Incorrect NCLEX PassPoint Questions

A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client? -Eat while lying flat. -Raise the hips using trapeze. -Rotate side to side. -Flex and extend the ankle on affected side.

A: Rationale: The client in balanced suspension traction can raise the hips using a trapeze. The client can then use the bedpan. The client can be in a sitting position to eat. The client should not move side to side but can turn toward the affected side. The client should not flex or extend the ankle on the affected side.

The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. What should the nurse explain to the client about this procedure? -Fluid and food will be withheld the morning of the examination. -A tranquilizer will be given before the examination. -An enema will be given before the examination. -No special preparation is required for the examination.

A: No special preparation is required for the examination. Rationale: A KUB radiographic examination ordinarily requires no preparation. It is usually done while the client lies supine and does not involve the use of radiopaque substances.

While suctioning a client's laryngectomy tube, the nurse should insert the catheter: -about 1 to 2 inches (2.5 to 5 cm). -as the client exhales. -until resistance is met, then withdraw it 0.4 to 0.8 inches (1 to 2 cm). -until the client begins coughing.

A: until resistance is met, then withdraw it 0.4 to 0.8 inches (1 to 2 cm). Rationale: The proper suctioning technique is to insert the suction catheter until resistance is met (typically about 5 to 6 inches [13 to 15 cm]), withdraw the catheter 0.4 to 0.8 inch (1 to 2 cm), then begin applying intermittent suction while withdrawing the catheter.It is not necessary to insert the catheter as the client exhales.Coughing by a client does not necessarily indicate when to begin or stop suctioning.

Which of the following variables should the nurse judge as least likely to indicate high risk when assessing a client's potential for suicide? -Age 60 and older. -Angry behavior. -Living alone. -Previous suicide attempts.

A: Angry behavior. Rationale: Anger is a low risk factor for suicide. Risk factors for completed suicide are hopelessness; medical illness; severe anhedonia (loss of ability to feel pleasure); male gender; Caucasian, Native American, or Aboriginal ethno-racial background; living alone; age 60 or older; unemployment; financial distress; or previous suicide attempt. Age 60 and older is a risk factor for completed suicide. Living alone is a risk factor for completed suicide. Previous suicide attempt is a risk factor for completed suicide.

A client has a throbbing headache when nitroglycerin is taken for angina. What should the nurse instruct the client to do? -Take acetaminophen or ibuprofen. -Limit the frequency of using nitroglycerin. -Take the nitroglycerin with a few glasses of water. -Rest in a supine position to minimize the headache.

A: Take acetaminophen or ibuprofen. Rationale: Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath.

The nurse working in an internal medicine clinic receives four phone calls from clients with chronic pancreatitis. Which client should the nurse contact first? -The client reporting foul-smelling fatty stools. -The client in need of pancreatic enzyme medication refill. -The client reporting chronic abdominal tenderness. -The client reporting increased thirst and hunger.

A: The client reporting increased thirst and hunger. Rationale: Clients with chronic pancreatitis are likely to develop diabetes as a result of the pancreatic fibrosis that occurs. The pancreas becomes unable to secrete insulin. Increased thirst and hunger are symptoms of diabetes. Chronic abdominal pain can be recurrent for months to years. The client with the need for pancreatic enzymes prescription refill is not in acute distress and can be called back later. A symptom of chronic pancreatitis is steatorrhea (fatty stools) and can become severe. The nurse should follow-up with the client to assess for volume and frequency of the stools, however, this client is not the priority.

A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client? -The client's intake and output are balanced. -The client performs oral hygiene every 4 hours. -The client verbalized the importance of increasing fluid intake. -The client's skin remains dry and intact throughout the hospital stay.

A: The client's intake and output are balanced. Rationale: During the planning step of the nursing process, the nurse identifies expected client outcomes, establishes priorities, and develops the care plan. This outcome provides measurable data showing resolution of the problem of deficient fluid volume that was identified in the nursing diagnosis statement. The other statements do not resolve the problem of fluid volume deficiency.

A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding? -The lung has fully expanded. -The lung has collapsed. -The chest tube is in the pleural space. -The mediastinal space has decreased.

A: The lung has fully expanded. Rationale: Cessation of fluid fluctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been reestablished; the chest tube is occluded; or the chest tube is not in the pleural space. Fluid fluctuation occurs because during inspiration intrapleural pressure exceeds the negative pressure generated in the water-seal system. Therefore, drainage moves toward the client. During expiration, the pleural pressure exceeds that generated in the water-seal system, and fluid moves away from the client. When the lung is collapsed or the chest tube is in the pleural space, fluid fluctuation is likely to be noted. The chest tube is not inserted in the mediastinal space.

The health care provider prescribes continuous IV nitroglycerin infusion for the client with myocardial infarction. What should the nurse do to ensure safe administration of this drug? -Use an infusion pump for the medication. -Take the blood pressure every 4 hours. -Monitor urine output hourly. -Obtain serum potassium levels daily.

A: Use an infusion pump for the medication. Rationale: IV nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.

A client comes to a community mental health clinic for a psychiatric evaluation at the family's request. During the initial interview, the client tells the nurse about painting the streets to beautify the city, lecturing subway riders about germ control, and banning smoking in order to clean up the environment. The client is irritable and easily distracted by the slightest sound. Which stage of mania is the client exhibiting? -hypomania -delirious mania -acute mania -dementia mania

A: acute mania Rationale: The client is demonstrating an expansive mood, high energy level, racing thoughts, and disjointed thinking. Any type of stimulation will distract the client from the current conversation. This behavior is indicative of the acute manic phase of mania. Hypomania is a mania phase characterized by an abnormally elevated mood, signs of inflated self-esteem, decreased sleep, flight of ideas, and pleasure-seeking behaviors. This phase lasts for 4 days or less. The delirious mania phase is when the client exhibits signs and symptoms of mania and delirium. Dementia mania isn't a phase of mania.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? -hyperabduction and extension of the arms with external rotation of the hips -neck extension and back arching with flattened shoulders -adduction and flexion of the extremities with gently rounded shoulders -abduction and flexion of the arms with flattened shoulders

A: adduction and flexion of the extremities with gently rounded shoulders Rationale: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? -administering pain medication. -completing the admission history -maintaining hydration -teaching about planned diagnostic tests

A: administering pain medication. Rationale: Administering pain medication would have the highest priority during the first hour after the client's admission.Completing the admission history can be done after the client's pain is controlled.Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief.It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable.

During a shift handoff, the nurse receives the following information: "The infant was born at 38 weeks' gestation to a gravida 1, para 1, 26-year-old mother by spontaneous vaginal birth. Mother is breastfeeding her infant." What additional information does the nurse need to make an accurate assessment? -age of infant in hours -length of labor -mother's marital status -mother's nutritional status

A: age of infant in hours Rationale: Many of the circulatory transitions that infants make after birth are normal for a period of time and become abnormal as the infant ages. The closing of the fetal shunts is an example. Pathology of hyperbilirubinemia is determined by when jaundice appears and acceptable levels are age dependent. The length of labor, the mother's marital status, and the mother's nutritional status have no influence on the assessment of the infant.

A 4-year-old, 40-lb (18.1-kg) child is brought to the pediatrician's office. The child has upper respiratory symptoms and has had a fever for 2 days. The physician diagnoses a viral illness, and the parent is instructed to treat the child with rest, fluids, and antipyretics. The nurse is reviewing the orders and questions which of the following? -acetaminophen 181 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 181 mg (10 mg/kg/dose) q6h for temperature higher than 102.5° F (39.2° C) -aspirin 294 mg (65 mg/kg/24 hours) q6h with intermittent doses of acetaminophen 217 mg q4h -acetaminophen 235 mg (10 to 15 mg/kg/dose) q4h for a temperature lower than 102.5° F (39.2° C) -acetaminophen 253 mg (10 to 15 mg/kg/dose) q4h with intermittent doses of ibuprofen 181 mg (10 mg/kg/dose) q6h for a temperature higher than 102.5° F (39.2° C)

A: aspirin 294 mg (65 mg/kg/24 hours) q6h with intermittent doses of acetaminophen 217 mg q4h Rationale: The correct dosage schedule for acetaminophen is 10 to 15 mg/kg/dose every 4 hours, and for ibuprofen it's 10 mg/kg/dose every 6 hours for a temperature higher than 102.5°F (39.2°C). Aspirin shouldn't be given to children because of the association between aspirin use in children with influenza virus or chickenpox and Reye's syndrome (a life-threatening condition characterized by vomiting and lethargy that may progress to delirium and coma).

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed? -laxative -anticholinergic -antacid -demulcent

A: laxative Rationale: After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? -abundance of scalp hair -thin, wasted appearance -descended testicles -numerous scrotal rugae

A: thin, wasted appearance Rationale: The premature neonate characteristically exhibits a thin, wasted appearance.The premature neonate commonly exhibits a scarcity of scalp hair.In the premature male neonate, testicles are typically high in the inguinal canal and absence of rugae on the scrotum is typical.

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? -keeping the head of the bed at 15 degrees or less -turning the client every 4 hours to prevent fatigue -using strict hand hygiene -providing oral hygiene daily

A: using strict hand hygiene Rationale: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

When teaching a client about lithium, the nurse should instruct the client to: -drink at least six to eight glasses of water per day and avoid caffeine. -limit the use of salt in the diet. -discontinue the medicine when the client is feeling better. -increase the amount of sodium in the diet.

A: Rationale: Caffeine should be avoided because it increases urine output. Clients need to maintain adequate fluid intake to avoid lithium toxicity. Don't limit or increase salt intake; the kidneys will retain or excrete lithium if salt intake varies. Clients should remain on medication even though they're feeling better.

The nurse is assisting with spirometry testing for a 6-year-old child with asthma. What instruction is most important for the nurse to give the child to obtain an accurate reading? -"You will only need to do this once, so give us your best effort." -"Hold the mouthpiece loosely between your lips while performing the test." -"Breathe out as hard as possible, and then breathe in deeply." -"Blow quickly into the mouthpiece using the pursed-lip method."

A: "Breathe out as hard as possible, and then breathe in deeply." Rationale: Several readings will be taken, during which the child is encouraged to give their best performance each time. The child should form a tight seal around the mouthpiece, breathe out forcefully, and then breathe in deeply. A pursed-lip method is not used for spirometry.

A client is to have radiation therapy after a modified radical mastectomy. What instructions should the nurse teach the client about caring for the skin at the site of the radiation therapy? -Wash the area with water. -Expose the area to dry heat. -Apply an ointment to the area. -Use talcum powder on the area.

A: Wash the area with water. Rationale: A client receiving radiation therapy should avoid lotions, ointments, and anything that may cause irritation to the skin, such as exposure to sunlight, heat, or talcum powder. The area may safely be washed with water if it is done gently and if care is taken not to injure the skin.

A client has been taking a decongestant for allergic rhinitis. Which finding suggests that the decongestant demonstrates maximum therapeutic effective? -oral dryness -increased tearing -reduced sneezing -headache improvement

A: reduced sneezing Rationale: Decongestants relieve congestion and sneezing and reduce labored respiration rate. It is anticipated that decongestants dry the mucous membranes, these are commonly reported side effects. The anticipated therapeutic effect would be demonstrated with a decrease in sneezing.

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the mostappropriate nursing action based on this finding? -Call the physician and inform him of the finding. -Tell the parents this is a normal finding for a neonate who was breech. -Keep the neonate on nothing-by-mouth status and observe for seizures. -Note the finding on the assessment record.

A: Note the finding on the assessment record. Rationale: Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture line and typically clears within a few days after birth. The nurse should note this finding on the assessment record, but no other action is needed. Caput succedaneum isn't found on neonates who were in the breech position.

A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. What should be included in a focused assessment for this complication? Select all that apply. -measurement of urine specific gravity -assessment of bowel sounds -characteristics of the first stool -measurement of gastric output -bilirubin levels

A: -assessment of bowel sounds -characteristics of the first stool -measurement of gastric output Rationale: A postoperative ileus is a functional obstruction of the bowel. Assessment of bowel sounds, the first stool, and the amount of gastric output provide information about the return of gastric function. Measurement of urine specific gravity provides information about fluid and electrolyte status; bilirubin levels provide information about liver function, and neither of these tests need to be included in a focused assessment for ileus.

A toddler is admitted to the emergency department with a suspected seizure disorder. When informing the parents about necessary diagnostic procedures, which statement is most appropriate for the nurse? -"We will prepare your child to have spinal fluid withdrawn and analyzed." -"The best way to diagnose seizures is through a computed tomography (CT) scan." -"It's important to confirm a previous history of seizures for the child." -"The child will need to have skull X-rays performed to verify the seizures."

A: "The best way to diagnose seizures is through a computed tomography (CT) scan." Rationale: CT scans provide the most benefit of the list provided in determining irregular brainwave activity. None of the other options would be used to measure brain wave activity.

A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment, the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? -Elevate the affected extremity. -Contact the nursing supervisor. -Administer oxygen. -Contact the physician.

A: Administer oxygen. Rationale: The client is demonstrating clinical manifestations consistent with a fatty embolus. Administering oxygen is the top priority. Elevating the extremity won't alter the client's condition. Notifying the nursing supervisor may be indicated by facility policy after other immediate actions have been taken. The nurse should contact the physician after administering oxygen.

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client? -Spray the house to eliminate infected insects. -Tell family members to try to stay away from the client. -Ask family members to wash their hands frequently. -Disinfect all clothing and eating utensils.

A: Ask family members to wash their hands frequently. Rationale: The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the single most important preventive action. Insects do not transmit hepatitis A. Family members do not need to stay away from the client with hepatitis. It is not necessary to disinfect food and clothing.

A college foreign exchange student is living with a family in England and is confused about the family's Catholic prayers and rituals. The student longs for her Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress? -spiritual alienation -spiritual guilt -spiritual anger -spiritual loss

A: spiritual alienation Rationale: Spiritual alienation occurs when an individual is separated from one's faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion.

The comatose victim of a car accident is to have a gastric lavage. Which position would be most appropriate for the client during this procedure? -lateral -supine -Trendelenburg's -lithotomy

A: lateral Rationale: An unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration.Positioning the client supine carries a major risk of airway obstruction from the tongue, vomitus, or nasopharyngeal secretions.Trendelenburg's position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema.The lithotomy position has no purpose in this situation.

A client of African descent is brought to the emergency department after sustaining injury in a vehicle accident. The client is bleeding profusely from the wounded leg. In which area would the nurse check for pallor in the client? -tongue -face -hands -abdomen

A: tongue Rationale: In a client of African decent, the nurse should check the tongue for pallor. Face, hands, and abdomen are not appropriate places to check for pallor because these areas may have heavy pigmentation.

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when they say -"I need to keep my inhaler at the bedside." -"I should eat a high-protein diet." -"I should become involved in a weight loss program." -"I should sleep on my side all night long."

A: "I should become involved in a weight loss program." Rationale: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication? -gastrointestinal bleeding -myocardial infarction -emesis -rib fracture

A: rib fracture Rationale: Proper hand placement during chest compressions is essential to reduce the risk of rib fractures, which may lead to pneumothorax and other internal injuries. Gastrointestinal bleeding and myocardial infarction are generally not considered complications of CPR. Although the victim may vomit during CPR, this is not associated with poor hand placement, but rather with distention of the stomach.

A client recently admitted to the hospital with sharp, substernal chest pain suddenly reports palpitations. The client ultimately admits to using cocaine 1 hour before admission. The nurse should immediately assess the client's: -pulse rate and character. -level of consciousness. -neurobehavioral functioning. -anxiety level.

A: pulse rate and character. Rationale: Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is likely to cause tachyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, these deficits are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not anxiety.

The nurse is teaching a group of adolescents about proper nutrition. The nurse should explain that during this phase of development, it is necessary to increase intake of which nutrients? Select all that apply. calcium -vitamin D -iron -protein -grain

A: -calcium -vitamin D -iron -protein Rationale: Increased intake of calcium and vitamin D are necessary for rapid skeletal growth. Iron and protein needs increase as girls begin the menstruation cycle and boys begin to develop lean muscle mass.

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within: -1 hour. -2 hours. -4 hours. -6 hours.

A: Rationale: Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor exhibits the following. Which interventions would the nurse do first? -Place the client on oxygen. -Confirm the rhythm with a 12-lead ECG. -Administer amiodarone I.V. as prescribed. -Assess the client's airway, breathing, and circulation.

A: Assess the client's airway, breathing, and circulation. Rationale: The rhythm the client is experiencing is ventricular tachycardia (VT). Although all of the options listed are appropriate for someone with stable VT, it is not yet known whether the client's VT is stable, unstable, or pulseless. Therefore, the nurse must first assess the airway, breathing, circulation, and level of consciousness to establish the client's stability. Different actions are required if the client's VT is unstable or pulseless.

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for? -surgery -colonoscopy -nasogastric (NG) tube insertion -barium enema

A: surgery Rationale: The client should be prepared for surgery because the signs and symptoms indicate bowel perforation. Appendicitis is a common cause of bowel perforation. Because perforation can lead to peritonitis and sepsis, surgery would not be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures are not necessary at this point.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube? -Change the tube feeding administration set at least every 24 hours. -Maintain the head of the bed at a 15-degree elevation continuously. -Check the gastrostomy tube for position every 2 days. -Maintain the client on bed rest during the feedings.

A: Change the tube feeding administration set at least every 24 hours. Rationale: The nurse should change tube feeding administration sets at least every 24 hours. Doing so prevents contamination and bacterial growth. The head of the bed should be elevated 30 to 45 degrees continuously to prevent aspiration. Checking for gastrostomy tube placement is performed before initiating the feedings and every 4 hours during continuous feedings. Clients may ambulate during feedings.

A nurse is caring for a client following a tonsillectomy and fails to routinely assess the back of the client's throat for signs of bleeding. The nurse manager reviews the client's chart and notices the omission of the assessments. Which is the best response to the nurse regarding the missing assessments? -"I hope you have malpractice insurance to cover your failures." -"Failure to complete these assessments constitutes negligent behavior." -"I assume that the client has refused to let you do the assessments." -"Everyone forgets things once in a while, but please don't do this again."

A: "Failure to complete these assessments constitutes negligent behavior." Rationale: By not checking the back of the throat for bleeding after a tonsillectomy, the nurse is negligent. Negligence is the omission of doing something that a prudent nurse would do following this type of surgery. Malpractice occurs when there is actual harm or injury to the client. The other options do not provide the nurse with an understanding of the seriousness of the behavior.

The nurse is caring for a client who has been diagnosed with pernicious anemia. Which statement by the client indicates an understanding of the treatment of pernicious anemia? -"I'll need to increase my dietary intake of foods that are high in vitamin B12." -"I'll receive my first injection of vitamin B12 tomorrow, and I'll return for a follow-up injection in 1 month." -"I understand that the oral form of vitamin B12 is preferred because it's safer and less expensive than the injection form." -"I'll need to take vitamin B12 replacements for the rest of my life."

