotic. The medication administration record indicates that the client received the broad spectrum antibiotic two hours ago. Which action should the nurse implement? A. Obtain peak and trough serum levels so the aminoglycoside antibiotic can be initiated. B. Schedule the initial dose of the aminoglycoside antibiotic for the following day. C. Withhold antibiotic administration until the healthcare provider clarifies the prescriptions. D. Administer the initial dose of the aminoglycoside antibiotic as soon as possible.

Answer: Administer the initial dose of the aminoglycoside antibiotic as soon as possible. The blood culture and sensitivity results identify the specific antibiotic that is most effective in treating the client's infection, so the aminoglycoside antibiotic should be administered as soon as possible (B). Obtaining peak and trough levels (A) before starting administration of the aminoglycoside provides no useful data. The prescription does not need clarification (C) from the healthcare provider. The aminoglycoside antibiotic is the correct antibiotic to treat the infection and should be started as soon as possible, rather than waiting until the next day (D).

A client with heart failure is prescribed digoxin (Lanoxin) 0.125 mg PO. The client's apical heart rate is 70 beats per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per minute. Which action should the nurse implement next? A. Administer the medication. B. Reassess the apical heart rate. C. Review the vital sign flowsheet. D. Inform the healthcare provider.

Answer: Administer the medication Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered (A) since the client is not demonstrating any signs of toxicity. (B and D) are not necessary because the apical pulse is above 60 beats per minute. Review of the client's past vital signs (C) provides data for evaluation of the client's clinical progress, but based on the client's present clinical findings, the medication should be administered next.

A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition? A. Acrophobia. B. Claustrophobia. C. Post-traumatic stress disorder. D. Agoraphobia

Answer: Agoraphobia Agoraphobia (C) is the fear of crowds or being in an open place. (B) is the fear of being in closed places. (A) is the fear of high places. Remember, a phobia is an unrealistic fear which is associated with severe anxiety. (D) consists of the development of anxiety symptoms following a life event that is particularly serious and stressful (war, witnessing a child killed, etc.) and is experienced with terror, fear, and helplessness--a phobia is different.

Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? A. Teach the client relaxation and thought stopping techniques. B. Administer a prescribed PRN antianxiety medication. C. Assist the client to identify stimuli that precipitates the ritualistic activity. D. Allow time for the ritualistic behavior, then redirect the client to other activities.

Answer: Allow time for the ritualistic behavior, then redirect the client to other activities. Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D) lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior as treatment progresses.

The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose? A. Formula or milk. B. Syrup. C. Applesauce. D. Orange juice.

Answer: Applesauce In order to prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications (B). Syrup is not used to mix with medications because of its high sugar content (A). Medications may alter the flavor of the food and cause the child to avoid those foods in the future, so orange juice (C), which provides essential nutritional elements, and formula or milk (D), which are essential foods in a child's diet, should not be mixed with medications.

During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next? A. No action required, as this is an expected finding for a school-aged child. B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately. C. Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible. D. Call the parents and have them take the child home from school for the rest of the day.

Answer: Ask the child if he/she has had a cold, runny nose, or any ear pain lately. More information is needed to interpret these findings (B). The tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of history and related signs and symptoms is indicated for accurate interpretation of the findings. (A, C, and D) are inappropriate actions based on the data obtained from the otoscope examination.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? A. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. B. Ask the client if this decision has been discussed with his healthcare provider. C. Document the client's request in the medical record. D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Answer: Ask the client if this decision has been discussed with his healthcare provider. Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action.

A client with pneumonia receives a prescription for tetracycline (Sumycin). What precaution should the nurse include in this client's teaching? A. Avoid diary products for 2 hours after taking the medication. B. Avoid over-the-counter medications containing alcohol. C. Do not use teeth whitening agents during the treatment regimen. D. Take the medication with a glass of orange juice

Answer: Avoid diary products for 2 hours after taking the medication. Dairy products should be ingested at least 2 hours after taking Sumycin (C) because calcium binds with tetracycline and decreases its absorption. Sumycin can be taken with orange juice (A) because it does not affect absorption of the medication. Sumycin does not cause a disulfiram-like reaction, so (B) is not indicated. Although Sumycin causes enamel hypoplasia and permanent yellow, gray, or brown staining of the teeth during the ages of tooth development (children younger than 8 years of age), it does not affect adult enamel, so (D) is not indicated.

A 4-year-old is brought to the emergency room for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergency room experience? A. Avoid using jargon, such as a "shot" when giving care B. Give the child some time after explaining procedures. C. Remind the preschooler how big children should act. D. Avoid the use of bandages to keep wounds open to air.

Answer: Avoid using jargon, such as a "shot" when giving care. Using positive terms and avoiding words that have frightening connotations (D) assist the preschool-age child in coping with an emergency room experience. Bandages (A) are important to preschool-aged children because this age group often believe bandages stop their insides from leaking out. Children need to feel comfortable expressing their fears and feelings and should not be shamed into cooperation by referencing expected "big" children behaviors (B). Preschool-age children should be told about procedures immediately before they are performed (C), which minimizes the time a child fantasies about the treatment, which causes increased anxiety.

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)? A. Teach insulin self-administration for a client with Type 1 diabetes. B. Update the nutrition needs in the plan of care. C. Evaluate goal attainment for a client with a below-the-knee prosthesis. D. Bathe an unconscious client with decubitus ulcers.