A: "I'll need to take vitamin B12 replacements for the rest of my life." Rationale: Clients who have been diagnosed with pernicious anemia are lacking adequate amounts of the intrinsic factor (IF) that is secreted by the gastric mucosa. IF is necessary for the absorption of cobalamin (vitamin B12) in the distal ileum. Without the presence of IF, dietary intake of vitamin B12is useless because it cannot be absorbed. Treatment of pernicious anemia includes IM injections of cobalamin, at first daily for 2 weeks, then weekly until the anemia is corrected. A maintenance schedule of monthly injections is then implemented. The injections will need to be continued for the rest of the client's life.

Which therapeutic modality would be used to treat an individual diagnosed with somatic symptom disorder? -suicide precautions -relaxation exercises -electroconvulsive therapy (ECT) -aversion therapy

A: relaxation exercises Rationale: Relaxation exercises will help decrease anxiety in a client with somatic symptom disorder. In a somatic symptom disorder, no threat of suicide exists. ECT and aversion therapy are not therapeutic strategies for this disorder.

During gentamicin therapy, the nurse should monitor a client's -serum potassium level. -serum glucose level. -partial thromboplastin time (PTT). -serum creatinine level.

A: serum creatinine level. Rationale: During gentamicin therapy, the nurse should monitor a client's serum creatinine level because the most notable adverse reactions to aminoglycoside therapy are nephrotoxicity and ototoxicity. The drug doesn't appear to affect serum potassium or glucose levels or PTT.

A mother brings her 18-month-old child to the clinic because the child eats ashes, crayons, and paper. Which information would be most important to obtain about this toddler? -whether the toddler is currently cutting large teeth -whether the toddler is experiencing a growth spurt -whether the toddler is experiencing changes in the home environment -whether the toddler is eating a soft, low-roughage diet

A: whether the toddler is experiencing changes in the home environment Rationale: It is important to determine if the child is experiencing any change in the home environment that could cause anxiety that is relieved through oral gratification. A craving to eat nonfood substances is known as pica. Nutritional deficiencies, especially iron deficiency, were once thought to cause pica, but research has not substantiated this theory.Pica is unlikely to be caused by the growth spurts, the cutting of large teeth, or soft, low-roughage diets.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? -mild fever -clear speech -tripod position -gradual onset of symptoms

A: tripod position Rationale: The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.

A nurse working in a new orthopedic unit is asked to initiate the practice of an abbreviated form of documentation, which requires less nursing time and readily detects changes in client status. Which documentation method should the nurse suggest? -charting by exception -medication administration records -problem, intervention, and evaluation note -focus data, action, and response note

A: charting by exception Rationale: The nurse should suggest the use of charting by exception, which is an abbreviated form of documentation. The FOCUS system of documentation organizes entries by data, action, and response. This system is broader in its view because a focus can be a problem area, but does not need to be. The problem, intervention, and evaluation note system simplifies documentation by incorporating the plan of care into the progress notes. The medication administration record documents only medication administration.

The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which position? -lithotomy -side-lying -hands and knees -prone

A: side-lying Rationale: Lumbar epidural anesthesia is usually administered with the client in a sitting or a left side-lying position with shoulders parallel and legs slightly flexed. These positions expose the vertebrae to the anesthesiologist. Paracervical and local anesthetics are usually administered with the client in the lithotomy position. The hands and knees or prone positions are not used for anesthesia administration.

In a 3-month-old infant, fluid and electrolyte imbalance can occur quickly, primarily because an infant has: -a lower percentage of body water than an adult. -a lower daily fluid requirement than an adult. -a more rapid respiratory rate than an adult. -immature kidney function.

A: immature kidney function. Rationale: Because of immature kidneys, an infant's glomerular filtration and absorption are inadequate, not reaching adult levels until age 1 to 2 years. An infant actually has a greater percentage of body water as well as higher daily fluid requirements than an adult. Although the infant's respiratory rate is higher, causing insensible water loss, immature kidney function is more responsible for fluid balance in an infant.

Parathyroid hormone (PTH) has which effects on the kidney? -stimulation of calcium reabsorption and phosphate excretion -stimulation of phosphate reabsorption and calcium excretion -increased absorption of vitamin D and excretion of vitamin E -increased absorption of vitamin E and excretion of vitamin D

A: stimulation of calcium reabsorption and phosphate excretion Rationale: PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D. PTH doesn't have a role in the metabolism of vitamin E.

A public health nurse is working in a community immunization clinic. Client information gathered at the clinic is stored and transported to the health unit on a portable memory device. Which action must the nurse take to protect the confidentiality of the information? -Have a backup copy on a portable computer. -Ensure that the information on the memory device is protected. -Make sure the nurse's computer is password protected. -Lock the memory device at all times

A: Ensure that the information on the memory device is protected. Rationale: The only way to ensure the information remains confidential is to encrypt it. The other options do not provide enough security if the device is lost or stolen. Passwords can be bypassed and the device can be stolen even from a locked area.

The nurse has restrained an infant. Which actions by the nurse are indicated? Select all that apply. -Document the reason for use and effectiveness of the restraint. -Inspect the skin for areas of pressure. -Reapply the restraint to cover the hip to 1 inch above the umbilicus. -Loosen the restraint so the infant can move from side to side. -Secure the ties for quick release. -Tie the ends to the side rails of the crib.

A: -Document the reason for use and effectiveness of the restraint. -Inspect the skin for areas of pressure. -Secure the ties for quick release. Rationale: Using restraints requires a primary care provider's prescription; the nurse should document the reason for use and effectiveness of the restraint. The nurse should also inspect the skin for areas of pressure caused by the restraint and remove the restraint periodically to provide skin care and range of motion. The ties should be secured so they can be released quickly if needed; the ties should be fastened to the bed springs, not the rails of the crib or the mattress. The belt restraint is positioned correctly; the restraint will limit the infant's movement yet allow for changing the diaper. The restraint should limit the infant's movement and not enable the infant to move from side to side.

A nurse has been assigned to four clients. Which client should the nurse see first? -A client with systemic lupus erythematosus (SLE) with malar rash on the face -A client with rheumatoid arthritis who is receiving adalimumab for inflammation -A client with Hodgkin's lymphoma complaining of fatigue and night sweats -A client with hemophilia who is receiving acetylsalisylic acid (ASA) for joint pain

A: A client with hemophilia who is receiving acetylsalisylic acid (ASA) for joint pain Rationale: A client with hemophilia should be seen first because ASA will increase bleeding. It should not be given to a client with hemophilia. Malar rash or "butterfly" rash is usually seen in clients with SLE. Adalimumab is a tumor necrosis factor (TNF) inhibiting anti-inflammatory drug given to clients with rheumatoid arthritis. A client with Hodgkin's lymphoma is expected to have fatigue and night sweats.

The nurse in pediatric intensive care is caring for an infant whose respiratory rate is 50 with nasal flaring, grunting and experiencing thick yellow nasal discharge. Vital signs are stable with oxygen saturation of 96% on 0.25 L of oxygen via face mask. Chest physiotherapy has been completed, and the infant is sleeping in the supine position. What should be the nurse's next intervention? -call the health care provider -suction the nares -give ordered medications -change the infant's position

A: suction the nares Rationale: The nurse should assess the client for respiratory compromise and clear the airway. Suctioning the nares to remove the thick mucus would be the first intervention. If the infant continues to show labored breathing, the practitioner should be notified and medications given. Repositioning the infant may help but would not be the first intervention.

A new nurse has transferred to the chemical dependency rehabilitation unit. Which action if performed by the new nurse would warrant the change nurse to intervene? -calling the Narcotics Anonymous group for the client -enforcing unit policies -confronting the client's inappropriate behaviors. -helping the client to express feelings

A: calling the Narcotics Anonymous group for the client Rationale: Calling Narcotics Anonymous to tell them to expect the client is inappropriate and unnecessary because it increases the client's dependency on the nurse. It is the client's responsibility to make arrangements for attending meetings.Enforcing unit policies is an important component in establishing a therapeutic milieu.Confronting inappropriate behaviors such as manipulation and use of defense mechanisms such as projection are part of the nurse's role in drug rehabilitation.Helping the client to express feelings appropriately through the use of assertiveness techniques teaches the client appropriate interpersonal skills.

Which action would be most appropriate for a neonate whose hemoglobin is 16 g/dL (160 g/L) immediately after birth? -Document this as a normal finding. -Assess for symptoms of polycythemia. -Recheck the hemoglobin in 1 hour. -Assess for skin pallor and anemia.

A: Document this as a normal finding. Rationale: Normal neonatal hemoglobin level ranges from 15 to 20 g/dL (150 to 200 g/L) blood. After birth, the hemoglobin level gradually decreases. The nurse should document this as a normal finding.The neonate does not demonstrate symptoms of polycythemia, such as red, ruddy skin color, a hematocrit level greater than 65% (0.65), or a hemoglobin level greater than 20 g/dL (200 g/L).Because the hemoglobin value is within normal parameters, there is no need for the nurse to recheck the hemoglobin in an hour.The hemoglobin level is within normal parameters. If it was decreased, then assessing for skin pallor and anemia would be warranted.

A client newly diagnosed with deep vein thrombosis (DVT) of the left lower left extremity is on bed rest. What should the nurse instruct the unlicensed assistive personnel (UAP) providing routine morning care for the client to do? -Check that the legs are in a low, dependent position. -Ensure that the lower extremity is elevated. -Massage the leg and foot with lotion. -Place one or two pillows under the client's left knee.

A: Ensure that the lower extremity is elevated. Rationale: DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return. Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow under the knee would position the foot in a low position, and pressure behind the knee may obstruct venous flow. Massaging the extremity could dislodge the thrombus.

A client infected with human immunodeficiency virus (HIV) has a low CD4+ level. What intervention should the nurse implement? -Increase nutritional protein with each meal. -Request human granulocyte colony-stimulating factor to improve WBC production. -Place the client in reverse isolation. -Provide antibiotics as per order.

A: Place the client in reverse isolation. Rationale: CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system. The test indicates the individual's risk of an opportunistic infection, but does not identify specific infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests. Because of the client's risk, isolation is recommended.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. What should the nurse do first? -Administer atropine 0.5 mg IV push. -Auscultate for abnormal heart sounds. -Prepare for transcutaneous pacing. -Take the client's blood pressure.

A: Take the client's blood pressure. Rationale: The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

The best method to remove cerumen from a client's ear involves: -inserting a cotton-tipped applicator into the external canal. -irrigating the ear gently. -using aural suction. -using a cerumen curette.

A: irrigating the ear gently. Rationale: Irrigation is the first strategy to loosen cerumen. Successful removal of the cerumen involves gentle irrigation behind the impacted cerumen. The flow of the solution must be behind the impaction to remove the cerumen from the canal. A cotton-tipped applicator or other device is not appropriate because it can cause damage to the eardrum. Use of aural suction or a cerumen curette is appropriate only if the impacted cerumen cannot be removed by irrigation.

A 3-year-old child of Vietnamese descent with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On examination, the nurse discovers red, round, weltlike lesions on the child's upper back and chest. Which question should the nurse ask next? -"Has your child been exposed to shingles?" -"Are you aware of any child abuse?" -"Does your child have any allergies?" -"Can you tell me about any cultural practices in your family?"

A: "Can you tell me about any cultural practices in your family?" Rationale: The nurse should consider that the lesions may be caused by cultural practice. Many Vietnamese people perform coining, a cultural practice in which a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of a disease. Coining can produce weltlike lesions on the child's back or chest, and children subjected to the practice are commonly thought to have been abused. Interviewing the family and assessing its cultural background can help distinguish between abuse and culture practice. Shingles, a form of herpes zoster, is a communicable disease usually affecting immunocompromised individuals and older adults. The disease produces small crusty pustules on the lower back and trunk. The description of the lesions doesn't fit those produced by an allergic reaction.

Parents of a school-age child with asthma express concern about letting the child participate in sports. What will the nurse instruct the parents about the relationship between exercise and asthma? -"Asthma attacks are triggered by allergens that trigger bronchoconstriction, not by exercise." -"Choose sports that do not require a lot of energy expenditure, because your child has chronically low oxygen levels." -"Continuous activities such as jogging are less likely to trigger asthma than intermittent activities such as baseball." -"Taking prophylactic medication before the activity can prevent asthma attacks, making exercise safer."

A: "Taking prophylactic medication before the activity can prevent asthma attacks, making exercise safer." Rationale: Although exercise may trigger asthma attacks, the nurse should tell the parents that taking prophylactic asthma drugs before beginning the activity can prevent attacks, enabling the child to engage in most sports. Children with asthma are not chronically hypoxic and have normal airway function between exacerbations. To say asthma attacks are triggered by allergens but not exercise isn't appropriate, because asthma attacks may be triggered by various factors, including allergens, exercise, medications, upper respiratory tract infections, and psychological stress. Provided the asthma is under control, most children can participate in sports and other physical activities; in fact, they benefit from exercise. Activity restrictions actually hamper peer interaction, which is essential to the development of the school-age child. A child with asthma may tolerate intermittent activities better than continuous ones.

A nurse has received report on her clients and notices that they're of varying ages. To prepare for the shift, the nurse reviews Erik Erikson's five stages of psychosocial development. Place the stages in chronological order from infancy to adolescence. Use all options. 1 Trust versus mistrust 2 Autonomy versus shame and doubt 3 Initiative versus guilt 4 Industry versus inferiority 5 Identity versus role confusion

A: -Trust versus mistrust -Autonomy versus shame and doubt -Initiative versus guilt -Industry versus inferiority -Identity versus role confusion Rationale: During the first stage of Erikson's five stages of psychosocial development, trust versus mistrust (birth to age 1), the child develops trust as the primary caregiver meets his needs. In the second stage, autonomy versus shame and doubt (ages 1 to 3), the child gains control of body functions and becomes increasingly independent. In the third stage, initiative versus guilt (ages 3 to 6), the child develops a conscience and learns about the world through play. In the fourth stage, industry versus inferiority (ages 6 to 12), the child enjoys working on projects with others, follows rules, and forms social relationships. As body changes begin to take place, the child enters the fifth stage, identity versus role confusion (ages 12 to 19), and becomes preoccupied with looks, how others view him, meeting peer expectation, and establishing his own identity.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. What should the nurse do first? -Lower the head of the bed. -Notify the health care provider (HCP). -Assist the client to take several deep breaths and cough. -Administer oxygen by nasal cannula as prescribed at 2L per minute.

A: Assist the client to take several deep breaths and cough. Rationale: Deep breathing and coughing help to increase lung expansion and prevent the accumulation of secretions in postoperative clients. An O2 saturation of 89% is not an unexpected or emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period. It is not necessary to notify the HCP prior to intervening with coughing/deep breathing, and it is not appropriate to position this client with the head of bed lower because this would make it more difficult for the client to expectorate secretions. Oxygen may be necessary, but the nurse should assist the client to cough and deep breath first, in an attempt to improve his oxygenation and saturation.

The nurse is unable to find the health record (chart) for a client who has arrived for a clinic visit. Which is the best action by the nurse? -Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. -Advise the client that the appointment will have to be rescheduled due to the fact that the medical record cannot be located. -Call one of the client's other healthcare providers to request that a copy of the medical records for the client be sent to the clinic. -Document the information about the visit on paper, and transcribe these notes into the client's medical record once it is located.

A: Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. Rationale: Documentation is an essential and legal component of providing care to clients. Information must be documented as it is collected. The nurse should not send the client away without the client getting the care that was to be provided. Therefore, the nurse creates a new record that contains all the client's appropriate identifiers so this can be added to the client's primary medical record when it is located. The nurse should be truthful about the missing records and should avoid transcribing notes whenever possible to avoid data errors. Another healthcare provider's records are not a substitute for the health record specific to this clinic. Requesting records from another provider would only be appropriate if relevant to the client's current reason for the visit and if the client consented to the transfer of this information.

While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which response by the nurse would be most appropriate? -Ignore the client's question and continue with morning care. -Tell the client "I'm not sure how the other woman is doing today." -Tell the client "I need to ask the woman's permission before discussing her well-being." -Explain to the client that "nurses are not allowed to discuss other clients on the unit."

A: Explain to the client that "nurses are not allowed to discuss other clients on the unit." Rationale: Legal regulations and ethical decision making require that the nurse maintain confidentiality at all times. The nurse's best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client's question is inappropriate because doing so would interfere with the development of a trusting nurse-client relationship. Confidentiality must be maintained at all times. Telling the client that the nurse is not sure may imply that the nurse will find out and then tell the client about the other woman. Asking the other woman's permission to discuss her with another client is inappropriate because confidentiality must be maintained at all times.

A nurse working on a medical unit is caring for a client with anemia. The nurse has a part-time business selling vitamin supplements. The nurse approaches the client, offering to sell the supplements to help "improve your blood." A second nurse overhears the conversation. How should the second nurse address this situation? -Tell the client that the client should not purchase anything from the nurse. -Inform the nurse that selling supplements to clients is a conflict of interest. -Interview the nurse's other clients to see if the nurse attempted to sell supplements to them. -Report the nurse to the nurse manager and the nursing regulatory body.

A: Inform the nurse that selling supplements to clients is a conflict of interest. Rationale: The first nurse is offering advice outside the scope of practice for an RN and could be accused of diagnosing and prescribing. The nurse is also working outside the therapeutic relationship. The client may feel pressured to purchase the supplements to get nursing care or further assistance from the nurse, which puts the nurse in a position of power over the client. It is not appropriate to tell the client to not purchase supplements from the nurse. It is also not appropriate to interview the nurse's other clients. Finally, as a professional, the second nurse should address the behavior with the colleague first and provide a teaching opportunity. If the first nurse does not agree to stop, or is found engaging in the behavior again, then reporting to the manager and regulatory body is appropriate.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first? -Firmly tell the father he must leave. -Notify the nursing coordinator on duty. -Notify the nurse-manager. -Notify hospital security or the local authorities.

A: Notify hospital security or the local authorities. Rationale: The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? -Tell the client that smoking is prohibited in the facility, and that if she smokes again, she'll be discharged. -Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. -Notify the physician and security immediately. -Ask the nursing assistant to dispose of the marijuana so that the client can't smoke anymore.

A: Notify the physician and security immediately. Rationale: The nurse should immediately notify the physician and security. The physician must be informed because illegal drugs can interfere with the labor process and affect the neonate after delivery. Moreover, the client might have consumed other illegal drugs. The nurse should also inform security because they're specially trained to handle such situations. Most hospitals prohibit smoking. The nurse needs to alert others about the client's illegal drug use, not simply explain to the client that smoking is prohibited. Smoking is dangerous around oxygen, and it's fine for the nurse to explain the hazard to the client; however, the nurse must first notify the physician and security. The nursing assistant shouldn't be asked to dispose of the marijuana.

The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, the nurse should perform which action next? -Tell the client to push between contractions. -Provide gentle support to the fetal head. -Apply gentle upward traction on the neonate's anterior shoulder. -Massage the perineum to stretch the perineal tissues.

A: Provide gentle support to the fetal head. Rationale: During a precipitous birth, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent too rapid of emergence leading to injury. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe birth of the infant over protecting the perineum by massage.

A 14-month-old child has a severe diaper rash. Which recommendation should the nurse provide to the parents? -Continue to use the baby wipes. -Change the diaper every 4 to 6 hours. -Wash the buttocks using mild soap. -Apply powder to the diaper area.

A: Wash the buttocks using mild s Rationale: Because the toddler has a severe diaper rash, it may be best to change all that the parents are doing. The buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is helpful to leave the diaper off and expose the buttocks to the air. Baby wipes commonly contain additives and perfumes that may be irritating to the baby's sensitive skin. The diaper needs to be changed more often than every 4 to 6 hours. Otherwise, the moist diaper environment will continue to irritate the skin, causing the rash to worsen. Powder has limited absorbing ability and will most likely irritate the area more. In addition, some powders contain perfumes or are scented and can irritate the skin.

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining this client? -reviewing facility policy regarding how long the client may be restrained -preparing an as-needed dose of the client's psychotropic medication -checking that the restraints have been applied correctly -asking if the client needs to use the bathroom or is thirsty

A: checking that the restraints have been applied correctly Rationale: A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding has been used. The nurse should document the client's response and status carefully after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. If an as-needed medication is ordered, it should be administered before the restraints are in place and with the assistance of other team members. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained.

The nurse is teaching the client to self-administer insulin. Which approach to establishing learning goals will likely be most effective? When the goals are established by the: -nurse and client because both need to be responsible for teaching. -health care provider and client because the health care provider is the manager of care and the client is the main participant. -client because the client is best able to identify his or her own needs and how to meet those needs. -client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team.

A: client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team. Rationale: Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse, pharmacist, and health care provider.Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse, pharmacist, and health care provider help the client arrive at his or her own perception of the need or reason to learn.

The client states to the nurse, "I take citalopram 40 mg every day as my health care provider prescribed. I have also been taking St. John's wort 750 mg daily for the past 2 weeks." Which findings would indicate that the client is developing serotonin syndrome? Select all that apply. -confusion -restlessness -constipation -diaphoresis -ataxia

A: confusion restlessness diaphoresis ataxia Rationale: Serotonin syndrome can occur if a selective serotonin reuptake inhibitor is combined with a monoamine oxidase inhibitor, a tryptophan-serotonin precursor, or St. John's wort. Signs and symptoms of serotonin syndrome include mental status changes (such as confusion, restlessness, or agitation) headache, diaphoresis, ataxia, myoclonus, shivering, tremor, diarrhea, nausea, abdominal cramps, and hyperreflexia. Constipation is not associated with serotonin syndrome.

A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which sign? -tachycardia -hypertension -elevated blood urea nitrogen concentration -hyperglycemia

A: hyperglycemia Rationale: During TPN administration, the client should be monitored regularly for hyperglycemia. The client may require small amounts of insulin to improve glucose metabolism. The client should also be observed for signs and symptoms of hypoglycemia, which may occur if the body overproduces insulin in response to a high glucose intake or if too much insulin is administered to help improve glucose metabolism. Tachycardia or hypertension is not indicative of the client's ability to metabolize the solution. An elevated blood urea nitrogen concentration is indicative of renal status and fluid balance.

Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase? -impaired physical mobility related to paralysis -ineffective breathing pattern related to neuromuscular impairment -impaired swallowing related to neuromuscular impairment -fluid volume deficits related to total urinary incontinence

A: ineffective breathing pattern related to neuromuscular impairment Rationale: An ineffective breathing pattern caused by the ascending paralysis of the disorder interferes with the child's ability to maintain an adequate oxygen supply. Therefore, this nursing diagnosis takes precedence. Additionally, as the neurologic impairment progresses, it will probably have an effect on the child's ability to maintain respirations. Although impaired swallowing, impaired physical mobility, and incontinence may occur with the ascending paralysis of this disorder, oxygenation is the priority.

A nurse is caring for a client with bipolar disorder. The care plan for a client in a manic state would include: -offering high-calorie meals and strongly encouraging the client to finish all food. -insisting that the client remain active through the day to be more likely to sleep at night. -allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits. -listening attentively to the client's requests with a neutral attitude, and avoiding power struggles.

A: listening attentively to the client's requests with a neutral attitude, and avoiding power struggles. Rationale: The nurse should listen to the client's requests, express willingness to seriously consider each request. The nurse should encourage the client to take short daytime naps because of so much energy expended. High-calorie finger foods should be offered to supplement the diet if the client can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice.

A nursing coordinator calls the intensive care unit (ICU) to inform the department that a client with a suspected pheochromocytoma will be admitted from the emergency department. The ICU nurse should prepare to administer which drug to the client? -nitroprusside -dopamine -insulin -lidocaine

A: nitroprusside Rationale: Excess catecholamine release occurs with pheochromocytoma and causes hypertension. The nurse should prepare to administer nitroprusside to control the hypertension until the client undergoes adrenalectomy to remove the tumor. Dopamine is used to treat hypotension, which is not associated with pheochromocytoma. Pheochromocytoma does not affect blood glucose levels, so insulin is not indicated in this client unless there is an underlying diagnosis of diabetes mellitus. Lidocaine is sometimes used to treat ventricular arrhythmias, which are not associated with pheochromocytoma.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing -raccoon's eyes and Battle's sign. -nuchal rigidity and Kernig's sign. -motor loss in the legs that exceeds that in the arms. -pupillary changes.

A: raccoon's eyes and Battle's sign. Rationale: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

A client comes to the emergency department with severe back pain. The client reports taking several pain pills at home but cannot remember how many and provides the nurse with an empty bottle of acetaminophen with codeine. Which laboratory value should the nurse address? -serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 -blood urea nitrogen (BUN) of 22 mg/dL and serum creatinine of 1.35 mg/dL -creatine phosphokinase (CPK) of 21 U/L -sodium (Na+) of 145 mEq/L and potassium (K+) of 5.5 mEq/L

A: serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 Rationale: Hepatic necrosis is the most serious toxic effect of an acute overdose of acetaminophen. The nurse should monitor the liver enzymes and INR level. Renal failure is not a consideration since the lab values are within normal limits. Total CPK would not need to be monitored; if the level is high, it usually means there has been injury or stress to muscle tissue, the heart, or the brain. The CPK level is within normal limits. Both the Na+ and K+ levels are also within normal limits.

An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Which anticipatory guidance for the parents and adolescent is most important? -the adolescent's sterility -the adolescent's future plans -technique for monthly testicular self-examinations -need for a lot of psychological support

A: technique for monthly testicular self-examinations Rationale: Because the incidence of testicular cancer is increased in adulthood among children who have had undescended testes, it is extremely important to teach the adolescent how to perform the testicular self-examination monthly. The undescended testicle is removed to reduce the risk of cancer in that testicle. Removal of a testis would not necessarily make the adolescent sterile because the other testicle remains. Although discussing the adolescent's future plans is important, it is not the priority at this time. Because the adolescent has been dealing with the situation for a long time, the need for a sports physical at this time should not be a cause of emotional distress requiring a lot of psychological support.

The nurse is assigned a client with end-stage ovarian cancer with recurrent ascites, and the client is to undergo paracentesis. Which activity is best to delegate to an experienced licensed practical nurse (LPN/VN)? -completing the client admission -vital signs every 15 minutes after the paracentesis -providing discharge instructions after the paracentesis -obtaining a paracentesis tray from central supply

A: vital signs every 15 minutes after the paracentesis Rationale: To delegate nursing care effectively, a nurse must know the client's condition, the competence and scope of practice of all nursing team members, and the level of supervision needed for the delegated nursing care task. The nurse must also consider the training, cultural competence, and experience of the delegate. Delegating nursing care requires critical thinking and professional judgment to ensure that the delegated nursing care task is the right task for the right person, the task is delegated under the right circumstances, the delegate receives the right directions and communication, and the performance of the task is properly supervised and evaluated. An experienced LPN/LVN would monitor and report vital signs to the RN. The paracentesis tray can be obtained by the unit clerk or unlicensed assistive personnel (UAP). The admission assessment and teaching require the RN's expertise and education.

In an outpatient addiction group, a recovering client said that before her treatment, her husband drank on social occasions. "Now he drinks at home, from the time he comes home from work and drinks until he goes to bed. He says that he doesn't like me anymore and that I expect him to do more work on the house and yard. I used to ignore that stuff. I don't know what to do." In which order of priority from first to last would the nurse make the comments? All options must be used. 1 "I hear how confused and frustrated you are." 2 "It can happen that as one person sobers up, the spouse deteriorates." 3 "What have you tried to do about your husband's behaviors?" 4 "What do you think you could do to have your husband come in for an evaluation?"

A: -"I hear how confused and frustrated you are." -"It can happen that as one person sobers up, the spouse deteriorates." -"What have you tried to do about your husband's behaviors?" -"What do you think you could do to have your husband come in for an evaluation?" Rationale: The client's feelings and concerns need to be validated so she will open up more. She also should know that the changes in her husband are not unusual. It helps to know the client has tried with her husband to determine if they are appropriate or not. Then there can be a discussion about getting help for her husband so that her efforts to stay sober are not compromised.

On an oncology unit, the nurse hears noises coming from a client's room. The client is found throwing objects at the walls and has just picked up the phone and is screaming, "How can God do this to me? It's the third type of cancer I've had. I've gone through all the treatment for nothing." In what order of priority from first to last should the nurse make the interventions? All options must be used. 1 "Please put the telephone down so we can talk." 2 "I can hear how upset you are about the cancer." 3 "Tell me what you are feeling right now." 4 "I wonder if you would like to talk to a member of the hospital clergy."

A: -"Please put the telephone down so we can talk." -"I can hear how upset you are about the cancer." -"Tell me what you are feeling right now." -"I wonder if you would like to talk to a member of the hospital clergy." Rationale: The first priority is a safe environment so the client and nurse are not hurt by the phone. Then, it is important to acknowledge the client's anger to help diffuse it. As the client calms down, the nurse can explore the client's feeling in more depth. Since the client implies anger at God, a clergy consult may be appropriate.

The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement interventions to ensure the client's safety? All options must be used. 1 Assess the client's respiratory status including oxygen saturation. 2 Ensure the client does not need toileting or pain medications. 3 Review the client's medications for interactions that may cause or increase confusion. 4 Contact the health care provider (HCP), and request a prescription for soft wrist restraints.

A: -Assess the client's respiratory status including oxygen saturation. -Ensure the client does not need toileting or pain medications. -Review the client's medications for interactions that may cause or increase confusion. -Contact the health care provider (HCP), and request a prescription for soft wrist restraints. Rationale: The nurse should first assess the client's respiratory status to determine if there is a physiological reason for the client's confusion. Other physiological factors to assess include pain and elimination. Safety needs including medication interactions should then be evaluated. Requesting restraints in order to maintain client safety should be used as a last resort.

Which action(s) should the nurse take prior to administering an oral medication to an infant? Select all that apply. -Ensure that it is the correct medication. -Verify that it is the correct dose. -Have the mother hold the infant. -Check the infant's pulse. -Verify the infant's name.

A: -Ensure that it is the correct medication. -Verify that it is the correct dose. -Verify the infant's name. Rationale: The nurse should first ensure that the medication is the correct medication, is the correct dose, the correct route, and the correct client. The infant's pulse would only need to be checked if the medication being administered impacted the pulse. After these steps, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45° angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps him from spitting out the drug and reduces the risk of aspiration. After administering the medication, the nurse should document that the medication was given.

A multiparous client at 33 weeks gestation is admitted to the labor and birth area with painless vaginal bleeding. Ultrasonography shows marginal placenta previa. Which nursing interventions should be included in the plan of care for this client? Select all that apply. -Institute bed rest. -Assess the cervix hourly. -Establish intravenous (IV) access. -Apply continuous fetal heart monitoring. -Administer oxygen as ordered.

A: -Institute bed rest. -Establish intravenous (IV) access. -Apply continuous fetal heart monitoring. -Administer oxygen as ordered. Rationale: A client with placenta previa, even marginal, is at an increased risk for inadequate tissue perfusion for the fetus. Interventions will be focused on maintaining adequate tissue perfusion. Bed rest reduces oxygen demands. Vaginal exams should be avoided to prevent further bleeding episodes. Establishing IV access allows for administration of fluids as necessary. The fetal heart rate should be continuously monitored to evaluate fetal status. Oxygen should be administered as ordered to increase oxygenation to mother and fetus.

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply. -Maintain integrity and shape social policy. -Develop, maintain, and improve health care environments. -Ask the hospital for fair compensation for work. -Be responsible and accountable for individual practice. -Increase professional competence and personal growth.

A: -Maintain integrity and shape social policy. -Develop, maintain, and improve health care environments. -Be responsible and accountable for individual practice. -Increase professional competence and personal growth. Rationale: The Code of Ethics describes those actions by the nurse that guide their practice. It is the responsibility of each nurse to be active in determining policy for health care for all citizens and assuring that the way nursing is practiced is of the highest caliber. Nursing needs to participate in the development of health care of the future, while caring for all members of society. In order to be productive in shaping policy, nurses need to be politically astute while growing personally and professionally to meet the needs of clients. The Code of Ethics does not address compensation for work.

The nurse is caring for a child with acute glomerulonephritis and is meeting with the family to discuss discharge instructions. Which of the following are important teaching points for the nurse to review with the child's family? Select all that apply. -Restrict the intake of sodium. -Increase protein in the diet. -Monitor fluid intake and output. -Report any signs of infection. -Administer potassium supplements.

A: -Restrict the intake of sodium. -Monitor fluid intake and output. -Report any signs of infection. Rationale: Sodium should be restricted to help control hypertension and symptoms of fluid excess. Monitoring fluid intake and output is an important step in assessing fluid balance and renal function. Any signs of infection should be reported immediately as they may indicate a worsening of the child's condition. High protein intake may promote renal damage by chronically increasing glomerular pressure (glomerular filtration rates). Protein restriction is appropriate for treatment of existing kidney disease. Potassium should also be restricted.

A client with chronic renal failure was recently told by the healthcare provider of being a poor candidate for a transplant because of chronic uncontrolled hypertension and diabetes mellitus. Now the client tells the nurse, "I want to go off dialysis. I'd rather not live than be on this treatment for the rest of my life." Which responses are appropriate? Select all that apply. -Take a seat next to the client and sit quietly to reflect on what was said. -Say to the client, "We all have days when we don't feel like going on." -Leave the room to allow the client privacy to collect thoughts. -Say to the client, "You're feeling upset about the news you got about the transplant." -Say to the client, "The treatments are now 3 days a week. Would you be willing to do two days per week?"

A: -Take a seat next to the client and sit quietly to reflect on what was said. -Say to the client, "You're feeling upset about the news you got about the transplant." Rationale: Silence is a therapeutic communication technique that allows the nurse and client to reflect on what has taken place or been said. By waiting quietly and attentively, the nurse encourages the client to initiate and maintain a conversation. By reflecting on the client's implied feelings, the nurse promotes communication. Using such platitudes as "We all have days when we don't feel like going on" fails to address the client's needs. The nurse would not leave the client alone abruptly stopping therapeutic communication. Negotiating treatment frequency is not in the scope of practice of the nurse.

The nurse is caring for a client with a diagnosis of cerebrovascular accident (CVA) with left-sided hemiparesis. What would be important nursing measures in the acute phase of care? Select all that apply. -Perform passive range of motion on both sides. -Perform active range of motion on both sides. -Turn and position every 2 hours. -Perform passive range of motion on the affected side. -Support the affected side with pillows.

A: -Turn and position every 2 hours. -Perform passive range of motion on the affected side. -Support the affected side with pillows. Rationale: A client with hemiparesis to the left side would need assistance to turn and position to prevent skin breakdown. Passive range of motion would be performed to the affected side, and active range of motion would be encouraged to the unaffected side. Support with pillows will help to prevent breakdown and contractures. Neither passive nor active range of motion would be necessary to both sides as the client has use of the unaffected side.

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. -Keep the client flat for at least 2 hours. -Provide sips of water to moisten the client's mouth. -Withhold food and fluids until the client's gag reflex returns. -Assess for hemoptysis and frank bleeding. -Alert the client to resume food and fluids when the client's voice returns. Monitor the client's vital signs.

A: -Withhold food and fluids until the client's gag reflex returns. -Assess for hemoptysis and frank bleeding. -Monitor the client's vital signs. Rationale: To prevent aspiration, the client should not receive food or fluids until the gag reflex returns. Although a small amount of blood in the sputum is expected if a biopsy was performed, frank bleeding indicates hemorrhage and should be reported to the physician immediately. Vital signs should be monitored after the procedure, because a vasovagal response may cause bradycardia, laryngospasm can affect respirations, and fever may develop within 24 hours of the procedure. To reduce the risk of aspiration, the client should be placed in a semi-Fowler's or side-lying position after the procedure until the gag reflex returns. The client does not lose the voice after a bronchoscopy, so voice should not be used as a gauge for resuming food and fluid intake.

A 5-month-old infant is brought to the emergency department with vomiting and diarrhea, which the parent states started 3 days ago. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply. -decreased or absent tearing -dry mucous membranes -sunken fontanel -clear, pale yellow urine -bounding pulse

A: -decreased or absent tearing -dry mucous membranes -sunken fontanel Rationale: Clinical manifestations of dehydration include decreased tearing; dry mucous membranes; sunken fontanels; weight loss; behavioral changes; scanty, concentrated urine; and a thready, fast pulse. Clear, pale yellow urine would indicate adequate hydration. A bounding pulse would indicate fluid volume excess.

A nurse is working in a rural health clinic that serves a large Amish population. The nurse is developing a program to address common health promotion strategies. Which aspect would be most important for the nurse to integrate into the program to promote its success? Select all that apply. -importance of the extended family in providing support -focus on being in tune with nature for health maintenance -limited involvement of community members for assistance -need to ask for permission before physically touching a client -role of females in being the primary decision makers for the family

A: -importance of the extended family in providing support -focus on being in tune with nature for health maintenance -need to ask for permission before physically touching a client Rationale: In the Amish culture, the extended family and community play important roles in supporting the client. They have a strong extended family social structure, and caring for the community is a strong value. Family structure is patriarchal, with the husband often the family spokesperson and decision maker. The Amish believe in the importance of nature to maintain health and often use natural remedies as a major part of care. Because touch is discouraged, permission is needed before touching a client.

A client is admitted to the hospital with an exacerbation of multiple sclerosis after an MRI revealed progressive demyelination. The nurse should assess for which symptom? Select all that apply. -progressive weakness of the extremities -loss of cognition -increased appetite -inability to ambulate independently -urinary incontinence

A: -loss of cognition -progressive weakness of the extremities -inability to ambulate independently -urinary incontinence Rationale: Multiple sclerosis is a chronic, progressive disease that results in the destruction of the myelin sheath. This eventually affects the proper transmission of nerve impulses and results in weakness of the extremities with exacerbations and remissions where the client may be wheelchair dependent. In later stages, urinary incontinence is present due to the lack of tone to the bladder. Increased appetite and loss of cognition are not symptoms of multiple sclerosis. The appetite may decrease due to weakness of muscles that involve chewing. Cognition is not affected. The client continues to be alert and oriented despite the other widespread neurological impairments.