Answer: Bathe an unconscious client with decubitus ulcers. Delegation requires determining which staff member is capable of performing what tasks. Basic hygiene (B) is within the role of the UAP. Coordination and planning of care (A), teaching (C), and evaluating desired goal attainment or client outcomes (D) are responsibilities outside the scope of practice for the UAP, and within that of the nurse.

An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. What is the priority nursing intervention? A. Place the infant under a radiant warmer. B. Begin humidified oxygen via hood. C. Stimulate infant crying. D. Evaluate the blood pH.

Answer: Begin humidified oxygen via hood. An oxygen saturation of less than 90% (normal oxygen saturation is 96% to 98%) requires oxygen administration (B). (A) is not necessary. (C) may utilize additional oxygen and will not correct the problem. (D) is important because it may decrease energy use for respiratory effort, but it will not correct a low saturation level.

A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time? A. Begin one-on-one supervision immediately. B. Keep the room dimly lit and turn on the radio. C. Push fluids and provide calorie-rich nutritional supplements. D. Check on the client every 15 minutes.

Answer: Begin one-on-one supervision immediately. One-on-one supervision (B) ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Checking every 15 minutes (A) does not provide sufficient assessment of the client's safety. Additional auditory stimulation and a dimly lit room (C) can create illusions that contribute to the client's altered sensory distress and should be avoided. Fluid replacement and nutritional supplements (D) should be initiated when the client is more stable because the risk for overhydration can occur as blood alcohol levels fall and fluids are retained.

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? A. Notify the client's surgeon immediately. B. Ask the client what he means by "heart trouble." C. Notify surgery that the ECG is over two years old. D. Call for an ECG to be performed immediately.

Answer: Call for an ECG to be performed immediately Clients over the age of 40 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. (D) should be implemented to ensure that the client's current cardiovascular status is stable. Additional data might be valuable (B), but since time is limited, the priority is to obtain the needed ECG. Documentation of vital signs is important, but does not replace the need for the ECG (C). The surgeon only needs to be notified if the ECG cannot be completed, or if there is a significant problem (A).

The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? A. Heightened neurologic reflexes. B. Gastrointestinal reflux. C. Anemia. D. Cardiac arrhythmias.

Answer: Cardiac arrhythmias. An adolescent with bulimia who purges by frequent self-induced vomiting, diuretic or laxative abuse can experience potassium depletion, which increases the risk for cardiac arrhythmias (B). (A) is more likely related to inadequate iron intake and absorption, not hypokalemia. (C) is related to frequent binging and gastric over-distention. Potassium depletion causes diminished reflexes, not (D)

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A. Evaluate the effectiveness of narcotic analgesics. B. Limit the client's intake of oral fluids and food. C. Teach the client about prevention of crises. D. Encourage the client to ambulate as tolerated.

Answer: Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated (B) frequently to determine if the client's pain is adequately controlled. (A, C, and D) are not indicated at this time.

At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information? A. Feelings of depression frequently lead to drug abuse and addiction. B. Careful monitoring should be provided during withdrawal from the drugs. C. Addiction is a chronic, incurable disease. D. Tolerance to the effects of drugs causes feelings of depression.

Answer: Careful monitoring should be provided during withdrawal from the drugs. The priority is to teach the parents that their son will need monitoring and support during withdrawal (B) to ensure that he does not attempt suicide. Although (A and C) are true, they are not as relevant to the parent's expressed concern. There is no information to support (D).

The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents? A. A child is insecure because trust is not fostered and developed during infancy. B. A toddler should be exposed to different routines to promote adapting to new experiences. C. Children of this age are comfortable with ritualism and display global thinking. D. Should be frequently moved in the environment to teach the child to acclimate to change.

Answer: Children of this age are comfortable with ritualism and display global thinking. A 2-year-old is ritualistic and wants consistency and routine, so changes in the toddler's environment or schedule is upsetting. Another mark of the toddler's sensitivity to change is global thinking (change in one small part, such as a minor shift in room arrangement or changes in the whole environment), and the 2-year-old's equanimity disintegrates (C). There is not enough information to make the assumption the child did not develop trust (A). Frequent changes (B and D) in the schedule or the environment can lead to insecurity on the part of the toddler.

A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A. Isocarboxazid (Marplan). B. Chlordiazepoxide (Librium). C. Diphenhydramine (Benadryl). D. Perphenazine (Trilafon).

Answer: Chlordiazepoxide (Librium). Librium (B), an antianxiety drug, as well as other benzodiazepines, is used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. (A) is an antipsychotic agent. (C) is an antihistamine and antianxiety drug. (D) is an MAO inhibitor.

The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? A. Clubbed fingers B. Machinery murmur. C. pedal pulses. D. Bradycardia

Answer: Clubbed fingers Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart disease. (B) is a classic sign of ventricular septal defect. (C) is characteristic of coarctation of the aorta.

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? A. Response to separation from family. B. Concern for body integrity. C. Socialization with other children. D. Ability to communicate verbally.

Answer: Concern for body integrity The preschooler's major stressor is concern for his body integrity (C). He fears that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most concern to the toddler. (D) is not a prime concern in this situation.

An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom? A. Pharyngitis and sputum production. B. Leukocytosis and febrile. C. Confusion and tachycardia. D. Polycythemia and crackles.