The nurse's assignment consists of four clients. From highest to lowest priority, in which order should the nurse assess the clients after receiving morning report? All options must be used. 1 the client with cirrhosis who became confused and disoriented during the night 2 the client with acute pancreatitis who is requesting pain medication 3 the client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted 4 the client with hepatitis B who has questions about discharge instructions

A: -the client with cirrhosis who became confused and disoriented during the night -the client with acute pancreatitis who is requesting pain medication -the client who is 1 day postoperative following a cholecystectomy and has a t-tube inserted -the client with hepatitis B who has questions about discharge instructions Rationale: The nurse should first assess the client with cirrhosis to ensure the client's safety and assess the client for the onset of hepatic encephalopathy. The nurse should then assess the client with acute pancreatitis who is requesting pain medication and administer the needed medication. The nurse should next assess the client who underwent a cholecystectomy and is 1 day postoperative to make sure that the t-tube is draining and that the client is performing postoperative breathing exercises. This client's safety is not at risk, and the client is not reporting having pain. The nurse can speak last with the client with hepatitis B who has questions about discharge instructions because this client's issues are not urgent.

An infant goes into cardiac arrest. While conducting resuscitation, the team notes critical supplies are missing because the cart was not restocked properly by the nurses after an earlier arrest. The baby sustains brain damage as a result of delays in obtaining needed supplies. How does the nurse manager address this situation? -Hold the nurses responsible because hospital procedure was not followed. -Report that the pharmacy did not restock the medications missing from the cart. -Report the situation to the director of nursing so practice can be changed. -Reassure the nurses that they will not be held liable for the negative outcome.

A: Rationale: Agency and hospital policies and procedures establish standards of care. If a nurse deviates from the standard, liability could result if an injury is sustained. In this case, the baby sustained brain damage because the nurses failed to follow the procedure for restocking the crash cart immediately after a code. The nurse needs to report to the pharmacy that the medications need to be restocked. The pharmacist cannot be blamed or held liable if they were not notified. The manager should not tell the nurses they will not be held liable. There is not evidence that current practice needs to be changed, just followed consistently.

Twenty-four hours after a client has given birth, the nurse documents that involution is progressing normally after palpating the client's fundus at which location? -slightly below the level of the umbilicus -midway between the umbilicus and the symphysis pubis -barely above the upper margin of the symphysis pubis -slightly above the level of the umbilicus

A: Rationale: Approximately 24 hours after childbirth, the height of the uterus is normally felt slightly below the umbilicus. Unless complications occur, this client can expect the fundus to descend at a rate of about 1 fingerbreadth per day.Immediately after childbirth, the top of the fundus normally is midway between the umbilicus and the symphysis pubis.The fundus is barely palpable above the upper margin of the symphysis pubis 7 to 10 days after childbirth.Palpation of the uterus above the umbilicus may indicate urinary retention or retained placental fragments.

During a prenatal visit, the client has told the nurse that she intends to give birth at a spiritual retreat center that is distant from population centers or healthcare facilities. What is the nurse's best response? -"It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?" -"That sounds fascinating, but have you given thought to what would happen if you had complications during or after delivery?" -"More and more women are choosing birth plans that do not involve being at a hospital." -"That is very exciting. Has your care provider given permission for you to pursue that?"

A: Rationale: Asking about what the woman hopes to gain or experience is an empathic and therapeutic way of initiating dialogue about this client's decision. Offering a warning will likely sever any follow-up discussion. Ultimately, clients do not need permission to enact a care plan. Acknowledging that nonhospital births are increasingly common is appropriate, but it is helpful to follow a statement with a question.

A client has recently experienced an embolic stroke, and is now stable. The client has been started on dabigitran. What information should the nurse provide to this client? -Dabigitran is the standard of care for preventing recurrent ischemic stroke. -Dabigitran is more effective than antiplatelet therapy in the presence of a thrombus. -Dabigitran is inexpensive and readily available, with few side effects. -Dabigitran helps prevent blood clots from forming in the presence of atrial fibrillation.

A: Rationale: Atrial fibrillation is the most common cause of embolic stroke. It is a newer anticoagulant medication approved for secondary stroke prevention in clients with atrial fibrillation of non heart valve origin. It helps prevent blood clots. Although anticoagulation is the standard of care for a client with stroke due to atrial fibrillation, antiplatelet medication remains the standard of care for non-cardiac thromboembolic stroke. Because of the increased risk of life-threatening bleeding, careful consideration is needed when ordering dabigatran.

A nurse is assessing a client with bipolar disorder. The client tells the nurse that the family health care provider prescribed lithium. Which symptom would indicate that the client is developing lithium toxicity? -lethargy -hypertension -hyperexcitability -low urine output

A: Rationale: Nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, hypotension, muscle weakness, and fine hand tremors are signs of lithium toxicity.

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? -"Do you have a history of GERD (gastroesophageal reflux disease)?" -"Have you ever had pain like this before?" -"What were you doing when the pain started?" -"Do you take any medications on a regular basis?"

A: Rationale: Subjective data (data from the client) about the chest pain helps the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking about the history and medications will yield helpful information, but would not be the most helpful.

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client? -Educate the client about the need to adhere to antibiotic therapy. -Educate the client about the accompanying risk of cervical cancer. -Assess the client's knowledge of hormonal contraceptives. -Assess the client for signs and symptoms of systemic infection.

A: Rationale: This client's external lesions should be treated, and she should receive education regarding the relationship between HPV and cervical cancer. Antibiotics would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

A client has cerumen build-up in the ear. What should the nurse instruct the client to do? Select all that apply. -Wash the external ear with a washcloth. -Instill cerumenolytic drops in the ear canal. -Use cotton tip applicators to remove the wax from the ear canal. -Use small forceps to remove the wax from the ear canal. -Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution.

A: -Wash the external ear with a washcloth. -Instill cerumenolytic drops in the ear canal. -Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution. Rationale: The nurse can advise the client with cerumen that is impacted in the ear to use a washcloth to clean the exterior part of the ear. The client can also instill cerumenocyltic drops to soften the ear wax. The client can then irrigate the ear canal with sterile water using a small bulb syringe. The client should not use cotton tipped applicators as they often push the cerumen further into the ear canal. The client should never put forceps in the ear.

The nurse is completing the preoperative checklist for a client going to surgery. Which client statement would be of the most concern to the nurse and require that the surgeon be notified immediately? -"I am allergic to penicillin." -"I had a few sips of water with dabagatran this morning." -"I have an advance directive in my chart." -"I have an implanted pacemaker."

A: "I had a few sips of water with dabagatran this morning." Rationale: Dabagatran must not be taken prior to surgery or serious risk of bleeding can result. It is important to note allergies and pacemaker on the preoperative checklist; an advanced directive should also be noted. However, they do not warrant a call to the surgeon.

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching? -"I'm going to visit my pastor weekly for a while." -"I will have to take vitamin B12 shots up to 1 year after surgery." -"I will call my physician if I begin to have abdominal pain." -"I will weight myself each day and record the weight."

A: "I will have to take vitamin B12 shots up to 1 year after surgery." Rationale: After a total gastrectomy, a client will need to take vitamin B12 shots for life. Dietary B12 is absorbed in the stomach, and the inability to absorb it could lead to pernicious anemia. Visiting clergy for emotional support is normal after receiving a cancer diagnosis. This action should be encouraged by the nurse. It's appropriate for the client to call the physician if the client experiences signs and symptoms of intestinal blockage or obstruction, such as abdominal pain. Because a client with a total gastrectomy will receive enteral feedings or parenteral feedings, they should weigh himself each day and keep a record of the weights.

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? -"I'll have to wear an external collection pouch for the rest of my life." -"I should eat foods from all the food groups." -"I'll need to drink at least eight glasses of water a day." -"I'll have to catheterize my pouch every 2 hours."

A: "I'll have to wear an external collection pouch for the rest of my life." Rationale: Additional teaching is required if the client states that an external collection pouch must be worn for the rest of the client's life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection. Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily.

The client exhibits a flat affect, psychomotor deficits, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate? -"I'll sit here with you for 15 minutes." -"I'll come back a little bit later to talk." -"I'll find someone else for you to talk with." -"I'll get you something to read."

A: "I'll sit here with you for 15 minutes." Rationale: The most appropriate action is for the nurse to remain with the client even if the client does not engage in conversation with the nurse. A client with severe depression may be unable to engage in an interaction with the nurse because the client feels worthless and lacks the necessary energy to do so. However, the nurse's presence conveys acceptance and caring, thus helping to increase the client's self-worth. Telling the client that the nurse will come back later, stating that the nurse will find someone else for the client to talk with, or telling the client that the nurse will get her something to read conveys to the client that she is not important, reinforcing the client's negative view of herself. Additionally, such statements interfere with the client's development of a sense of security and trust in the nurse.

The nurse is teaching a client about glaucoma treatments. What statement by a client demonstrates an understanding of the need for medication adherence? -"I will experience diplopia if I don't take my medication as ordered." -"If I don't take my medication as ordered, I will experience permanent vision loss." -"It is important to take my medication as ordered to prevent anticholinergic effects." -"I will experience pupillary constriction if I don't take my medication as ordered."

A: "If I don't take my medication as ordered, I will experience permanent vision loss." Rationale: Without treatment, glaucoma may progress to irreversible blindness. Treatment won't restore visual damage but will halt disease progression. Blurred or foggy vision, not diplopia, is typical in glaucoma. Miotics, which constrict the pupil, are used to treat glaucoma and to permit outflow of the aqueous humor. Clients with glaucoma should avoid medications with anticholinergic effects, but taking glaucoma medications cannot prevent these effects.

A client who is recovering from a subtotal gastrectomy experiences dumping syndrome and is to eat six small meals a day. The client asks the nurse, "When will I be able to eat three meals a day again like I used to?" Which response by the nurse is most appropriate? -"Eating six meals a day is time-consuming, isn't it?" -"You will have to eat six small meals a day for the rest of your life." -"You will be able to tolerate three meals a day before you are discharged." -"Most clients can resume their normal meal patterns in about 6 to 12 months."

A: "Most clients can resume their normal meal patterns in about 6 to 12 months." Rationale: The symptoms related to dumping syndrome that occur after a gastrectomy usually disappear by 6 to 12 months after surgery. Most clients can begin to resume normal meal patterns after signs of the dumping syndrome have stopped. Acknowledging that eating six meals a day is time-consuming does not address the client's question and makes an assumption about the client's concerns. It is not necessarily true that a six-meal-a-day dietary pattern will be required for the rest of the client's life. Clients will not be able to eat three meals a day before hospital discharge.

The parents of an adolescent client newly diagnosed with anorexia nervosa are meeting with the nurse during the admission process. Which remarks should the nurse interpret as typical for parents of a client with anorexia nervosa? -"We've given her everything, and look how she repays us!" -"She's had behavior problems for the past year both at home and at school." -"She's been a model child. We've never had any problems with her." -"We have five children, all normal kids with some problems at times."

A: "She's been a model child. We've never had any problems with her." Rationale: Parents commonly describe their child as a model child who is a high achiever and compliant. These adolescents are typically well liked by teachers and peers. It is not typical for behavior problems to be reported. The description about having given the child everything and being repaid is more likely to describe an adolescent who is exhibiting behavior problems.

The nurse is teaching a client about levothyroxine. Which instruction should a nurse offer the client? -"Take the drug on an empty stomach." -"Take the drug with meals." -"Take the drug in the evening." -"Take the drug with vitamin C."

A: "Take the drug on an empty stomach." Rationale: The nurse should instruct the client to take levothyroxine (synthetic thyroid hormone) on an empty stomach (to promote regular absorption) in the morning (to help prevent insomnia and to mimic normal hormone release). Taking the drug in the evening may lead to sleeplessness. Although vitamin C may increase the absorption of some medications such as iron, it does not have this effect with levothyroxine.

While looking out the window at trees, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which statement by the nurse is best? -"I've been in that school many times. I promise there are no creatures there." -"Why do you think there are creatures, and what do they want with you?" -"That sounds scary. I don't see any creatures at the school." -"There are no creatures. Schizophrenia causes you to see things that are untrue."

A: "That sounds scary. I don't see any creatures at the school." Rationale: A therapeutic statement by the nurse should focus on the client's feelings and provide factual information. Using "I" statements focuses on the nurse when the focus should be the client. Do not explore hallucinations. Stating the creatures are untrue is a confrontational statement.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? -"The paralysis caused by this disease is temporary." -"You'll be permanently paralyzed; however, you won't have any sensory loss." -"It must be hard to accept the permanency of your paralysis." -"You'll first regain use of your legs and then your arms."

A: "The paralysis caused by this disease is temporary." Rationale: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

Which statement by a client who has been taking buspirone as prescribed for 2 days indicates the need for further teaching? -"This medication will help my tight, aching muscles." -"I may not feel better for 7 to 10 days." -"The drug does not cause physical dependence." -"I can take the medication with food."

A: "This medication will help my tight, aching muscles." Rationale: Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. Buspirone is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects occurring in 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.

A client with schizophrenia and delusions tells a nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusion. Which response by the nurse is appropriate? -"This subject seems to be troubling you. Let's walk to the activity room." -"Describe the man who's out to get you. What does he look like?" -"There is no reason to be afraid of that man. This hospital is very secure." -"There is no need to be concerned about a man who isn't even real."

A: "This subject seems to be troubling you. Let's walk to the activity room." Rationale: This remark distracts from the delusion by engaging the client in a less-threatening or more-comforting activity at the first sign of anxiety. The nurse should reinforce reality and discourage the client's false belief. The other options focus on the content of the delusion rather than on the meaning, feeling, or distress it evokes.

After teaching the parents of a 15-month-old child who has undergone cleft palate repair how to use elbow restraints, which statement by the parents indicates effective teaching? -"We'll keep the restraints in place continuously until our health care provider says it's okay to remove them." -"We can take off the restraints while our child is playing, but we'll make sure to put them back on at night." -"The restraints should be taped directly to our child's arms so that they'll stay in one place." -"We'll remove the restraints temporarily, one at a time, at least three times a day to check his skin, then put them right back on."

A: "We'll remove the restraints temporarily, one at a time, at least three times a day to check his skin, then put them right back on." Rationale: Elbow restraints help to keep the child from placing fingers or any other object in the mouth that would cause injury to the operative site. The restraints are worn at all times except when they are removed to check the skin. Because of the risk for skin breakdown, the restraints are removed periodically during the day to assess the child's underlying skin. It is advisable to remove only one restraint at a time while keeping hold of the child's hand on the unrestrained side. Toddlers are quick and usually want to explore the area in the mouth that the surgery has made feel different. The restraints should be in place at all times during sleep and play to prevent inadvertent injury to the operative site. Taping the restraints directly to the skin is not advised because skin breakdown can occur when tape is reapplied to the same area over several weeks. The restraints can be fastened to clothing to keep them from slipping.

A nurse is caring for a client with antisocial personality disorder. Which statement is most appropriate for the nurse to make when explaining unit rules and expectations to this client? -"The other members of the health care team and I would like you to attend group therapy each day." -"You'll find your condition will improve much more quickly if you attend group therapy each day." -"You'll be expected to attend group therapy each day." -"Please try to attend group therapy each day."

A: "You'll be expected to attend group therapy each day." Rationale: Rules and explanations must be brief and clear and leave little room for misinterpretation. A client with antisocial personality disorder tends to disregard rules and authority and to be socially irresponsible. The words "You'll be expected to attend..." are concise and concrete and convey precisely what the client is expected to do. The other options can be interpreted as indicating that attendance at group therapy is advised but not mandatory.

The nurse is flushing a peripheral intravenous access device. Place the steps in the order that the nurse should perform them. All options must be used. 1 Cleanse the end cap with an antimicrobial swab. 2 Insert the saline flush syringe into the cap on the extension tubing. 3 Pull back on saline flush syringe to aspirate the catheter for blood return. 4 Instill saline solution over 1 minute. 5 Remove the syringe and reclamp the extension tubing. 6Remove gloves and perform hand hygiene.

A: -Cleanse the end cap with an antimicrobial swab. -Insert the saline flush syringe into the cap on the extension tubing. -Pull back on saline flush syringe to aspirate the catheter for blood return. -Instill saline solution over 1 minute. -Remove the syringe and reclamp the extension tubing. -Remove gloves and perform hand hygiene. Rationale: The first step is to cleanse the end cap with an antimicrobial swab to reduce the risk for contamination. The second step is to insert the saline flush syringe into the cap on the extension tubing to prepare to flush the intravenous site. The third step is to pull back on saline flush syringe to aspirate the catheter for blood return to confirm patency. The fourth step is to instill saline solution over 1 minute to maintain patency of the peripheral intravenous access device site. The fifth step is to remove the syringe from the peripheral intravenous access device because the normal saline has been administered and reclamp the extension tubing to prevent air from entering the peripheral intravenous access device. The sixth step is to remove gloves and perform hand hygiene to reduce the risk of transmission of microorganisms.

A client with chronic hepatitis C is experiencing nausea, anorexia, and fatigue. During the health history the client states that he is homosexual, drinks one to two glasses of wine with dinner, is taking St. John's Wort for a "bit of depression," and takes acetaminophen for frequent headaches. What should the nurse do? Select all that apply. -Instruct the client that the wine with meals can be beneficial for cardiovascular health. -Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. -Instruct the client to increase the protein in his diet and eat less frequently. -Advise the client of the need for additional testing for HIV. -Encourage the client to obtain sufficient rest.

A: -Instruct the client to ask the health care provider (HCP) about taking any other medications as they may interact with medications the client is currently taking. -Advise the client of the need for additional testing for HIV. -Encourage the client to obtain sufficient rest. Rationale: Clients with chronic hepatitis C should abstain from alcohol as it can speed cirrhosis and end-stage liver disease. Clients should also check with their HCPs before taking any nonprescription or prescription medications, or herbal supplements. It is also important that clients who are infected with HCV be tested for HIV, as clients who have both HIV and HCV have a more rapid progression of liver disease than those who have HCV alone. Clients with HCV and nausea should be instructed to eat four to five times a day to help reduce anorexia and nausea. The client should obtain sufficient rest to manage the fatigue.

A client moves in with her family after her boyfriend of 4 weeks told her to leave. She is admitted to the subacute unit after reporting feeling empty and lonely, being unable to sleep, and eating very little for the last week. Her arms are scarred from frequent self-mutilation. What should the nurse do in order of priority from first to last? All options must be used. 1 Monitor for suicide and self-mutilation. 2 Monitor sleeping and eating behaviors. 3 Discuss the issues of loneliness and emptiness. 4 Discuss her housing options for after discharge.

A: -Monitor for suicide and self-mutilation. -Monitor sleeping and eating behaviors. -Discuss the issues of loneliness and emptiness. -Discuss her housing options for after discharge. Rationale: Safety is the priority concern, and then eating and sleeping patterns need to be reestablished. After intervening to meet basic needs, delving into the loneliness and emptiness are important for determining underlying issues that need to be followed up in outpatient counseling. Although the client is living with her family currently, other options might be appropriate for her to consider.

A client receives 12 units of intermediate- or long-acting insulin and 6 units of fast-acting insulin each morning. Place the following actions in chronological order of how the nurse would demonstrate how to mix insulins. Use all options. 1 Wipe off the vials with an alcohol swab. 2 Inject 12 units of air into the intermediate- or long-acting insulin vial. 3 Inject 6 units of air into the fast-acting insulin vial. 4 Withdraw 6 units of fast-acting insulin. 5 Withdraw 12 units of intermediate- or long-acting insulin insulin.

A: -Wipe off the vials with an alcohol swab. -Inject 12 units of air into the intermediate- or long-acting insulin vial. -Inject 6 units of air into the fast-acting insulin vial. -Withdraw 6 units of fast-acting insulin. -Withdraw 12 units of intermediate- or long-acting insulin insulin. Rationale: The nurse should wipe the insulin bottles with an alcohol swab before each use to eliminate contamination. Then the nurse should inject 12 units of air into the intermediate- or long-acting insulin vial, without touching the insulin. Next, the nurse should insert 6 units of air into the fast-acting insulin and draw up the insulin into the syringe. Fast-acting insulin should be drawn into the syringe first to avoid the risk of mixing the long-acting insulin into the vial and delaying the onset of action of the regular insulin in an emergency. Lastly, the nurse should draw 12 units of intermediate- or long-acting insulin into the syringe.

A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply. -ascites -jugular vein distention -orthopnea -cough -hepatomegaly -crackles

A: -orthopnea -cough -crackles Rationale: Left-sided heart failure produces primarily pulmonary signs and symptoms, such as orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and symptoms, such as ascites, jugular vein distention, and hepatomegaly.

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply. -pepperoni pizza -oatmeal -bacon -cheese -apple juice -soft drinks

A: -pepperoni pizza -bacon -cheese -soft drinks Rationale: Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content.

During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use? -0.6 mg I.M. -1 mg I.V. -2 mg I.M. -2 mg I.V.

A: 1 mg I.V. Rationale: To reverse arrhythmias, bradycardia, or sinus arrest, the usual adult dosage of atropine is 0.5 to 1 mg I.V. every 3 to 5 minutes as needed. The drug isn't administered I.M. for the treatment of bradycardia.

A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below: -10,000/?l. -20,000/?l. -75,000/?l. -135,000/?l.

A: 10,000/?l. Rationale: The client with ITP is at greatest risk for cerebral hemorrhage when the platelet count falls below 10,000/?l. Although platelet counts of 20,000/?l and 75,000/?l are below normal and increase the client's risk for bleeding, they don't increase the risk as much as a platelet count below 10,000/?l. A platelet count of 135,000/?l is normal and wouldn't occur in a client with ITP.

An infusion of lidocaine hydrochloride is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute? Record your answer using a whole number.

A: 2 Rationale: First, calculate the concentration of mg/mL: 1,000 mg divided by 250 mL equals 4mg/mL.Next, multiply the number of milligrams per milliliter by the pump setting in milliliters per hour: 4 mg/mL x 30 mL/h = 120 mg/h.Next, divide the milligrams per hour by 60 to obtain milligrams per minute: 120 mg/h divided by 60 min/h equals 2 mg/min.

The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long? -1 week -2 to 4 weeks -5 to 7 weeks -8 weeks

A: 2 to 4 weeks Rationale: Full benefit from an antidepressant medication usually takes about 2 to 4 weeks on an adequate dose.

A health care provider (HCP) prescribes 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in how many minutes? -5 minutes -10 minutes -20 minutes -30 minutes

A: 20 minutes Rationale: A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by IV push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis.

A nurse has just received report on four clients. Which client should the nurse see first? -A client who underwent a thyroidectomy and has new onset hoarseness. -A client who has Cushing's syndrome who has been noted to have a blood sugar of 134 mg/dL (7.4 mmol/L). -A client who is in renal failure and a laboratory report noting a creatinine of 3.2 mg/dL (282.3 µmol/L). -A client who was diagnosed with ulcerative colitis and recently passed 100 mL of loose bloody stools.

A: A client who underwent a thyroidectomy and has new onset hoarseness. Rationale: New onset of hoarseness following a thyroidectomy may be a sign of tracheal edema and impending airway obstruction, and the nurse should evaluate this client first. The client with Cushing's syndrome may have increased blood sugars associated with stress and hospitalization and will need further information to determine whether the blood sugar was obtained when the client was fasting. A client in renal failure would be expected to have an increase in creatinine, and the nurse can later follow up to compare this result with previous results. The client with ulcerative colitis will experience loose, bloody stools and needs to be continuously evaluated for amounts, but this is not the nurse's first priority.

A client admitted with a diagnosis of schizoaffective disorder, manic phase, who is currently taking fluoxetine, valproic acid, and olanzapine as prescribed, has had an increase in manic symptoms in the past week. The health care provider prescribes a valproic acid blood level to be drawn at once. What does the nurse understand is the rationale for this prescription? -All clients taking valproic acid need periodic valproic acid levels drawn. -Fluoxetine can decrease the effectiveness of the valproic acid. -A decrease in the level of valproic acid could explain the increase in manic symptoms. -The valproic acid level is needed before a short course of lorazepam for agitation can be prescribed.

A: A decrease in the level of valproic acid could explain the increase in manic symptoms. Valproic acid is commonly used to treat manic symptoms. Therefore, a decrease in the valproic acid level could explain the increase in manic symptoms. Periodic determinations of the valproic acid level are necessary to determine the effectiveness of the drug. However, the stat nature of the specimen to be drawn indicates an immediate problem. Fluoxetine is not known to decrease the effectiveness of valproic acid. The valproic acid level is not needed before beginning a short course of therapy with lorazepam.

What is the main advantage of using a floor stock system? -A nurse can implement medication orders quickly. -A nurse receives input from the pharmacist. -The system minimizes transcription errors. -The system reinforces accurate calculations.

A: A nurse can implement medication orders quickly. Rationale: A floor stock system enables a nurse to implement medication orders quickly. It doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out? -Administer morphine sulfate. -Administer atropine sulfate. -Teach deep-breathing exercises. -Teach leg lifts and muscle-setting exercises.

A: Administer morphine sulfate. Rationale: Atropine sulfate causes pupil dilation. This action is contraindicated for the client with glaucoma because it increases intraocular pressure. The drug does not have this effect on intraocular pressure in people who do not have glaucoma. Morphine causes pupil constriction. Deep-breathing exercises will not affect glaucoma. The client should resume taking all medications for glaucoma immediately after surgery.

Which statement is correct regarding the Omnibus Reconciliation Act of 1986? -All families of clients who are nearing death, or who have died, must be asked about organ and tissue donation. -The medical examiner should be notified whenever donated organs or tissues may be available. -The facility may not release the donor's name without the family's permission. -Hospitals need not have designated requesters who approach families for organ and tissue donation.

A: All families of clients who are nearing death, or who have died, must be asked about organ and tissue donation. Rationale: The federal Omnibus Reconciliation Act of 1986 mandates that all hospitals establish written protocols for identifying potential organ and tissue donors. The act sets standards organ procurement agencies must meet. The medical examiner should be notified of a potential organ or tissue donor only if the medical examiner is involved in the case. Although a facility must have the family's permission to release the donor's name and information, this stipulation isn't part of the Omnibus Reconciliation Act of 1986. Requesters for donation are healthcare professionals who have received special training on properly approaching family members regarding organ or tissue donation.

What should the nurse do when a hospitalized client is observed to have a ritualistic pattern of behavior? -Isolate the client so that he will not disturb others. -Observe the client closely for marked changes in behavior. -Remind the client that he can control his behavior if he wishes. -Allow the client to continue so that he will not become more anxious.

A: Allow the client to continue so that he will not become more anxious. Rationale: It is best to accept compulsive behavior in a comparatively permissive manner. The client may become increasingly anxious if he is denied the ritualistic activity. Isolating the client is inappropriate because it will have no effect on the behavior and will decrease the client's self-esteem. Observing for marked changes in behavior is unwarranted as this is unlikely. Reminding the client that he can control his behavior if he wishes is inappropriate in this situation because the action is needed to control anxiety. The nurse works with the client to find alternative anxiety-management methods that will result in a decrease in ritualistic behavior. Interrupting the behavior will increase anxiety.

Which suggestion should the nurse give to an adolescent athlete with Osgood-Schlatter disease of the left knee? -Apply ice on the knee after playing. -Use crutches until healing has occurred. -Stop playing until healing has occurred. -Make an appointment with a physical therapist.

A: Apply ice on the knee after playing. Rationale: Most adolescents with Osgood-Schlatter disease are able to continue to exercise and use ice afterward. Ibuprofen also may be prescribed. Because Osgood-Schlatter disease is self-limited, crutches or physical therapy are usually unnecessary, and the adolescent usually does not need to stop playing sports. Only in severe cases would the adolescent have to stop playing sports.

The nurse is preparing to administer propranolol to a client for control of migraine headaches. The client also has a prescription for sumatriptan as needed for a headache. The client's pulse rate is 56 bpm. What should the nurse do next? -Contact the health care provider (HCP). -Assess blood pressure. -Administer oxygen. -Administer sumatriptan

A: Assess blood pressure. Rationale: One of the actions of propranolol, a drug used in the treatment of migraine headaches, is to inhibit arterial vasodilation. The nurse should assess the client's blood pressure to evaluate overall circulatory response to the medication. Until the nurse determines the client's blood pressure, there is no immediate need to contact the HCP. There is no immediate need to administer oxygen. The client has not indicated pain; it is not necessary to administer the sumatropin at this time.

The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client reports anxiety because of receiving less monitoring than in the CCU. How can the nurse allay the client's fears? -Assign the same nurse to the client when possible. -Obtain an order for an antianxiety medication. -State that the client would not have been moved out of CCU in an unstable condition. -Move the client to a room far from the nurses' station to reduce exposure to noise.

A: Assign the same nurse to the client when possible. Rationale: Assigning the same nurse when possible provides continuity of care and stability, thereby reducing the client's anxiety. An anxiolytic might be counterproductive and "overkill;" the client needs reassurance first. The client might have been the "most stable" choice in the event of an urgent need for a CCU bed. A room close to nurses' station would provide this client with a sense of security because the nurses are close by in the event of an emergency.

The nurse is developing a teaching plan for the client with aplastic anemia. Which is most important to include in the plan? -Eat animal protein and dark green, leafy vegetables every day. -Avoid exposure to others with acute infections. -Practice yoga and meditation to decrease stress and anxiety. -Get 8 hours of sleep at night, and take naps during the day.

A: Avoid exposure to others with acute infections. Rationale: Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complementary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest.

A client diagnosed with leukemia is now experiencing neutropenia. Which assessment is a priority for the nurse? -Blood glucose -Bowel sounds -Heart sounds -Breath sounds

A: Breath sounds Rationale: Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia. Frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it will not help detect pneumonia.

A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response? -Instruct the mother on the importance of the medication. -Ask the mother if she has considered using any medical assistance programs in her community. -Confer with the HCP about whether a less expensive drug could be prescribed. -Consult with the social worker.

A: Confer with the HCP about whether a less expensive drug could be prescribed. Rationale: The nurse must act as an advocate for the client when the client cannot afford treatment. It may be possible to substitute a less expensive antibiotic. Correct procedure includes contacting the HCP to explain the mother's economic situation and request a substitution. For example, amoxicillin is more economical than azithromycin. If it is not possible to use another antibiotic, then the nurse can explore other avenues with the mother and/or social worker.

The nursing staff is divided over withdrawing care from a competent, chronically ill client. The nurse-manager would take which step to meet the needs of the staff? -Contact the institutional ethics committee for strategies. -Arrange a meeting with the client's family and nursing staff. -Assign only nurses who agree with the client's plan of care. -Encourage the staff to talk to the client about their concerns.

A: Contact the institutional ethics committee for strategies. Rationale: The institutional ethics committee can help the staff develop strategies to resolve their ethical dilemma. The Patient's Bill of Rights states that the client (not the family) has the right to make decisions about the care plan and to refuse recommended treatment. Arranging a meeting with the client's family is inappropriate, whether or not they are in agreement with the client's wishes. Assigning only nurses that agree with the client's wishes is not a reasonable staffing option. Talking to the client about their concerns is inappropriate as it takes the focus away from the client.

A client with stage IV classification of heart failure tells the family and the nurse that the current advance directive needs to be changed, as the client does not want any more treatment, only to be comfortable. What is the first action that the nurse initiates? -Convey the client's request to the treatment team. -Contact the physician for input on the advance directive change. -Communicate to the family what comfort care means. -Coordinate a thorough assessment of the client's new condition.

A: Convey the client's request to the treatment team. Rationale: An important change in a client's advance directive needs to be promptly conveyed to the treatment team. The physician is a part of the team, and no additional action needs to be taken. In providing care for the client and the family, the nurse is vigilant about performing a thorough assessment of the client's condition and providing the family with necessary education and information.

A client receiving chemotherapy for cervical cancer indicates that she has an advance directive. She tells the nurse that she worries her children will not honor her wishes if her condition should worsen. In order to facilitate the honoring of the client's wishes, what should the nurse encourage the client to do? -Recommend that the client contact her attorney. -Obtain additional legal documents. -Discuss her end-of-life wishes with her family. -Appoint a proxy who is not a family member.

A: Discuss her end-of-life wishes with her family. Rationale: Family opposition does not override an advance directive. However, the client should ensure that family members know what her wishes are, even if they do not agree with them. After discussing her wishes with her family, the client can decide if she should seek additional legal advice, obtain legal documents, or name an outside proxy.

A primipara has given birth to her baby, with labor, birth, recovery, and the postpartum period in the same hospital room. The client had a midline episiotomy and epidural anesthesia. While assessing the client's pulse 30 minutes after the birth, the nurse determines that the pulse rate is 60 bpm. What should the nurse do? -Do nothing because this pulse rate is considered a normal finding. -Contact the client's primary care provider to notify about the pulse rate. -Check the client's record to determine the amount of blood loss. -Recheck the pulse in 30 minutes and compare the two readings.

A: Do nothing because this pulse rate is considered a normal finding. Rationale: Bradycardia, pulse rate of 60 bpm or less, is a normal assessment finding for 6 to 10 days in the postpartum period as the woman's body adjusts to the nonpregnant state.The primary care provider does not need to be notified because the pulse rate is within the normal parameters for the postpartum period.Checking the client's record for the amount of blood loss would be appropriate if the client's rate was elevated (e.g., above 100 bpm), suggesting possible hemorrhage. If the client's pulse was rapid and thready, shock might be possible.Rechecking the pulse rate in 30 minutes then comparing the two readings is unnecessary. The pulse rate, because it is within normal postpartum parameters, would need to be checked according to the agency's policy for vital sign monitoring postpartum.

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true? -During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth. -Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days. -Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms. -A client with genital herpes lesions may have sexual contact but must use a condom.

A: During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth. Rationale: Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature birth. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.

The nurse is receiving shift report on four clients on an antenatal unit. The four clients are: (1) a 35-week-gestation mother with severe preeclampsia started on a maintenance dose of magnesium sulfate 1 hour ago; (2) a 30-week-gestation client with preterm labor on an oral tocolytic and having no contractions in 6 hours; (3) a hyperemesis client with emesis 4 times in the past 12 hours; and (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure during change of shift report. Which action should the nurse take first? -Evaluate the client with preeclampsia for maternal and fetal tolerance of magnesium sulfate and the labor pattern. -Assess the client with preterm labor for tolerance of tocolytics and the labor pattern. -Assess the hyperemesis client for nausea for further emesis, or dehydration. -Evaluate the placenta previa client without an exam.

A: Evaluate the placenta previa client without an exam. Rationale: The first action taken should be to evaluate the placenta previa client who has pelvic pressure. The pelvic pressure may be caused by a fetal head creating pressure in the pelvis indicating a potential birth. This client should be evaluated without a pelvic exam and then consult with the health care provider (HCP). A vaginal exam is contraindicated as it may stimulate bleeding of the placenta. The second action would be to complete an assessment on the client with preeclampsia and her fetus to evaluate for tolerance and effectiveness of the magnesium sulfate. The hyperemesis client needs to be evaluated for hydration status and for medication. The preterm labor client is stable on the oral medication and should be seen last.

A client who has a urinary diversion tells the nurse, "This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore." What is an appropriate goal for the nurse to set with this client? -Manage anxiety about not being normal. -Learn how to care for the urinary diversion. -Overcome feelings of worthlessness. -Express fears about the urinary diversion.

A: Express fears about the urinary diversion. Rationale: It is normal for clients to express fears and concerns about the body changes associated with a urinary diversion. Allowing the client time to verbalize concerns in a supportive environment and suggesting that she discuss these concerns with people who have successfully adjusted to ostomy surgery can help her begin coping with these changes in a positive manner. Although the client may be anxious about this situation and may be feeling worthless, the underlying problem is a disturbance in body image. There are no data to indicate that the client does not know how to care for the urinary diversion.

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan? -Contact and inform all registered nurses about the disaster to elicit their help in assisting with the casualties. -Follow the formal written plan of action for coordinating the response of the hospital staff. -Volunteer to report to whichever unit needs the most assistance. -Transport medical supplies to where casualties are being evaluated.

A: Follow the formal written plan of action for coordinating the response of the hospital staff. Rationale: When a disaster occurs, a formal written plan of action is put into place. All nurses will follow the formal plan of action. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan will focus on having health professionals and supplies available.

The nurse is going to lunch and is conducting a "hand-off of care" to the charge nurse. Which information should the nurse communicate to the charge nurse during the "hand-off of care" communication? -Tell the charge nurse that the nurse is going to lunch. -Verify that the charge nurse has assigned someone else to take care of the client. -Give the charge nurse information about what care should be given while the nurse is at lunch. -Remind the charge nurse about the client's history and current medications.

A: Give the charge nurse information about what care should be given while the nurse is at lunch. Rationale: Hand-off of care communication is an interactive communication allowing the opportunity for questioning between the giver and receiver of client information, including up-to-date information regarding the client's care, treatment, and services, as well as the client's current condition and any recent or anticipated changes. "Hand-off" communication does occur when a nurse is leaving the nursing unit, but the purpose is not to let the charge nurse know that the nurse is going to lunch or to have someone else assigned to care for the client. "Hand-off" communication focuses on current information, not the client's history.

A client with acute mania is to receive lithium carbonate 600 mg PO three times daily and 2 mg of haloperidol PO at bedtime. Which action should the nurse take? -Refuse to give the medications as prescribed. -Give the lithium only. -Request a decreased dosage of lithium. -Give the medications as prescribed.

A: Give the medications as prescribed. Rationale: Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a benzodiazepine such as lorazepam. Antipsychotic agents, such as haloperidol, are prescribed to produce a neuroleptic effect until the lithium, produces a clinical response. After a clinical response is achieved, the antipsychotic agent usually is discontinued. Additionally, the dosages of each drug listed are appropriate. Therefore, the nurse would administer the drugs as prescribed.