Answer: Confusion and tachycardia. The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate (D). (A, B, and C) are often absent in the elderly with bacterial pneumonia.

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A. Add oral methadone to the protocol. B. Discontinue ibuprofen. C. Continue gabapentin. D. Add aspirin to the protocol.

Answer: Continue gabapentin. Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given €Å"around the clock€� rather than by the client's PRN requests.

During the well-child assessment of an 18-month-old male toddler, the nurse determines the child does not walk while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing diagnosis should the nurse formulate? A. Delayed growth and development. B. Alteration in health maintenance. C. Alteration in parenting. D. Alteration in nutrition.

Answer: Delayed growth and development. This child does not demonstrate gross motor or psychosocial skills typical of an 18-month-old toddler, which best supports delayed growth and development (C). Additional information about the child's growth parameters is needed to support (A, B, or D).

A 48-year-old client is experiencing a severe anaphylactic reaction to an injection of contrast media. What pharmacologic agent is of greatest use in this situation? A. Epinephrine (Adrenalin). B. Nitroprusside (Nipride). C. Dopamine (Intropin). D. Loratadine (Claritin).

Answer: Epinephrine (Adrenalin). Epinephrine (D) is the drug of choice in treating hypotension and circulatory failure associated with anaphylaxis because it is a potent vasoconstrictor. An anaphylactic reaction is an acute systemic hypersensitivity reaction that occurs within minutes of antigen exposure (such as with contrast material containing iodine) that can result in peripheral vascular collapse. (A) may eventually be necessary if the client does not respond to initial treatment of hypotension with epinephrine. Antihistamines, including (B), are useful adjunctive therapies. (C) is contraindicated.

A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's growth and development, which intervention is most important for the nurse to implement? A. Provide instructions about formula preparation and feeding schedules. B. Demonstrate feeding strategies and infant cues that indicate hunger and satiation. C. Encourage the parents to participate in a planned program of play with the infant. D. Refer the parents for psychological counseling to identify parental detachment.

Answer: Demonstrate feeding strategies and infant cues that indicate hunger and satiation. NFTT most often occurs due to inadequate parent knowledge or a disturbance in maternal-child attachment, but the first goal for infants with NFTT is to provide nutrition to promote "catch-up" growth. The nurse should demonstrate positive feeding strategies that reduce parent and infant frustration, such as recognizing the infant's cues indicated by vigorous sucking and satiation (C). (A) encourages normal growth and development, but is not likely to teach the parents how to respond to the infant's nutritional needs. Although family dysfunction may contribute to NFTT and (B) may eventually be indicated, additional assessment is needed before such a referral is made. (D) provides a structured schedule, but positive infant feeding strategies should be implemented first.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? A. Describe diet changes that can improve the management of her diabetes. B. Evaluate the client's ability to do glucose monitoring. C. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. D. Demonstrate self-administration of insulin.

Answer: Describe diet changes that can improve the management of her diabetes. Diet modifications (A) are effective in managing Type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client. (B, C, and D) are interventions that should also be implemented, but do not have the priority of (A).

What action should the nurse implement to provide analgesic titration for a client in pain? A. Teach the client to increase the time range between doses of pain medication. B. Monitor the effects of continuous intravenous infusion of narcotic analgesics. C. Determine the optimal analgesic dosage required that causes the least side effects. D. Plan with the client how to use a specific total dose of analgesic over a 24-hour period.

Answer: Determine the optimal analgesic dosage required that causes the least side effects. No given dosage of an analgesic provides the same level of pain relief for every patient, and so titration upward or downward is determined based on the client's response, so that the optimal dosage achieves adequate pain relief with minimal side effects (D) for the client. Titration does not necessarily mean continuous intravenous infusion (B), but considers dose adjustments to achieve a therapeutic analgesic response. An individual's response to the medication dosage is the assessment for titration, not a specific total dose over 24 hours (C). Although (A) may be a component of pain management, particularly during rehabilitation or remission, the titration dose should be implemented as long as analgesia is needed.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? A. Assessment of the client's vital signs. B. Determine the time the client last voided. C. Document the finding as the only action. D. Insert a rectal tube for the passage of flatus.

Answer: Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided (C) should be determined next. Documentation (B) should be made, but the client's distended bladder requires additional intervention. (A and D) are not priority actions based on the client's abdominal findings.

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Determine who is legally empowered to make decisions. C. Notify the hospital ethics committee of the client situation. D. Refer the client and family members for hospice care.

Answer: Determine who is legally empowered to make decisions. When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution.

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? A. Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache." B. Do not give if the child has chickenpox, the flu, or any other viral illness. C. If the child's tongue darkens, discontinue the Pepto Bismol immediately. D. Avoid the use of Pepto Bismol until the child is at least 16 years old.

Answer: Do not give if the child has chickenpox, the flu, or any other viral illness. Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium.

A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain? A. Family history of suicide. B. Drugs taken in last 7 days. C. Frequency of anxiety attacks. D. Usual coping mechanisms.

Answer: Drugs taken in last 7 days. Use of prescribed, over-the-counter, and illicit drugs (A) is the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations. (B, C, and D) are worthwhile assessment findings, but they do not have the priority of (A).

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A. Excessive CNS stimulation will be reduced. B. Co-dependent behaviors will be decreased. C. Client's level of consciousness will increase. D. Client will not demonstrate cross-addiction.

Answer: Excessive CNS stimulation will be reduced. Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (A). (B, C, and D) are all appropriate outcome statements for the client described, but do not have the priority of (A).

A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? A. Experiencing culture shock. B. Refuses to participate in school activities. C. Lacks the maturity needed in school. D. Going through minority group discrimination.

Answer: Experiencing culture shock. An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock (A) describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication, so a child who is unable to communicate in the spoken language in the school environment may lack the skills necessary to participate, and is not refusing to participate (C). The child may be adequately mature (B), accepted by peers (D) within the environment, but continues to not join in because of the impact of culture shock.

The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider? A. Low-grade fever, diaphoresis, hypertension, and tachycardia. B. Global confusion and inability to recognize family members. C. Agitation, vomiting, and visual and auditory hallucinations. D. Restlessness, anxiety, and difficulty sleeping.

Answer: Global confusion and inability to recognize family members. Delirium tremens (DT) or alcohol withdrawal delirium usually peaks 2 to 3 days (48 to 72 hours) after cessation or reduction of intake (although it can occur later) and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal, manifested as global confusion and an inability to recognize family members (B), is life-threatening and requires emergency medical intervention. The early signs of withdrawal (A) develop within a few hours after cessation or reduction of alcohol (ethanol) intake; the signs peak after 24 to 48 hours (C and D) and then rapidly and dramatically disappear, unless the withdrawal progresses to alcohol withdrawal delirium.

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? A. Have a bulb syringe readily available to remove secretions. B. Give small, frequent feedings of fluids. C. Accurately chart observations regarding breath sounds. D. Encourage older siblings to visit.

Answer: Have a bulb syringe readily available to remove secretions A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration and prevent tiring, but an open airway has a higher priority! (B) is important for evaluation of therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs usually have a higher priority than psychosocial needs (D) and an open airway is the highest physiological need!

The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? A. Avoid consuming alcohol and caffeinated beverages. B. Wear a condom when having sexual intercourse. C. Have intercourse or masturbate at least twice a week. D. Empty the bladder completely with each voiding.

Answer: Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation (D) decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated fluids. (A, B, and C) do not reduce the risk of spreading the infection internally.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. B. He comments on the community service announcements about preventing complications associated with diabetes. C. He is provided with the most current information about the dangers of untreated diabetes. D. He visits his diabetic brother who just had surgery to amputate an infected foot.

Answer: He visits his diabetic brother who just had surgery to amputate an infected foot. The loss of a limb by a family member (D) will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease. (A, B, and C) may influence his behavior but do not have the personal impact of (D).

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? A. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen. B. Help the client to determine ways to increase his fluid intake. C. Obtain an appointment for the client to see an ear, nose, and throat specialist. D. Schedule an appointment with an allergist to determine if the client is allergic to the cat.

Answer: Help the client to determine ways to increase his fluid intake. The nurse should suggest creative methods to increase the intake of fluids (A), such as having disposable fruit juices readily available. Clients with COPD should have at least three liters of fluids a day. These clients often reduce fluid intake because of shortness of breath. (B) is not indicated. These symptoms are not indicative of an allergy (C). Many elderly depend on their pets for socialization and self-esteem. Humidified oxygen will not relieve these symptoms and increased oxygen levels will stifle the COPD client's trigger to breathe (D).

A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer? A. Pneumococcal. B. Hepatitis B. C. Human papillomavirus. D. Measles-mumps-rubella.

Answer: Hepatitis B Multiple sexual contacts are associated with the risk for hepatitis B, so (B) has the highest priority for this client. The MMR vaccine (A), which contains attenuated live viruses that are teratogenic, is not recommended during pregnancy. The safety of the human papillomavirus (C) during pregnancy has not been determined and should not be given or completed during pregnancy. The pneumococcal vaccine (D) is not indicated at this time.

The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? A. Thinning hair and dry scalp. B. Increase in muscle tone but decreased muscle strength. C. Increase in abdominal fat deposits. D. Increase in appetite and taste-bud acuity.

Answer: Increase in abdominal fat deposits. An increase in the abdominal girth (D) may be indicative of the onset of metabolic syndrome, which places the client at risk for cardiac disease and requires further assessment. During middle adulthood, common findings include thinning hair, dry skin and scalp (A), changes in taste bud acuity (B), and muscle size and strength (C), which are consistent with normal system functioning during aging.

An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately? A. Elevated serum calcium level. B. Positive rapid plasma reagin (RPR). C. Increased serum creatinine level. D. Increased thyroid stimulating hormone (TSH).

Answer: Increased thyroid stimulating hormone (TSH). The healthcare provider should be notified of (D) immediately. An increased TSH suggests a low thyroxine level because the TSH is trying to stimulate thyroxine production, and hypothyroidism symptoms mimic those of depression. (A) often increases with aging. (B) is indicative of syphilis and should be reported, but does not have the priority of (C). (D) has implications for other illnesses, such as non-Hodgkin's lymphoma or hyperparathyroidism.

The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? A. Poor concentration skills suggests limited intelligence. B. The inability to think abstractly indicates limited intelligence. C, Acute psychiatric illnesses impair intelligence. D. Intelligence is influenced by social and cultural beliefs.