Which nursing intervention would be most effective in helping a 2-year-old child stay quiet after a bronchoscopy? -Allow the child to go to the playroom. -Have the parents stay at the bedside. -Have the child play with another child in the room. -Turn on the television so the child can watch cartoons.

A: Have the parents stay at the bedside. Rationale: A toddler has a short attention span and is energetic. Thus, keeping a 2-year-old child quiet is a challenge. Because the parents know their child well, the parents have a better chance of helping the child stay quiet. Therefore, they should be encouraged to stay with the child at the bedside.Allowing the child to go to the playroom would most likely encourage the child to be active rather than quiet.A 2-year-old child engages in parallel play but does not know how to play with others.A 2-year-old child's attention span is short, so watching television would keep the child quiet for only a short time.

A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the healthcare team take first? -Initiate fluid replacement therapy. -Administer insulin. -Correct diabetic ketoacidosis. -Determine the cause of diabetic ketoacidosis.

A: Initiate fluid replacement therapy. Rationale: The healthcare team first initiates fluid replacement therapy to prevent or treat circulatory collapse caused by severe dehydration. Although diabetic ketoacidosis results from insulin deficiency, the client must have an adequate fluid volume before insulin can be administered; otherwise, the drug won't circulate throughout the body effectively. Therefore, insulin administration follows fluid replacement therapy. Determining and correcting the cause of diabetic ketoacidosis are important steps, but the client's condition must first be stabilized to prevent life-threatening complications.

A client is prescribed a bisacodyl suppository. When administering the suppository, the nurse will include what actions? -Insert the suppository approximately 1 inch (2.5 cm) into the rectum, or just past the internal anal sphincter. -Have client sit on a commode or toilet immediately after the insertion of the suppository to prevent incontinence. -Ensure the suppository is in direct contact with the stool in the rectum to facilitiate mechanism of action. -Position client on the right side in Sim's position to ensure the flexure of the rectum is at the proper angle for insertion.

A: Insert the suppository approximately 1 inch (2.5 cm) into the rectum, or just past the internal anal sphincter. Rationale: The nurse should advance a rectal suppository far enough into the rectum to pass the internal anal sphincter. The client should lie on the left side in Sim's position and should be directed to attempt to hold the suppository in the rectum for at least 20 minutes. This way the nurse ensures the suppository comes in contact with mucous membranes for better absorption of the medication rather than having it in the stool.

An adolescent client is hospitalized with bacterial meningitis. At 1730, the client's mother reports her child is "burning up." The nurse is reviewing the client's medication administration records in the medical record. The health care provider (HCP) has prescribed ibuprofen 325 mg every 3 to 4 hours for temperature over 99°F (37.2°C). The child's temperature at 1730 is 102.5°F (39.1°C). What should the nurse do first? -Notify the HCP. -Initiate tepid sponge bath. -Institute seizure precautions. -Administer another dose of aspirin.

A: Notify the HCP. Rationale: Because the client's temperature continues to rise in spite of recently administering ibuprofen, the nurse notifies the HCP. After notifying the HCP, the nurse can bathe the client with tepid water. If the temperature cannot be lowered shortly, the client is also at risk for seizures; the nurse pads side rails and observes for seizure activity. The nurse cannot administer another dose of ibuprofen without the HCP's orders.

The nurse from the previous shift identified a client as a high risk for falls. The oncoming nurse finds the client on the floor at the beginning of the shift. The nurse assesses the client and notes no injuries. What is the best action by the nurse? -Assist the client to a comfortable position on the floor, and ensure the call light is in reach. Place a fall-risk alert sign outside the client's room, and then notify the next of kin. -Complete an incident report on the previous shift for allowing the fall, and then reassess the client's fall-risk level. -Move the client to a safe position, and modify environmental factors that could have contributed to the fall. Documentation is unnecessary as no injuries occurred. -Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan.

A: Notify the health care provider, and document the fall in the chart, including location, injuries, the fact the health care provider was notified, and any changes to the care plan. Rationale: The nurse should notify the health care provider, then document the facts related to the fall, such as the location of the fall, health care provider notification, injury (if any), and necessary follow-up or changes in the care plan that occurred as a result of the fall. If an injury was present the client should remain where the fall occurred; however, if no injuries are noted the client should be assisted off the floor. The nurse should not include information that places blame on other health care members. The fall must be reported even if the client does not suffer an injury. Documentation of the incident in the client's chart is required.

A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take? -Refuse to float to the ICU. -Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment. -Report to the ICU and accept a total client assignment; ask the nurses for assistance when necessary. -Report to the ICU, tell the ICU nurses the pediatric nurse has never worked in the ICU, and let the nurses decide what tasks the pediatric nurse can perform.

A: Notify the nursing supervisor that the pediatric nurse feels unqualified and untrained for the assignment. Rationale: The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained to float in the ICU. The nursing supervisor can advise the pediatric nurse about tasks the pediatric nurse is qualified to perform in the ICU without jeopardizing the pediatric nurse's nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable way for managing resources. Having the ICU nurses determine what tasks the pediatric nurse can perform makes the ICU nurses responsible for the pediatirc nurse's performance. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never accept responsibility for a total client care assignment if the nurse doesn't have the skills to plan and deliver care.

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take? -Notify the physician immediately to have the physician determine client competency. -Have the client sign a do-not-resuscitate (DNR) form. -Determine whether the client's family was consulted about this decision. -Consult the palliative care group to direct care for the client.

A: Notify the physician immediately to have the physician determine client competency. Rationale: Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.

The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention? -Reinforce the risks of not having the surgery -Notify the provider immediately -Notify the nursing supervisor -Record the client's refusal in the nurses' notes

A: Notify the provider immediately Rationale: The nurse should notify the health care provider. The health care provider is responsible for providing information regarding the procedure, risks, benefits and expected outcomes. After notifying the provider, the nurse should document the situation and client response in the client's record.

A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of the car and beginning to approach the client's building, a group of people begin following and jeering at the nurse. Which is the nurse's best response to this situation? -Leave the area in the car, provided the nurse can get to it safely. -Perform the home visit and ensure that the group is gone before leaving. -Confront the group of people in an assertive but non-aggressive manner. -Call out to attract attention from bystanders.

A: Perform the home visit and ensure that the group is gone before leaving. Rationale: The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove themself from the situation, provided this can be achieved without incurring further risk.

The mother of a toddler tells the nurse her son bites other children. What should the nurse advise the mother to do? -Talk to the child about how much biting hurts. -Place the child in "time-out." -Spank the child gently, but firmly. -Make an appointment with a child psychologist.

A: Place the child in "time-out." Rationale: Biting is an unacceptable aggressive behavior that should not be allowed. Placing the child who did the biting in time-out is most appropriate because it removes the child from the situation and the other children and also teaches the child that the behavior is inappropriate.The toddler should be removed from the situation; talking to the child will not help the child learn that the behavior is not appropriate.Spanking the child is inappropriate because doing so reinforces the hitting behavior as appropriate.Biting is a common behavior in toddlers and can be managed by the parents unless the child does not respond to being placed in "time-out"; it is not necessary to refer the mother to a child psychologist at this time.

The nurse is caring for a child in Bryant's traction (see figure). What action should the nurse take? -Adjust the weights on the legs until the buttocks rest on the bed. -Provide frequent skin care. -Place a pillow under the buttocks. -Remove the elastic leg wraps every 8 hours for 10 minutes.

A: Provide frequent skin care. Rationale: The traction is positioned correctly; the nurse should provide frequent skin care to the back and shoulder areas. The hips and buttocks should be lifted off the bed to provide counter traction; the nurse should not adjust the weights. The nurse should not place a pillow under the buttocks as this would prevent counter traction. The elastic wraps should remain on the legs unless removal is prescribed by the health care provider (HCP).

After the physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond? -Provide the information requested. -Encourage the client to withdraw from the trial. -Not provide the information because it's beyond the scope of nursing practice. -Tell the client that the information should come from the physician who first presented it to them.

A: Provide the information requested. Rationale: As part of the multidisciplinary team, the nurse is empowered to assist the client to better understand the process, as long as the nurse has an understanding of the treatment plan. The nurse shouldn't discourage the client from participating in the research study. Providing information to the client about the clinical trial isn't beyond the scope of nursing practice. The information doesn't need to come from the physician who originally presented the material to the client.

A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first? -Monitor the coworker's behaviors. -Report the suspicion to the nurse manager. -Discuss the suspicion directly with the coworker. -Keep track of the quantity of medications in the cart throughout the shift.

A: Report the suspicion to the nurse manager. Rationale: The nurse should report the suspicion to the nurse manager. The American Nurses Association does not advise confronting coworkers in these situations. Monitoring the coworker's behavior or keeping track of the quantity of medications in the cart do not solve these problem. These actions allow the coworker to continue working with clients while possibly under the influence of drugs, which is not safe.

A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now "unable to concentrate at her card game" and "it seems harder and harder to finish my errands because I am so tired." What should the nurse suggest that the client do to manage the exhaustion? -Take frequent naps. -Limit activities. -Increase fluid intake. -Avoid contact with others.

A: Take frequent naps. Rationale: This client is likely experiencing fatigue and should increase her periods of rest. The fatigue may be caused by anemia from depletion of red blood cells due to the chemotherapy. Asking the client to limit her activities may cause the client to become withdrawn. The information given does not support limiting activity. Increasing fluid intake will not reduce the fatigue. The information does not indicate that the client is immunosuppressed and should avoid contact with others.

When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should make which suggestion to the client? -Take the prednisone with food. -Take over-the-counter antiemetics. -Exercise three to four times a week. -Eat foods that are low in potassium.

A: Take the prednisone with food. Rationale: Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the health care provider (HCP) who prescribed the prednisone. The client should ask the HCP about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.

Ibuprofen is prescribed for a client with osteoarthritis. Which instruction about ibuprofen should the nurse include in the client's teaching plan? -Report the development of tinnitus. -Increase vitamin B12 intake. -Take with food or antacids. -Have the complete blood count (CBC) monitored monthly.

A: Take with food or antacids. Rationale: Ibuprofen should be taken with food or antacids to avoid the development of gastrointestinal distress. Tinnitus is not an adverse effect of ibuprofen; it is a sign of salicylate toxicity. There is no need to increase vitamin B12 intake. The CBC is not typically monitored monthly, although clients should be told to report signs of unusual bleeding because ibuprofen can prolong bleeding time.

The client has just undergone abdominal surgery and returned from the post-anesthesia care unit (PACU) with a patient-controlled analgesia (PCA) pump. Which interventions should the nurse implement? Select all that apply. -Tell the client to push the button when in pain. -Administer a bolus of pain medication. -Change the patient-controlled analgesia (PCA) cartridge. -Check the patient-controlled analgesia (PCA) settings with another nurse. -Assess the IV insertion site.

A: Tell the client to push the button when in pain. Check the patient-controlled analgesia (PCA) settings with another nurse. Assess the IV insertion site. Rationale: The client is the only person who should push the PCA button and only when in pain. The settings should be checked with another nurse, ensuring the correct dosage is being administered. The PCA is intravenous and the site should be patent and free of erythema and infiltration.

The client is discussing the client's medication history with the nurse. During the discussion, the client pulls out a list of the prescribed medications, which include fish oil and St. John's Wort. What is the nurse's understanding of why these alternative therapies are used by the client? -The client has a history of depression. -The client has a history of coronary diseases. -The client has a history of digestive issues. -The client has a history of diabetes.

A: The client has a history of depression. Rationale: The client has a history of depression. Fish oil and St. John's wort are alternative therapies to treat depression.

After an amniotomy, which client goal should take the highest priority? -The client will express increased knowledge about amniotomy. -The client will maintain adequate fetal tissue perfusion. -The client will display no signs of infection. -The client will report relief of pain.

A: The client will maintain adequate fetal tissue perfusion. Rationale: Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.

A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? -The dobutamine may need to be decreased. -The client is experiencing an allergic reaction to the dobutamine. -The client is experiencing an exacerbation of the heart failure. -The dobutamine needs to be increased.

A: The dobutamine may need to be decreased. Rationale: Dobutamine is a vasoactive adrenergic that works by increasing myocardial contractility and stroke volume in order to increase the cardiac output in heart failure clients. A serious side effect of adrenergic drugs is the worsening of a preexisting cardiac disorder. Increasing the dosage of the drug will worsen the problem. The client does not show symptoms of allergic reaction or heart failure.

A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take? -Since the client is still admitted to the hospital, the nurse must hold the statement in confidence. -The nurse must start the process to warn the client's husband. -An assessment of the client's response to treatment must be performed. -The comment must be held in confidence because the client did not report the statement directly to the nurse.

A: The nurse must start the process to warn the client's husband. Rationale: Confidentiality must be broken if there are credible threats made against another person's safety. Confidentiality does not override the safety of other persons.

Parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate? -Caloric requirements per kilogram of body weight increase slightly during the preschool-age period. -The preschooler's nutritional requirements differ greatly from those of a toddler. -The quality of food that a preschooler consumes is more important than the quantity. -Protein should account for 25% of the preschooler's total caloric intake.

A: The quality of food that a preschooler consumes is more important than the quantity. Rationale: Stating that food quality is more important than quantity is most accurate because a high caloric intake may include many empty calories. The preschooler's caloric requirement is slightly lower than the toddler's. Overall, however, the preschooler's nutritional requirements are similar to a toddler's. The preschooler requires 1.5 g/kg of protein daily, satisfied by two meat servings, three milk servings, four bread servings, and four fruit and vegetable servings.

A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the area where the nurse should expect to feel the fundus.

A: The uterus would be palpable at the level of the umbilicus between 4 and 24 hours after birth. The fundus of the uterus should be paplated for position and firmness.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? -Fetal development needs to be complete before testing. -The volume of amniotic fluid needed for testing will be available by 15 weeks. -Cells indicating hemophilia A are not produced until 15 weeks' gestation. -Performing an amniocentesis prior to 15 weeks' gestation carries a greater infection rate.

A: The volume of amniotic fluid needed for testing will be available by 15 weeks. Rationale: The volume of fluid needed for amniocentesis is 15 mL, and this is usually available at 15 weeks' gestation. Fetal development continues throughout the prenatal period. Cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks' gestation. Amniocentesis carries a slight risk of infection regardless of when the procedure is performed.

A client with a new ileal conduit asks what the disadvantages are to this type of stoma. The nurse explains that the client may experience which disadvantage? -Stool continuously oozes from it. -Absorption of nutrients is diminished. -Peristalsis is greatly decreased. -Urine drains from it continuously.

A: Urine drains from it continuously. Rationale: The ureters are implanted in a segment of the ileum, and urine drains continually because there is no sphincter. The other choices all reflect bowel-associated problems.

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? -a 20-year-old who is unresponsive and has a high injury to his spinal cord -an 80-year-old who has a compound fracture of the arm -a 10-year-old with a laceration on his leg -a 25-year-old with a sucking chest wound

A: a 25-year-old with a sucking chest wound Rationale: During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.

Which client requires increased sensory stimulation to prevent sensory deprivation? -a 24-year-old client who has been admitted with an anxiety disorder and appears very agitated -a 60-year-old client who is blind, reads books through use of Braille, listens to the radio, and regularly takes walks around the unit -a 65-year-old client who has employment-induced presbycusis and advanced glaucoma -an 84-year-old client who has hemiparesis and ambulates with a walker

A: a 65-year-old client who has employment-induced presbycusis and advanced glaucoma Rationale: There is more risk of sensory deprivation when the primary senses are impaired. This client is most at risk for sensory deprivation because of two sensory deficits: hearing and vision. These two are primary senses that help a person stay oriented and communicate with others. The 24-year-old client has senses intact but is experiencing an anxiety disorder. The 60-year-old client has one sensory deficit, blindness, but is compensating by reading books and listening to tapes. An elderly person with mobility problems, who is using mobility aids, and hence can still socialize is not experiencing sensory deficits.

The nurse is obtaining a health history from a client with a sexually transmitted disease. Which description from the client indicates the likelihood of syphilis? "In my genital area I have: -tender pimples." -a wart." -a moist ulcer." -itching."

A: a moist ulcer." Rationale: The chancre of syphilis is characteristically a painless, moist ulcer. The serous discharge is very infectious. Because the chancre is usually painless and disappears, the client may not be aware of it or may not seek care. The chancre does not appear as pimples or warts, and does not itch, thus making diagnosis difficult.

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to -a nutritionist. -a perinatologist. -a nurse-midwife. -an endocrinologist.

A: a perinatologist. Rationale: An elevated AFP level may indicate a fetal congenital abnormality. The physician will likely refer the client to a perinatologist, who cares for clients with high-risk pregnancies. A nutritionist provides guidance about a healthy diet. A nurse-midwife follows low-risk pregnancy cases. An endocrinologist deals with metabolic disorders. Referrals to these providers aren't necessary at this time.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then -advance both legs. -advance the unaffected leg. -advance the affected leg. -advance both crutches.

A: advance both crutches. Rationale: The nurse should instruct the client to advance both crutches to the step below, then transfer their body weight to the crutches as they bring the affected leg to the step. The client should then bring the unaffected leg down to the step.

A nurse is making assignments for the infant unit. The shift's team members include a licensed practical nurse (LPN) with 10 years of experience, a registered nurse (RN) with 3 months of experience, and a client care assistant. Which assignment is most appropriate for the LPN? -an infant being discharged to home following placement of a gastrostomy tube -an infant just returned from the postanesthesia care unit who requires hourly assessment of vital signs -an infant requiring abdominal dressing changes for a wound infection -an infant with agonal respirations who is receiving palliative care

A: an infant requiring abdominal dressing changes for a wound infection Rationale: The infant requiring dressing changes is within an LPN's scope of practice. This care has a predictable outcome. Client and family teaching — such as how to care for a gastrostomy tube — is an RN's responsibility. A client care assistant can be assigned to obtain vital signs and report the findings to the supervising RN. Because the outcome of the infant with agonal respirations is unpredictable, the RN shouldn't delegate this client's care to the LPN.

A 6-year-old child is admitted to a pediatric unit for the treatment of osteomyelitis. Which essential medication classification would the nurse anticipate as documented on the medication report? -anti-inflammatory -analgesic -antibiotic -antipyretic

A: antibiotic Rationale: Staphylococcus. aureus is the most common causative pathogen of osteomyelitis; the usual source of the infection is an upper respiratory infection (URI) or skin lesion. The nurse anticipates an intravenous antibiotic as the essential medication. The nurse may have an anti-inflammatory medication as adjunct therapy. By decreasing the infection, the client may experience decreased pain; thus, not needing an analgesic. The nurse would administer an antipyretic if the child was febrile.

A nurse-manager must include which items as part of the personnel budget? -anticipated overtime payments for staff -computers for staff use -office supplies for secretarial use -videos for staff education

A: anticipated overtime payments for staff Rationale: Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Any expense or single item of equipment costing more than $500 is part of the capital budget. Office supplies and videos are part of the operating budget.