Answer: Intelligence is influenced by social and cultural beliefs. Social and cultural beliefs (D) have significant impact on intelligence. Chronic psychiatric illness may impair intelligence (C), especially if it remains untreated. Limited concentration does not suggest limited intelligence (A). Difficulties with abstractions are suggestive of psychotic thinking (B), not limited intelligence.

When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness? A. Logical mathematics and linguistic abilities. B. Bodily kinesthetic and spatial abilities. C. Linguistic and musical abilities. D. Interpersonal and intrapersonal skills.

Answer: Interpersonal and intrapersonal skills. Interpersonal and intrapersonal intelligence form one's personal intelligence or "emotional quotient," so the nurse should focus inquiries on social skills (B). (A and D) assesses cognitive and mental status. (C) determines neurophysical interpretation of one's body within the environment, but does not assess emotional intelligence.

The practical nurse (PN) is working with the registered nurse (RN) to provide care for several clients. Which task should the RN, rather than the PN, perform? A. Apply a neck brace prior to ambulating a client the first day after a cervical laminectomy. B. Assist a healthcare provider performing a joint fluid aspiration of a client's knee. C. Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia. D. Remove the staples from a client's incision one week after hip arthroplasty.

Answer: Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia. Care of a stage IV pressure ulcer (C) is a complex, sterile procedure that requires assessment of the wound, and evaluation of the effectiveness of the treatment plan, and should be performed by the RN. (A, B, and D) are procedures that require the skill and expertise of a licensed nurse, but are within the scope of practice for a PN (C).

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Confusion. B. Stomatitis. C. Dyspnea. D. Nocturia.

Answer: Nocturia As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal failure.

A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? A. Inadequate milk supply in mother. B. Milk allergy. C. Normal growth curve of a breast-fed infant. D. Failure to thrive.

Answer: Normal growth curve of a breast-fed infant. When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk supply (C)

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Report the client's acuity level to the nursing supervisor. B. Request hospice care for the client. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent.

Answer: Notify family members of the client's condition. The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D).

A client with Paget's disease is started on calcitonin (Calcimar) 500 mcg subcutaneously daily. During the initial treatment, what is the priority nursing action? A. Assess the injection site for inflammation. B. Observe the client for signs of hypersensitivity. C. Evaluate the client's level of pain. D. Monitor the client's alkaline phosphatase levels.

Answer: Observe the client for signs of hypersensitivity. The nurse's highest priority is to observe for signs of hypersensitivity, such as skin rash, hives, or anaphylaxis (D). Calcitonin is given to a client with Paget's disease to lower serum calcium levels. However, hypersensitivity can cause life-threatening anaphylaxis. Calcitonin may cause local site inflammation, so (A) is important, but does not have the priority of (D). A reduction in (B and C) are indicators that the calcitonin is having the desired effect.

The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take? A. Pass the information on in the report. B. Hold the next dose of theophylline. C. Notify the healthcare provider because the value is high. D. Repeat the lab study because the value is too high.

Answer: Pass the information on in the report. The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report (A). (B, C, and D) would be inappropriate actions in view of the laboratory finding.

The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? A. Assessment inconclusive. B. Poor skin turgor. C. Adequate hydration. D. Normal skin elasticity

Answer: Poor skin turgor Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor (B), the skin remains tented or suspended for a few seconds before returning to a normal position. (A, C and D) are inaccurate.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A. Glucose. B. Sodium. C. Antidiuretic hormone. D. Potassium.

Answer: Potassium Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (D) (hypokalemia)--hypertension is the most prominent and universal sign. (B) is normal or elevated, depending on the amount of water reabsorbed with the sodium. (A) is decreased with diabetes insipidus. (C) is not affected by primary aldosteronism.

The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority? A. Pain related to postoperative condition. B. Potential for fluid volume deficit. C. Alteration in bowel elimination. D. Anxiety of parents related to newborn's condition.

Answer: Potential for fluid volume deficit. All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern (A) for any newborn infant. Though three loose stools in 24-hours is not significant, depending on the amount of fluid lost with each stool, potential for fluid volume deficit is always a concern for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of their body weight consisting of fluid. (B, C, and D) do not have the priority of (A).

A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority? A. Insert an orogastric tube for gastric lavage. B. Prepare a set-up for an endotracheal intubation. C.Draw blood for stat chemistries and blood gases. D. Insert a Foley catheter to monitor renal functioning.

Answer: Prepare a set-up for an endotracheal intubation. Diazepam causes respiratory depression, so preparation for intubation (B) to protect the airway is the priority intervention at this time. (A) may be necessary, but the child is lethargic and confused, with a lowered respiratory rate, so (B) takes priority. (C and D) are interventions that should be implemented, but they are both secondary to ensuring an open airway.

Which action should the nurse implement first for a client experiencing alcohol withdrawal? A. Apply vest or extremity restraints. B. Provide a diet high in protein and calories. C. Give an alpha-adrenergic blocker. D. Prepare the environment to prevent self-injury.

Answer: Prepare the environment to prevent self-injury. Self-destructive or violent behavior provides a potentially immediate and life-threatening risk to the client and others, so a safe environment should be provided (D) by removing any potential objects that could inflict self-injury. Secondary prevention strategies (frequent orientation to surroundings, restraints to prevent self-injury (A), and the administration of antianxiety agents or alpha-adrenergic blockers (B) for hallucinations, delusions, confusion, and agitation) should then be implemented. Once the client is stabilized, nutritional issues (C) should be addressed.