The nurse is interviewing an adolescent with a new onset of fatigue. What communication strategies will be least effective for the nurse to establish a therapeutic relationship with the adolescent? -asking personal questions unrelated to the situation -writing down everything the client says -asking open-ended questions -discussing the nurse's own thoughts and feelings about the situation -listening to the client

A: asking personal questions unrelated to the situation writing down everything the client says discussing the nurse's own thoughts and feelings about the situation Rationale: The use of listening can be therapeutic and instills a sense of interest in the client. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though the adolescent is being interrogated with unnecessary questions. Writing everything down during the interview can be a distraction and does not allow the nurse to observe how the adolescent behaves. Discussing the nurse's thoughts and feelings may bias the assessment and is inappropriate when interviewing any client. Open-ended questions allow the adolescent to share information and feelings and listening to the client are effective communication skills.

What is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks? -repeating the directions until the client follows them -asking the client to do one step of the task at a time -demonstrating for the client how to do the task -maintaining routine and structure for the client

A: asking the client to do one step of the task at a time Rationale: Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.

An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse's priority should be the potential for -hyperglycemia. -fluid volume excess. -aspiration. -constipation.

A: aspiration Rationale: Of the choices listed, aspiration is the most serious potential complication of tube feedings. Dehydration — not fluid volume excess — is a concern because of decreased free water intake. Hyperglycemia is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation is a problem, but it usually isn't a serious one. The client would most likely experience diarrhea.

A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client that if the medication isn't taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse's statement? -assault -battery -negligence -autonomy

A: assault Rationale: Assault occurs when one person puts another in fear of harmful or threatening contact. Battery is physical contact with another person. Negligence involves actions that are below the standard of care. Autonomy is an ethical principle of self-determination, and does not constitute a legal issue.

A student nurse witnesses a registered nurse performing a procedure on a client without obtaining informed consent for the procedure. The student nurse recognizes that the registered nurse is guilty of committing: -breach of confidentiality. -assault and battery. -harassment. -neglect of duty.

A: assault and battery. Rationale: Performing a procedure on a client without informed consent can be grounds for charges of assault and battery. Harassment means to annoy or disturb someone, and breach of confidentiality refers to conveying information about the client. Neglect of duty is failure to perform care that a prudent nurse would provide under similar circumstances.

The nurse on a medical-surgical unit has interventions to complete in the morning. Which tasks are most appropriate to delegate to an unlicensed assistive personnel (UAP)? Select all that apply. -assisting a client with ambulation -monitoring a client's pain level with activity -evaluating a client's ability to perform self-care -applying a hydrogel to a sacral pressure injury -opening breakfast foods on the breakfast tray

A: assisting a client with ambulation opening breakfast foods on the breakfast tray Rationale: The nurse is able to delegate assisting with ambulation and opening breakfast foods to the UAP. Monitoring and evaluating clients are not in the scope of practice of the unlicensed personnel. Applying a hydrogel is also not in the unlicensed personnel's scope of practice.

After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which position? -left side, with the neck slightly flexed -back, with the head turned to the left side -abdomen, with the head down -back, with the neck slightly extended

A: back, with the neck slightly extended Rationale: When receiving oxygen by mask, the neonate is placed on the back with the neck slightly extended, in the "sniffing" or neutral position. This position optimizes lung expansion and places the upper respiratory tract in the best position for receiving oxygen. Placing a small rolled towel under the neonate's shoulders helps to extend the neck properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the neonate can be positioned in the prone position, which allows for lung expansion in the oxygenated environment. Placing the neonate on the left side does not allow for maximum lung expansion. Also, slightly flexing the neck interferes with opening the airway. Placing the neonate on the back with the head turned to the left side does not allow for lung expansion. Placing the neonate on the abdomen interferes with proper positioning of the oxygen mask.

A client is diagnosed with agoraphobia without panic disorder. Which type of therapy would most the nurse expect to see included in the plan of care? -insight therapy -group therapy -behavior therapy -psychoanalysis

A: behavior therapy Rationale: The nurse should suggest behavior therapy, which is most successful for clients with phobias. Systematic desensitization, flooding, exposure, and self-exposure treatments are most therapeutic for clients with phobias. Self-exposure treatment is being increasingly used to avoid frequent therapy sessions. Insight therapy, exploration of the dynamics of the client's personality, is not helpful because the process of anxiety underlies the disorder. Group therapy or psychoanalysis, which deals with repressed, intrapsychic conflicts, is not helpful for the client with phobias because it does not help to manage the underlying anxiety or disorder.

The nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk? -blond, blue-eyed, fair-skinned child with eczema -African descent, dark-eyed child with asthma -child with dark complexion who is overweight and has labile personalities -child with dark complexion who is overweight and has labile personalities

A: blond, blue-eyed, fair-skinned child with eczema Rationale: Infants with PKU are usually blond, blue-eyed, and fair, and often have eczema. The other physical assessment findings are not typically found in children with PKU.

Which measure is contraindicated when the nurse assists a child who has leukemia with oral hygiene? -applying petroleum jelly to the lips -cleaning the teeth with a toothbrush -swabbing the mouth with moistened cotton swabs -rinsing the mouth with a nonirritating mouthwash

A: cleaning the teeth with a toothbrush Rationale: The oral mucous membranes are easily damaged and are commonly ulcerated in the client with leukemia. It is better to provide oral hygiene without using a toothbrush, which can easily damage sensitive oral mucosa. Applying petroleum jelly to the lips, swabbing the mouth with moistened cotton swabs, and rinsing the mouth with a nonirritating mouthwash are appropriate oral care measures for a child with leukemia.

Which medication would the nurse expect the provider to prescribe as prophylaxis against Pneumocystis carinii pneumonia for a client with leukemia? -co-trimoxazole -oral nystatin suspension -prednisone -vincristine

A: co-trimoxazole Rationale: The most common cause of death from leukemia is overwhelming infection. P. carinii infection is lethal to a child with leukemia. As prophylaxis against P. carinii pneumonia, continuous low dosages of co-trimoxazole are typically prescribed. Oral nystatin suspension would be indicated for the treatment of thrush. Prednisone isn't an antibiotic, and increases susceptibility to infection. Vincristine is an antineoplastic agent.

A client is color blind. The nurse understands that this client has a problem with -rods. -cones. -lens. -aqueous humor.

A: cones. Rationale: Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.

Three days after admission of a neonate born at 30 weeks' gestation, the neonatologist plans to assess the neonate for intraventricular hemorrhage (IVH). The nurse should plan to assist the neonatologist by preparing the neonate for which test? -cranial ultrasonography -arterial blood specimen collection -radiographs of the skull -complete blood count specimen collection

A: cranial ultrasonography Rationale: Neonates who weigh less than 1,500 g or are born at less than 34 weeks' gestation are susceptible to IVH. Cranial ultrasound scanning can confirm the diagnosis. The spinal fluid will show an increased number of red blood cells. Arterial blood gas specimen collection is done to evaluate the neonate's oxygen saturation level. Skull radiographs are not commonly used because of the danger of radiation. Additionally, computed tomography scans have replaced the use of skull x-ray films because they can provide more definitive results. Complete blood count specimen collection is usually performed to determine the hemoglobin, hematocrit, and white blood cell count. The results are not specific for IVH.

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? -asking frequently whether the client understands the instructions -asking an interpreter to relay the instructions to the client -writing out the instructions and having a family member read them to the client -demonstrating the procedure and having the client return the demonstration

A: demonstrating the procedure and having the client return the demonstration Rationale: Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Asking whether the client understands the instructions isn't appropriate because clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

The nurse is administering a subcutaneous injection (see accompanying figure). After releasing the skin, prior to injecting the medication, the needle pulls out of the skin. The nurse should: -wipe the area with alcohol, and make one more attempt to insert the needle. -discard the needle, attach a new needle to the syringe, and administer the medication. -discard the needle and syringe, obtain new needle and syringe, and draw a new dose of the medication. -using a new needle, syringe, and medication, stretch the skin taut and administer the medication.

A: discard the needle, attach a new needle to the syringe, and administer the medication. Rationale: If the needle becomes dislodged from the tissue prior to administering the medication, the nurse should discard the needle, attach a new needle, and reattempt to administer the medication using appropriate technique. The nurse should not reuse the needle but can reuse the syringe and medication. To administer a subcutaneous injection, the nurse should bunch the skin around the insertion site (not stretch the skin) to lift the subcutaneous tissue from the muscle.

The health care provider prescribes fluoxetine orally every morning for a 72-year-old client with depression. Which transient adverse effect of this drug requires immediate action by the nurse? -nausea -dizziness -sedation -dry mouth

A: dizziness Rationale: The presence of dizziness could indicate orthostatic hypotension, which may cause injury to the client from falling. Nausea, sedation, and dry mouth do not require immediate intervention by the nurse.

A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, muscle contractions that contort the client's neck. This client is exhibiting which extrapyramidal reaction? -dystonia -akinesia -akathisia -tardive dyskinesia

A: dystonia Rationale: Dystonia, a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs. Akinesia refers to decreased or absent movement; akathisia, to restlessness or inability to sit still; and tardive dyskinesia, to abnormal muscle movements, particularly around the mouth.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? -ambenonium -pyridostigmine -edrophonium -carbachol

A: edrophonium Rationale: Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

A nurse discovers that an I.V. site in a client's hand has infiltrated, causing localized pain and swelling. Which intervention would relieve the client's discomfort most effectively? -elevating the hand and wrapping it in a warm towel -placing an ice pack on the hand -administering an as-needed analgesic -wrapping the arm in an elastic bandage from wrist to elbow

A: elevating the hand and wrapping it in a warm towel Rationale: Elevating the arm promotes venous drainage and reduces edema; applying warmth increases circulation and eases pain and edema. Ice application would relieve pain but not edema. An analgesic wouldn't correct the primary cause of the discomfort. Wrapping the arm above the hand would slow venous return and is contraindicated.

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that -the client requires an antiviral agent. -enteric precautions must be continued. -enteric precautions can be discontinued. -the client's infection may be caused by droplet transmission.

A: enteric precautions must be continued. Rationale: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" -one-time order -stat order -standing order -as-needed order

A: standing order Rationale: This example is a standing order. Prescribers write a one-time order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. An as-needed order doesn't indicate a specific administration time; it gives guidelines for when to administer the medication. Many pain medication orders are as-needed orders.

The nurse is evaluating the effectiveness of a teaching plan for a client recovering from an upper respiratory tract infection. Which is an expected outcome of the plan? The client will: -maintain a fluid intake of 800 ml every 24 hours. -have a temperature below 100ºF (37.8ºC). -cough productively without chest discomfort. -experience less nasal obstruction and discharge.

A: experience less nasal obstruction and discharge. Rationale: A client recovering from an upper respiratory tract infection should report decreasing or no nasal discharge and obstruction. Daily fluid intake should be increased to more than 1 L every 24 hours to liquefy secretions. The temperature should be below 100° F (37.8° C) with no chills or diaphoresis. A productive cough with chest pain indicates a pulmonary infection, not an upper respiratory tract infection.

The nurse is instructing the client about taking metoclopramide. The nurse should instruct the client to report which adverse effect? -constipation -urine retention -hypotension -extrapyramidal reactions

A: extrapyramidal reactions Rationale: Clients taking metoclopramide should be instructed to report any involuntary movements of the face, eyes, or extremities because adverse effects of the drug include extrapyramidal reactions and Parkinsonism-like reactions. Other common adverse effects include diarrhea (not constipation) and nausea.The drug does not typically affect urinary patterns.Occasionally the client may experience transient hypertension.

A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: -help the family prepare for the infant's imminent death. -implement measures to facilitate the attachment process. -provide emotional support so the family can adjust to the birth of an infant with health problems. -prepare the family for the extensive surgical procedures the infant will require.

A: help the family prepare for the infant's imminent death. Rationale: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding? -two to three bowel sounds per minute -high pitched, tinkling bowel sounds -high pitched gurgling noises in four abdominal quadrants -sounds heard only in bilateral lower quadrants

A: high pitched gurgling noises in four abdominal quadrants Rationale: High-pitched gurgles heard in four abdominal quadrants are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible? A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible? -hypocalcemia -hypercalcemia -hypokalemia -hyperkalemia

A: hypokalemia Rationale: The nurse should monitor the client receiving an I.V. infusion of terbutaline for hypokalemia, lactic acidosis, chest pain, arrhythmias, dyspnea, bloating, chills, or anaphylactic shock. Terbutaline doesn't cause calcium imbalances.

A client is admitted from the emergency department reporting severe right lower quadrant abdominal pain and an elevated white blood cell count and a low grade fever. The nurse continues to monitor the patient while waiting for the physician. The nurse will identify the following as a major concern: -hypotension. -increased pain. -vomiting. -a low sedimentation rate on the patients lab report.

A: hypotension. Rationale: The most severe complication of appendicitis is rupture of the appendix, which can lead to a life-threatening infection. The correct answer is hypotension. This would be indicative appendix rupture and possible septic shock. Increased pain is normal while awaiting surgery as well as vomiting. The sedimentation rate would be elevated

If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to -investigate and correct the discrepancy, if possible, before proceeding. -immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy. -document the discrepancy on an incident report. -document the discrepancy on a opioid-inventory form.

A: immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy. Rationale: Reporting a noted discrepancy to the nurse-manager, nursing supervisor, and pharmacy should be the nurse's first step. Although the discrepancy may be easily corrected if investigated, the investigation isn't a nurse's responsibility. Documenting the discrepancy on an incident report or opioid-inventory form doesn't address the problem.

A physician orders a palliative care consult for a client with end-stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on the nurse's knowledge of palliative care? decreasing administration of pain medications reducing oxygen requirements increasing the need for antianxiety agents decreasing the use of bronchodilators

A: increasing the need for antianxiety agents Rationale: The nurse should anticipate that the physician will increase antianxiety agents during treatment to maintain comfort throughout the dying process. Bronchodilators, pain medications, and home oxygen therapy help promote client comfort. Therefore, they should be continued as part of palliative care.

The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring? -muscle relaxation -intake and output -widening of the pulse pressure -pupil dilation

A: intake and output Rationale: After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

The nurse should assess an older adult with macular degeneration for: -loss of central vision. -loss of peripheral vision. -total blindness. -blurring of vision.

A: loss of central vision. Rationale: Macular degeneration generally involves loss of central vision. Gradual blurring of vision can occur as the disease progresses and may result in blindness; however, loss of central vision is the most common finding. Tiny yellowish spots, known as drusen, develop beneath the retina. Loss of peripheral vision is characteristic of glaucoma.

A client recovering from a closed head injury is restless and agitated. The client still has a central venous catheter in place for antibiotic therapy. The nurse doesn't want to sedate the client, but needs to protect the catheter and other less-restrictive measures have failed. Which method of restraint is best for this client? -soft wrist restraints applied to both wrists -soft restraints applied to each extremity -a vest restraint -mitt restraints applied to both hands

A: mitt restraints applied to both hands Rationale: Mitt restraints are the best choice for this client because they help protect the central venous catheter without restricting the client's movement. Restricting a restless client's movement can lead to restraint-related injury. Soft wrist restraints and soft restraints to each extremity aren't necessary and can cause client injury. A vest restraint isn't necessary because the client isn't attempting to get out of bed.

Which of these involves charting information about the client and client care in chronological order? -focus charting -SOAP charting -narrative charting -PIE charting

A: narrative charting Rationale: Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

Important teaching for a client receiving risperidone should include advising the client to: -maintain a therapeutic level by doubling a dose if the client misses a dose. -be sure to take the drug with a meal because it can severely irritate the stomach. -discontinue the drug if the client gains weight. -notify the physician if the client notices an increase in bruising.

A: notify the physician if the client notices an increase in bruising. Rationale: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. The client shouldn't double the drug dose. This drug doesn't irritate the stomach, and weight gain isn't an adverse effect of risperidone therapy.

The client with an open femoral fracture was discharged to home and reports having a fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. The nurse should interpret these findings as the client may be experiencing which complication? -a pulmonary embolus -osteomyelitis -a fat embolus -a urinary tract infection

A: osteomyelitis Rationale: Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.

The client with an open femoral fracture was discharged to home and reports having a fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. The nurse should interpret these findings as the client may be experiencing which complication? -a pulmonary embolus -osteomyelitis -a fat embolus -a urinary tract infection

A: osteomyelitis Rationale: Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.

A neonate receives an Apgar score of 6 at 5 minutes of age. What additional asessment will the nurse prioritize for this 5-minute Apgar score? -oxygen saturation -heart rate -temperature -respiratory rate

A: oxygen saturation Rationale: Apgar scores at 1 minute gives the nurse an indication of the neonate's adaptation to extrauterine life. At 5 minutes, a clearer picture of the neonate's overall central nervous system status is obtained. When a neonate has a score between 4 and 6, the neonate is having some difficulty. A score of 6 or below indicates there is respiratory difficulty, so the nurse should assess the oxygen saturation to determine the level of need for supplemental oxygen therapy and to provide a baseline upon which to determine response to treatment. Heart rate and respiratory rate are already incorporated in the Apgar assessment. Body temperature can affect Apgar score and hypothermia needs to be addressed, but oxygen saturation takes priority.

A client chronically complains of being unappreciated and misunderstood by others, is argumentative and sullen, and always blames others for the client's failure to complete work assignments. The client expresses feelings of envy toward people the client perceives as more fortunate. The client voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder? -dependent personality -passive-aggressive personality -avoidant personality disorder -obsessive-compulsive disorder

A: passive-aggressive personality Rationale: The client with passive-aggressive personality disorder displays a pervasive pattern of negative attitudes, chronic complaints, and passive resistance to demands for adequate social and occupational performance. The client with a dependent personality is unable to make everyday decisions and allows others to make important decisions for the client. In addition, the client with a dependent personality commonly volunteers to do things that are unpleasant so that others will like the client. The avoidant personality displays a pervasive pattern of social discomfort, fear of negative evaluation, and timidity. The client with obsessive-compulsive disorder displays a pervasive pattern of perfectionism and inflexibility.

A client is being discharged with nasal packing in place. What should the nurse instruct the client to do? -Perform frequent mouth care. -Use normal saline nose drops daily. -Sneeze and cough with mouth closed. -Gargle every 4 hours with salt water.

A: perform frequent mouth care Rationale: Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sneezing and coughing, the client should do so with the mouth open to decrease the chance of dislodging the packing. Gargling should not be attempted with packing in place.

The nurse is providing discharge teaching for a client who will be taking lithium. Which condition would necessitate a call to the client's healthcare provider? -development of black tongue -increased lacrimation -periods of excitability -persistent gastrointestinal upset

A: persistent gastrointestinal upset Rationale: Persistent gastrointestinal upset indicates a mild-to-moderate toxic reaction to lithium. Black tongue is an adverse reaction of mirtazapine, not lithium. Increased lacrimation and periods of excitability aren't adverse effects of lithium.

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should be the priority for the nurse to include in the teaching plan? -postoperative respiratory care exercises -nasogastric intubation and care -nutritional care during recovery -postoperative analgesia and pain control methods

A: postoperative respiratory care exercises Rationale: The nurse must teach the client about respiratory care such as using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients do not have a nasogastric tube in place after a cholecystectomy. Teaching about nutritional care and pain control after surgery should be included, but would not be the priority.

A nurse is administering a prescribed dose of an injection to a middle-aged client with Bell's palsy. What are the sources of fulfillment in the middle-years of an adult client's life? -productive activity -advanced study -sense of faith -personal experiences

A: productive activity Rationale: The middle years are fulfilled through productive activity—in Erikson's term, generativity. This time is of growth and renewed questioning, in some ways very similar to adolescence. For young adults, their beliefs and attitudes change due to some situations such as advanced study or education or new religious affiliations possibly intertwined with achieving intimate relationships, choosing careers, and starting families. The challenge during this stage is to establish one's own sense of faith and commitment based on personal experience and reflection on meaning in life.

A prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to: -ask the nurse to read the policy book before administering the blood. -give a thorough explanation of the procedure for blood administration to the nurse. -ask the nurse to determine how confident he or she is to administer the blood safely. -reassign the client to another nurse who is experienced in blood administration.

A: reassign the client to another nurse who is experienced in blood administration. Rationale: The best option in this situation is to reassign the client to a nurse with experience in blood administration.The policy book and explanation are resources, but the nurse is a pediatric nurse who has never administered blood before, and therefore, an unsafe situation is created.An explanation is insufficient teaching for safe and proper blood administration, and reading policy book may be a resource, but having an experienced nurse administer the blood is a safer decision.Asking about the nurse's confidence is not sufficient evidence that the nurse can administer the blood. Asking an experienced nurse to administer the blood is a safer option.

A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which best describes why the nurse is asking questions about the family's birth plan? -establishing rapport with the family -acting as an advocate for the family -attempting to correct any misinformation the family may have received -recognizing the family as active participants in their care

A: recognizing the family as active participants in their care Rationale: The nurse recognizes the family as active participants in their care by discussing and inquiring about their birth plans, fostering a collaborative relationship with the family. After acknowledging the family as active participants, the nurse is then able to advocate for the family throughout the labor and birth experience. Considering principles of family-centered maternity and newborn care, nurses must advocate for clients to have autonomy in decision making and provide respect and informed choice to ensure that clients and their families are empowered to take responsibility to make decisions. It is the nurse's role to guide and support choices rather than direct or correct.

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has: -an elevated pulse. -confusion. -severe abdominal pain. -constipation.

A: severe abdominal pain Rationale: A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency.An elevated pulse and confusion may occur for various reasons; the assistant should report all vital signs, but the severe pain must be brought to the nurse's attention immediately.Constipation will not require immediate intervention.

A nurse is completing an admission interview of a client newly diagnosed with multiple myeloma. The client expresses concerns about insurance coverage and financial needs. Based on this information, to whom would the nurse initiate a referral? -hospice -financial advisor -social services -case management

A: social services Rationale: A social worker can be extremely beneficial in helping clients identify additional personal and community funding resources and support groups. A hospice referral is not appropriate for a client with a new diagnosis who is seeking treatment. The nurse would not refer the client to a financial advisor as these advisors typically focus on wealth management, not the identification of resources. A referral to case management would be contingent on the client's insurance requirements and would not address the immediate concern.

Which finding indicates that the infant has adequately evacuated the barium after undergoing a barium enema? -absence of fecal mass in the lower abdomen -stools that progress from clay-colored to brown -bowel sounds of 30 per minute -stool guaiac that is negative

A: stools that progress from clay-colored to brown Rationale: The presence of barium produces white or clay-colored stools. A change in stool color from clay-colored to normal brown is an indication that the barium has been evacuated.Presence or absence of a fecal mass does not give definitive information about the passage or retention of barium.Bowel sounds of 30 per minute suggest normal functioning but do not necessarily indicate passage of barium.A stool guaiac test is done to determine the presence of occult blood not barium.

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: -tension and irritability. -slow pulse. -hypotension. -constipation.

A: tension and irritability. Rationale: Amphetamines are a nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Diarrhea, not constipation, is a common adverse effect.

When the nurse is working in the mother-baby unit, which client would the nurse anticipate giving Rho(D) immune globulin (human) to? -the Rh-positive mother with an Rh-negative baby -the Rh-negative mother with an Rh-positive baby -the Rh-positive baby with an Rh-negative mother -the Rh-negative baby with an Rh-positive mother

A: the Rh-negative mother with an Rh-positive baby Rationale: Rho (D) immune globulin (human) is given to an Rh-negative mother after the birth of an Rh-positive baby to prevent the woman from making antibodies that are sensitized to attack foreign Rh-positive blood cells in future pregnancies. Rho D is also given during pregnancy to Rh-negative mothers at 28 weeks, with invasive procedures, or after any trauma, such as an automobile accident. Rho (D) is not given to Rh-positive mothers and is never given to babies.

A nurse is caring for a male neonate who has hypospadias. His parents are planning to have the neonate undergo circumcision before discharge. When teaching the parents about the child's condition, the nurse should tell them -the baby can still be circumcised as planned. -the foreskin will be needed at the time of surgical correction. -circumcision is necessary because the foreskin obstructs the urethral meatus. -circumcision will correct the hypospadias.

A: the foreskin will be needed at the time of surgical correction. Rationale: Circumcision is the surgical removal of the foreskin of the penis. In hypospadias, the urethral meatus is on the underside of the penis. A neonate with hypospadias shouldn't be circumcised because the surgeon may need to use the foreskin for surgical repair. The foreskin doesn't block the urethral meatus, which may be located near the glans, along the underside of the penis, or at the base. Circumcision doesn't correct hypospadias because the location of the urethral meatus isn't changed during circumcision.

Following an incisional approach to an abdominal hysterectomy, the nurse should assess the client for: -thrombophlebitis. -ascites. -peripheral edema. -hypostatic pneumonia.

A: thrombophlebitis Rationale: Clients who have had major pelvic surgery are especially at risk for developing thrombophlebitis postoperatively. Extensive manipulation of the pelvic organs and removal of lymph glands can lead to edema, stasis, and circulatory congestion.Ascites, peripheral edema, and hypostatic pneumonia are not complications that would be specifically anticipated after pelvic surgery.

Which type of mouth care is most appropriate when the nurse is caring for a client with dentures who has severe stomatitis? -using a soft toothbrush to provide oral hygiene -rinsing the mouth with a commercial mouthwash before and after each meal -cleansing the gums and oral mucosa with an oral swab with an astringent every shift -keeping dentures in place to decrease development of edema

A: using a soft toothbrush to provide oral hygiene Rationale: A soft toothbrush, Toothette, or gauze pad should be used to provide oral hygiene at least every 2 hours to promote client comfort and prevent superinfection.Commercial mouthwash is contraindicated because of high alcohol content that is irritating to inflamed mucosa.Oral swabs with an astringent should be avoided because they are drying and also can promote bacterial growth.Leaving dentures in place will have no effect on the development of edema. Additionally, further irritation of the oral mucosa may occur if dentures are left in place. Dentures should be removed to aid in relieving the client's discomfort or pain.

Under which circumstance may a nurse communicate medical information without the client's consent? -when certifying the client's absence from work -when requested by the client's family -when treating the client with a sexually transmitted disease -when prescribed by another health care provider (HCP)

A: when treating the client with a sexually transmitted disease Rationale: Sexually transmitted infections are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency and to otherwise maintain the client's confidentiality. The client's family cannot request release of medical information without the client's consent. A HCP's prescription is not a substitute for a client's consent to release medical information in the absence of a communicable disease.

The nurse assesses a client's outflow is less than the inflow during a peritoneal dialysis exchange. What actions will the nurse use to increase peritoneal dialysis outflow? Select all that apply. -Increase the inflow. -Check the level of the drainage bag. -Contact the health care provider. -Check the peritoneal dialysis system for kinks. -Reposition the client to a side lying.

A: -Check the level of the drainage bag. -Check the peritoneal dialysis system for kinks. -Reposition the client to a side lying. Rationale: The nurse will check the level of the drainage bag and the peritoneal dialysis system for kinks to try and increase client outflow by ensuring catheter flow by gravity. Repositioning the client to the side will also increase outflow by adjusting the catheter. If the nurse adds more dialysate, the client will only have more peritoneal fluid. The nurse will notify the health care provider if positioning and ensuring catheter flow have not worked.

Nurses who provide care in a large, long-term care facility use charting by exception (CBE) as the preferred method of documentation. This documentation method may have which drawbacks? -vulnerability to legal liability because the nurse's safe, routine care is not recorded -increased workload for nurses to complete necessary documentation -failure to identify and record problems and associated interventions -significant differences in charting among nurses from lack of standardization

A: vulnerability to legal liability because the nurse's safe, routine care is not recorded Rationale: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality and safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

A nurse is providing postprocedure instructions for a client who is to undergo a esophagogastroduodenoscopy. The nurse should begin this process -immediately before discharge -before the procedure. -immediately following the procedure. -in the preadmission area.

A: before the procedure. Rationale: A client who undergoes esophagogastroduodenoscopy receives sedation during the procedure, and their memory becomes impaired. Clients tend not to remember instructions provided after the procedure. The nurse's best course of action is to give the instructions prior to the client going to the procedure. The client needs to be aware at discharge of potential complications and signs and symptoms to report to the physician.

A mother expresses concern because her 3-year-old son frequently fondles his penis. The mother does not know the best approach for the child's behavior. What is the nurse's best response to the mother? -"This behavior is normal for a child of his age." -"You should discourage this behavior now before it worsens as he gets older." -"This is a strong sign that he is ready for toilet training." -"We should obtain a urine sample to assess for an infection."

A: "This behavior is normal for a child of his age." Rationale: Children ages 1 to 3 years enjoy fondling their genitals. Punishment for genital fondling may lead to guilt and shame regarding sexual behavior later in life.

A nurse is conducting an examination of a 6-month-old infant. The nurse documents what finding as indicative of normal development? -Babinski -startle -Moro -dance

A: Babinski Rationale: The nurse should be able to elicit the Babinski reflex because it may be present the entire first year of life. The startle reflex actually disappears around 4 months of age; the Moro reflex, by 3 or 4 months of age; and the dance reflex, after the third or fourth week.

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? -total iron-binding capacity -hemoglobin (Hb) -total protein -sweat test

A: total protein Rationale: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

Which precautions should the health care team observe when caring for clients with hepatitis A? -gowning when entering a client's room -wearing a mask when providing care -assigning the client to a private room -wearing gloves when giving direct care

A: wearing gloves when giving direct care Rationale: Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not need a private room unless incontinent of stool.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? -IgA -IgB -IgE -IgG

A: IgE Rationale: Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations? -simple mask -nonrebreather mask -face tent -nasal cannula

A: nonrebreather mask Rationale: A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

Following nasal surgery, the client has packing in the nose. The nurse should: -perform frequent mouth care. -examine the nares for ulcerations. -monitor temperature every 4 hours. -instill normal saline nose drops.

A: perform frequent mouth care. Rationale: Mouth breathing dries the oral mucous membranes. Frequent mouth care is necessary for comfort and to combat the anorexia associated with the taste of blood and loss of the sense of smell.Checking the nares for ulcerations and monitoring the temperature every 4 hours are not necessary.Nose drops are not instilled with packing in place.

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)? -monitoring his temperature every 4 hours -increasing fluid intake -covering the client with a light blanket -providing a low-calorie diet

A: providing a low-calorie diet Rationale: Because a client with a fever has an increased basal metabolism rate, the client needs additional calories in their diet, not fewer calories. Monitoring the client's temperature, increasing their fluid intake, and covering the client with a light blanket are therapeutic interventions for a fever.

The parents of a child with rheumatic fever express concern that their other children will develop the disease. Which response from the nurse is best? -"This disease is not contagious." -"Your other children are as likely to develop this disease." -"Medicine is available to prevent this, so check with your primary care provider." -"Your other children are girls, so they are less likely to get it."

A: "This disease is not contagious." Rationale: Usually other children in the family do not get rheumatic fever. The disorder is not contagious.There is no medicine to give the children as prophylactic therapy. They have already been exposed to their sibling's streptococcal infection. If the other children do not have a streptococcal infection, they probably will not develop it.Girls, just like boys, are at risk for developing rheumatic fever.

A client is admitted to the mental health unit in the manic phase of bipolar disorder. The client refuses to take the prescribed medication. Which would be the most appropriate action by the nurse? -Call security to assist with administering the medication. -Ask the client the reason for not taking the medication. -Put the medication in the client's coffee or food. -Administer the medication by the parenteral route.

A: Ask the client the reason for not taking the medication. Rationale: All clients, including those on a mental health unit, have the right to refuse medication. It is important to find out why a client is refusing to take a medication to understand if the cause can be eliminated or modified. The other options would be considered unethical and may constitute abuse. Disguising or hiding medication that has been refused would be considered abuse.

When administering an I.V. medication through a central line, the nurse notes that a client's central line gauze dressing was last changed 24 hours previously. What is the appropriate action by the nurse? -Change the central line dressing. -Proceed to administer the I.V. medication. -Complete an incident report. -Contact the healthcare provider.

A: Proceed to administer the I.V. medication. Rationale: Gauze dressings should be changed every 2 days so the nurse should proceed to administer the medication. There is no need for an incident report or to contact the healthcare provider.

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? -"Avoid drinking liquids until the gag reflex returns." -"Avoid eating milk products for 24 hours." -"Notify a nurse if you experience blood in your urine." -"Remain supine for the time specified by the physician."

A: "Remain supine for the time specified by the physician." Rationale: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.

The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action? -closed glottis pushing -open glottis pushing -"rest and descent" -squatting while pushing

A: closed glottis pushing Rationale: Closed glottis pushing, or when a woman is told to hold her breath when she pushes typically while the nurse typically counts to 10, creates the Valsalva maneuver and is associated with decreased perfusion. Open glottis pushing, on the other hand, encourages women to listen to their own body cues for when to breathe and when to bear down. "Rest and descent" and squatting have positive influences on the second stage of labor and birth.

A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the medical record. Which action would be mostappropriate for the nurse to implement? -wearing a protective gown and particulate respiratory mask when completing treatments -washing hands before and after entering the room -restricting visitors -contacting the health care provider (HCP) for a prescription for hematopoietic factors such as erythropoietin

A: washing hands before and after entering the room Rationale: Chemotherapy causes myelosuppression with a decrease in red blood cells (RBCs), WBCs, and platelets. This client's data demonstrate neutropenia, placing the client at risk for infection. An ANC of 500 to 1,000/mm3 (0.5 to 1 × 109/L) indicates a moderate risk of infection; less than 500/mm3 (0.5 × 109/L) indicates severe neutropenia and a high risk of infection. When the WBC count is low and immature WBCs are present, normal phagocytosis is impaired. Precautions to protect the client from life-threatening infections may be instituted when ANC is less than 1,000/mm3 (1 × 109/L). Hand washing is the best way to avoid the spread of infection. It is not necessary to wear a gown and mask to take care of this client. It is also not necessary to restrict visitors; however, visitors should be screened to avoid exposing the client to possible infections. Erythropoietin is used for stimulating RBCs, not WBCs. Granulocyte colony-stimulating factors or granulocyte macrophage colony-stimulating factors are useful for treating neutropenia.

The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which sign or symptom? -decreased salivation -bradycardia -cold intolerance -nausea

A: cold intolerance Rationale: Cold intolerance may be associated with anemia because of the diminished oxygen supply to the peripheral circulation. Decreased salivation is not associated with anemia. Tachycardia may be expected in severe anemia. Clients with anemia are usually not nauseated.

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within: -1 hour. -2 hours. -4 hours. -6 hours.

A: 4 hours Rationale: Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

A nurse is preparing a dose of amoxicillin for a 3-year-old with acute otitis media. The child weighs 33 lb (15 kg). The dosage prescribed is 50 mg/kg/day in divided doses for every 8 hours. The concentration of the drug is 250 mg/5 ml. How many milliliters would the nurse administer? Record your answer using a whole number.

A: 5 Rationale: The nurse should calculate the daily dosage for the child:50 mg/kg/day × 15 kg = 750 mg/day.To determine divided daily dosage, the nurse would know that "every 8 hours" means three times per day. So, the nurse would perform that calculation in this way:Total daily dosage ÷ 3 times per day = Divided daily dosage750 mg/day ÷ 3 = 250 mgThe drug's concentration is 250 mg/5 ml, so nurse would administer 5 ml.

The nurse monitors a client following the insertion of a chest tube for a hemopneumothorax. Which observation should the nurse report to the healthcare provider? -600 mL of blood in the collection chamber in 1 hour -intermittent bubbling in the water seal chamber -continuous bubbling in the suction-control chamber -subcutaneous emphysema at the insertion site

A: 600 mL of blood in the collection chamber in 1 hour A blood loss of 600 mL may place the client in danger of developing hypovolemic shock. All of the other choices are normally expected with a chest tube.

A client is diagnosed with osteoporosis. Which statements would the nurse include when teaching the client about the disease? Select all that apply. -Osteoporosis is common in females after menopause. -Osteoporosis is a degenerative disease characterized by a decrease in bone density. -Daily medication is needed to cure the disease. -Osteoporosis can cause pain and injury. -Passive ROM exercises can promote bone growth. -Limit weight bearing and repetitive exercises.

A: -Osteoporosis is common in females after menopause. -Osteoporosis is a degenerative disease characterized by a decrease in bone density. -Osteoporosis can cause pain and injury. Rationale: Osteoporosis is a degenerative metabolic bone disorder in which the rate of bone resorption accelerates and the rate of bone formation decelerates, thus decreasing bone density. Postmenopausal women are at increased risk for this disorder because of their loss of estrogen. Osteoporosis is a treatable disease but there is no cure. The decrease in bone density can cause pain and injury. Osteoporosis is not an inherited disorder; however, low calcium intake because of an intolerance of milk products does contribute to it. Passive ROM exercises may be performed, but they will not promote bone growth. The client should be encouraged to participate in weight-bearing exercise because it promotes bone growth.

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for -hypoxia. -fever. -visual disturbance. -gait alteration.

A: hypoxia Rationale: Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.

A client has received an infusion of antibiotics and is now experiencing an anaphylactic reaction. What is the most important intervention by the nurse? -Administer a bolus of normal saline solution -Maintain a patent airway -Administer epinephrine -Monitor vital signs

A: Maintain a patent airway Rationale: The first priority is to maintain a patent airway. The client will then require an epinephrine injection. If hypotension develops, a saline bolus may be given. The client's vital signs should be monitored, but not as the first action.

An infant who has been in foster care since birth requires a blood transfusion. Who will the nurse approach to give written, informed consent for the procedure? -the foster mother -the social worker for the foster home -a Child Protective Services representative -the nurse manager

A: the foster mother Rationale: When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social worker, the nurse, and the nurse manager have no legal rights to give consent in this scenario. Child Protective Services would become involved only if there was a disagreement between the healthcare provider's recommendation and the foster mother's willingness to consent to treatment.