An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? A. Reduce peripheral tissue hypoxia and nailbed clubbing. B. Prevent the return of oxygenated blood to the lungs. C. Increase the flow of unoxygenated blood to the lungs. D. Stop the flow of unoxygenated blood into systemic circulation.

Answer: Prevent the return of oxygenated blood to the lungs. Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.

The nurse-manager observes that a staff nurse consistently fails to complete assigned care for clients who are obese. When counseling this employee, what issue is the priority concern? A. Reduction of client complaints. B. Dissatisfaction of co-workers. C. Poor time management skills. D. Violation of ethical principles.

Answer: Violation of ethical principles. The priority concern is the lack of fair and equal treatment of obese clients assigned to this staff nurse for care. This reflects a violation of the ethical principle of justice (A). Counseling the nurse about (B) is important because using time effectively allows the nurse to ensure that all clients receive fair and equal treatment, but this is of less concern than (A). (C and D) may also be important concerns, but they are secondary to ensuring justice.

During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? A. Productive cough with grayish-white sputum. B. An increased chest diameter. C. Clubbing of the fingers. D. Racing pulse with exertion.

Answer: Productive cough with grayish-white sputum. Chronic bronchitis, one of the diseases comprising the diagnosis of COPD, is characterized by a productive cough with grayish-white sputum (A), which usually occurs in the morning and is often ignored by smokers. (D) is not related to chronic bronchitis; however, it is indicative of other problems such as ventricular tachycardia and should be explored. (B and C) are symptoms of emphysema and are not consistent with the other symptoms. (B) is usually referred to as a "barrel chest."

The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention? A. Frequent nonproductive cough. B. Prolonged exhalations. C. Oxygen saturation is 95% by pulse oximeter. D. Thick yellow rhinorrhea.

Answer: Prolonged exhalations. Prolonged exhalation (A) indicates breathing difficulty, and intervention for this should be taken immediately. Nasal discharge (B) and a productive cough (C) are not findings that indicate the child is in immediate distress. An oxygen saturation of 95% is a normal finding (D).

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? A. Propanolol (Inderal). B. Furosemide (Lasix). C. Dobutamine (Dobutrex). D. Captopril (Capoten).

Answer: Propanolol (Inderal). Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (D), an ACE inhibitor, nor (B), a loop diuretic, causes bradycardia. (C) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate.

A 14-year-old is brought to the emergency room after a biking accident. How should the nurse interact with the adolescent? A. Provide clear explanations while encouraging questions. B. Limit the number of choices to be made by the adolescent. C. Have the parents remain with the adolescent at all times. D. Furnish rewards for cooperation during procedures.

Answer: Provide clear explanations while encouraging questions. Adolescents are capable of abstract thinking and understand explanations, so the opportunity to ask questions (C) should be provided. Giving rewards (A), such as stickers for cooperation with treatments or procedures are best used with a younger child. An adolescent's modesty should be respected, so the presence of the parents (B) at the bedside should be a choice made by the adolescent. An adolescent's ability to think abstractly engages problem solving, so the 14-year-old should be allowed to make decisions about care, not (D).

The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What intervention should the nurse implement? A. Question the healthcare provider's prescription. B. Instruct the client to swallow the tablet whole. C. Administer 30 minutes before eating. D. Evaluate the effectiveness 1 hour after administration.

Answer: Question the healthcare provider's prescription. Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse (D). (A, B, and C) are not recommended nursing actions for the administration of aluminum and magnesium hydroxide (Maalox).

A client is taking sulfisoxazole (Gantrisin) for a urinary tract infection (UTI) and complains of nausea and gastric upset since starting the medication. Which additional adverse reaction should the nurse instruct the client to report? A. Diarrhea. B. Muscle cramping. C. Rash. D. Hematuria.

Answer: Rash Side effects of sulfisoxazole (Gantrisin), a sulfonamide antibiotic, include possible allergic response, manifested by skin rash (A) and itching, which can progress to Stevens-Johnson syndrome - erythema multiforme, a severe hypersensitivity reaction. Other gastrointestinal disturbances, such as diarrhea (B), crystalluria and photosensitivity are other side effects that commonly occur with "sulfa" agents but do not need the discontinuation of the prescription. Hematuria (C) is associated with a UTI. Muscle cramping (D) is mostly likely related to an electrolyte disturbance.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A.Refuse to perform the task that is beyond the nurse's experience. B. Review the steps in the procedure manual. C. Ask another nurse to assist while implementing the procedure. D. Follow the agency's policy and procedure.

Answer: Refuse to perform the task that is beyond the nurse's experience. According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C).

A client receives a new prescription for an angiotensin-converting enzyme (ACE) inhibitor. What client history contraindicates its use? A. Asthma. B. Heart failure. C. Coronary artery disease. D. Renal artery stenosis.

Answer: Renal artery stenosis Angiotensin-converting enzyme (ACE) inhibitors can cause severe renal insufficiency in clients with bilateral renal artery stenosis (C) or stenosis in the artery to a single remaining kidney. ACE inhibitors should not be used during the second and third trimesters of pregnancy and should be used with caution in clients who are taking potassium-sparing diuretics or who have hyperkalemia. The use of ACE inhibitors is not contraindicated for clients with asthma (A). ACE inhibitors are indicated for clients with heart failure (B). Ramipril, an ACE inhibitor, is approved for use in high risk clients for future cardiac events, including those with a history of coronary artery disease (D).

A nurse receives an emphatic complaint from a client in a semi-private room that the night shift nurse did not come into the room the entire night. What action should the nurse implement first? A. Verify occurrence with client's roommate while he's ambulating in the hall. B. Telephone the night shift nurse as soon as possible to ask about the situation. C. Discuss the situation with staff to determine if this client has a history of complaining. D. Review the night shift nurse's documentation with the charge nurse.

Answer: Review the night shift nurse's documentation with the charge nurse. The client's concern needs to be assessed immediately. This can best be accomplished by reviewing the documentation with administration, i.e., the charge nurse, to determine the client's needs and the night nurse's response. The night shift nurse may need to be contacted at some point (A) but reviewing the documentation should occur first. The nurse should not discuss the situation with (C or D).

What is the most effective time management strategy for a nurse who needs to review 10 client records in 2 weeks? A. Delegate other nursing responsibilities to the team members. B. Designate 15 minutes a day to respond to each time-waster. C. Schedule specific times on a written calendar to review 2 charts per day. D. Review all records 2 days before the due date to focus on the deadline.

Answer: Schedule specific times on a written calendar to review 2 charts per day. Creating a disciplined approach by scheduling time periods for each issue is the most effective time-management strategy (C). Although (A and B) are options, the priority responsibility is to accomplish the goal within the designated time frame without imposing on others. (D) can create more stress that may hinder accomplishing the goal.

Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? A. Context. B. Counter transference. C. Therapeutic self-disclosure. D. Self-analysis.

Answer: Self-analysis Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs, so (B) is a primary tool used by the nurse to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. Although (A, C, and D) may occur in a nurse-client relationship, they may not contribute to establishing a therapeutic relationship.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Prealbumin. B. Transferrin. C. Serum albumin. D. Urine urea nitrogen.

Answer: Serum albumin Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C).

A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? A. Urine specific gravity. B. Serum creatinine. C. Blood Urea Nitrogen (BUN). D. Sedimentation rate.

Answer: Serum creatinine Creatinine (A) is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration. (B) is also an indicator of renal activity, but it can be affected by non-renal factors such as hypovolemia and increased protein intake. (C) is a nonspecific test for acute or chronic inflammatory processes. (D) is useful in assessing hydration status, but not as useful in assessing glomerular function.

Which ego-defense mechanisms are exhibited by a phobic client who refuses to leave home? A. Fantasy. B. Denial. C. Intellectualization. D. Symbolization.

Answer: Symbolization Symbolization (D) allows external objects to carry the internal emotional feeling through some act such as refusing to leave a "safe" harbor. (A) is the unconscious failure to acknowledge an event, thought or feeling. (C) is pretending, usually of a more desirable situation. (B) is using reason to avoid emotional conflicts.

A client with chronic pancreatitis receives a new prescription for pancrelipase (Pancrease). Which instruction is most important for the nurse to include in this client's teaching? A. Take the medication when consuming food. B. Stay away from products containing alcohol. C. Ingest 8 oz of grapefruit juice with the medication. D. Avoid prolonged exposure to direct sunlight.

Answer: Take the medication when consuming food. With the loss of exocrine function for a client with chronic pancreatitis, replacement of pancreatic enzymes using pancrelipase (Pancrease) becomes necessary. Diarrhea and steatorrhea (fatty stools) indicate insufficient pancreatic enzymes are present to digest dietary fats and other of nutrients, so pancrelipase, a fat-digesting enzyme, should be consumed with any type of food (D). (A, B, and C) are not related to the administration of Pancrease.

A mother expresses concern to the nurse about the behavior of her 15-year-old adolescent who is frequently finding fault and criticizing her. What information should the nurse provide? A. Teens create psychological distance from parents in order to separate from them. B. The family value system may need to be changed to meet the teen's changing needs. C. Parents should relinquish their relationship with their teen to the teen's peers. D. Conflicts in the parent-teen relationship are to be expected during adolescence.

Answer: Teens create psychological distance from parents in order to separate from them. Although a mutually respectful parent-adolescent relationship is important, an adolescent may use critical and fault-finding behavior as a mechanism to separate from the parent (B). Changing the family's value system to meet the teen's needs (A) does not provide consistency for an adolescent who is examining oneself. (C) does not provide guidance or boundary setting that is needed to foster judgment during adolescence. Although (D) may occur as an adolescent struggles for independence, healthy family dynamics foster the parent-teen relationship even though it may not seem as important to the teen as it was in earlier years.

A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention should the nurse take at this time? A. Arrange for emergency admission to a detoxification unit. B. Tell the client that therapy cannot take place while she is intoxicated. C. Talk to the spouse about strategies to limit the client's drinking. D. Have the client admitted to the inpatient psychiatric unit.

Answer: Tell the client that therapy cannot take place while she is intoxicated. Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur (D) because the client's judgment is altered. (A and C) are not necessary at this time. (B) is ineffective.

Which statement best describes durable power of attorney for health care? A. The healthcare decisions made by another person designated by the client are not legally binding. B. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.

Answer: The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time.

A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because my husband told me I will be deported if my depression is not cured." What information should the nurse report to the healthcare provider? A. The client is not competent to sign permission for treatment. B. All the elements of informed consent were met. C. The client's consent may have been coerced. D. The woman may not fully understand the risks and benefits.

Answer: The client's consent may have been coerced. Informed consent requires that the choice is freely given. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced (A) based on family pressure. (B, C, and D) are not accurate.

The healthcare provider discontinues prednisone, a glucocorticoid, for a client with chronic obstructive pulmonary disease. What instructions should the nurse give the client about the regimen to follow? A. The dose must be tapered over the course of 7 to 10 days. B. Another glucocorticoid should be used to prevent cross-tolerance. C. Life-long treatment is common for chronic disease. D, The drug should be stopped immediately if no longer needed.

Answer: The dose must be tapered over the course of 7 to 10 days. To minimize the impact of adrenal insufficiency, withdrawal of exogenous glucocorticoids should be done by gradually decreasing the dosage over several days (C). Prolonged treatment with a glucocorticoid is not indicated for life (A) and can cause life-threatening adrenal insufficiency if abruptly terminated (B). Tapering the dosage should be done rather than substituting another glucocorticoid (D).

A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? A. We don't really know what or when CHDs occur. B. The heart develops in the third to fifth weeks after conception. C. They usually occur in the first trimester of pregnancy. D. It depends on what the causative factors are for a CHD.

Answer: The heart develops in the third to fifth weeks after conception. The cardiovascular system is the first organ system to develop and function in the embryo. The blood vessel and blood formation begin in the third week, and the heart is developmentally complete in the fifth week (D). Regardless of the etiological factor, the heart is vulnerable during its period of development -- the third to fifth weeks. (A, B, and C) are inaccurate.

A single-parent mother brings her 3-year-old daughter to the emergency department after the child fell off a playground swing at school and hit her head. Which finding should prompt the nurse to advocate for continued hospital observation of the child instead of discharging the child to care at home? A. The mother states they do not have the money to pay for transportation home. B. The child had a 10 second loss of consciousness immediately after the fall. C. The mother is slurring her words and is not attentive to discharge instructions. D. The child indicates that she is tired and wants to take a nap.

Answer: The mother is slurring her words and is not attentive to discharge instructions Having a responsible adult to make on-going observations is the most important criteria for discharging anyone to their home after a head injury. The child (who needs observation) should not go home with an impaired adult (C). Alternative arrangements can be made regarding the follow-up care (A). The events of the head injury do not necessarily indicate the need for hospitalized observation (B). It is normal to be drowsy after a concussion (D); immediate intervention is needed if the child cannot be aroused from sleep.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. After instruction, the nurse will ensure the client understands foot care rationale. B. The nurse will provide client instruction for daily foot care. C. Upon discharge, the client will list three ways to protect the feet from injury. D.The client will demonstrate proper trimming toenail technique.

Answer: Upon discharge, the client will list three ways to protect the feet from injury. An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. (C) is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or more of these elements.

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that A. only an RN should be assigned to monitor this child's temperature. B. a tympanic measurement of temperature will provide the most accurate reading. C. the licensed practical nurse should be instructed to obtain rectal temperatures on this child. D. the healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.

Answer: a tympanic measurement of temperature will provide the most accurate reading. (B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management--sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary

A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because A. they occur in healthy young adults who have recently been debilitated by an upper respiratory infection. B. gram-negative organisms are more resistant to antibiotic therapy. C. they occur in the lower lobe alveoli which are more sensitive to infection. D. gram-negative pneumonias usually affect infants and small children.

Answer: gram-negative organisms are more resistant to antibiotic therapy. The gram-negative organisms are resistant to drug therapy (B) which makes recovery very difficult. Gram-negative pneumonias affect all lobes of the lung (C). The mean age for contracting this type of pneumonia is 50 years (A and D), and it usually strikes debilitated persons such as alcoholics, diabetics, and those with chronic lung diseases.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's A. blood pressure is 104/68. B. serum digoxin level is 1.5. C. serum potassium level is 3. D. apical pulse is 68/min.

Answer: serum potassium level is 3. Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/ml (toxic levels=>2 ng/ml); (B) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client A. have her own teeth or dentures?" B. take aspirin and if so, how much?" C. take nitroglycerin?" D. take digitalis?"

Answer: take digitalis?" Elderly persons are particularly susceptible to digitalis intoxication (D) which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. (A) is irrelevant.

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's A. blood pressure, both standing and sitting. B. temperature. C. pulse rate, both apically and radially. D. skin color and turgor.

Answer: temperature It is very important to check the client's temperature (B). Infection is the most common factor precipitating respiratory distress. Clients with COPD who are on maintenance doses of corticosteroids are particularly predisposed to infection. (A and C) are important data for baseline and ongoing assessment, but they are not as important as temperature measurement for this client who is taking steroids. Assessment of skin color and turgor is less important (D).

The father of an 8-year-old tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father? A. The father should decrease his expectations to give the son a chance to succeed. B. The child has an introverted personality and should be encouraged to play isolated games. C. The child should be given opportunities to achieve a sense of competency in an area he chooses. D. The father should encouraged the son to participate in team sports instead of less physical activities.

Answer:The child should be given opportunities to achieve a sense of competency in an area he chooses. According to Erickson, the developmental stage "Industry versus inferiority" builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in (D). The father does not need to decrease his expectations (A), but should be encouraged to shift the expectation to an activity the child takes pleasure in. (B) does not encourage autonomy. (C) can cause a feeling of inadequacy.