Kaplan

A client diagnosed with AIDS is admitted to the medical unit with complaints of fatigue, a persistent dry cough, and dyspnea on exertion. Vital signs include BP 136/88, temperature 104°F (40°C), pulse 95, respirations 22. Which of the following actions by the nurse is BEST? 1. Administer a tepid sponge bath with the patient in semi-Fowler's position. 2. Limit oral intake to a maximum of 2,000 ml of fluid per day. 3. Encourage the patient to perform passive ROM four times a day. 4. Suction the patient every four hours to maintain a patent airway.

1

A client diagnosed with a severe thought disturbance has not been taking his medication and appears to be hallucinating more actively. The client claims that the medicine makes him drowsy during the day. Which of the following actions by the nurse is BEST? 1. Ask the physician to schedule the client's entire dose at bedtime. 2. Tell the client that he is getting sicker and must take his medicine. 3. Teach the client about the side effects of the medication. 4. Ask the family to talk to the client about this problem.

1

A client diagnosed with chronic alcoholism who occasionally uses marijuana and cocaine is attending a second group therapy meeting. The client comments, "I am having difficulty sitting still. Am I bothering some of the group members? Maybe I should stop coming to these group meetings." Which of the following nursing actions is MOST appropriate? 1. Encourage the client to share his problem with the group members. 2. Remove the client from the group and assess his needs. 3. Recognize that this is manipulative behavior and encourage the client to remain in the group. 4. Tell the client not to concern himself about the group members and to continue in the group.

1

A client has taken levothyroxine sodium (Synthroid) 0.4 mg daily for 4 days. Which of the following findings should cause the nurse to recommend a change in the client's medication? 1. The client develops nervousness and difficulty sleeping. 2. The client states that she has no energy and is "just tired." 3. The client has coarse hair and skin. 4. The client has a persistent weight gain.

1

A client returns to the floor following a bronchoscopy. The client complains of thirst and requests ice chips. The physician left an order for the patient to resume a regular diet. The nurse should take which of the following actions? 1. Touch the back of the client's throat with a tongue depressor. 2. Observe the client while he sucks on a few ice chips. 3. Provide clear fluids to the client and advance to soft foods. 4. Assess the client's tissue turgor and intake and output.

1

A mother tells the nurse the 7-year-old sibling of her child diagnosed with cystic fibrosis is having difficulty in school, fights frequently with playmates, and throws toys. Which of the following is the BEST response by the nurse? 1. "Did your child have these behaviors before his sister was diagnosed?" 2. "That is typical of 7-year-olds." 3. "Spend time with each child daily and it will stop." 4. "He is jealous of the attention his sister is receiving."

1

A young adult is in a motor vehicle accident and has been admitted to an emergency department. Which of the following observations indicates to the nurse that the client should not be left alone? 1. Disorientation and irregular vital signs. 2. Irregular vital signs and hostility. 3. Rapid respirations and agitation. 4. Elevated vital signs and apprehension.

1

An adolescent is admitted to the hospital after sustaining a concussion because of an auto accident. The nurse is MOST concerned if which of the following is observed? 1. The patient's blood pressure changes from 130/88 to 150/74. 2. The patient's pupils are equal and react to light and accommodation. 3. The patient has difficulty remembering what happened just before the accident. 4. The patient has a urinary output of 120 ml from 5 PM until 7 PM.

1

An elderly patient diagnosed with Alzheimer's disease frequently wanders down the halls of the extended care facility and displays restless agitation. The physician orders a vest restraint. When the nurse takes the restraint to the room, the patient refuses to put it on. It is MOST important for the nurse to take which of the following actions? 1. Take the restraint away, and check the patient frequently. 2. Notify the physician immediately that the patient refused the restraint. 3. Ask a coworker to hold the patient and gently apply the restraint. 4. Exchange the vest restraint for wrist restraints.

1

During the first trimester of pregnancy, a client experiences hyperemesis, which results in a decrease in weight, poor skin turgor, and a chloride deficiency. Which of the following nursing orders should the nurse implement FIRST? 1. Offer fluids every hour as tolerated. 2. Complete an intake and output record every 4 hours. 3. Start an IV immediately upon admission. 4. Perform a weight check every morning.

1

Prior to a nurse discharging an infant home with the parents, which of the following statements, if made by the mother to the nurse, indicates a need for further teaching about newborn care? 1. "I will notify my physician about absence of breathing for 10 seconds." 2. "I will notify my physician about more than one episode of projectile vomiting." 3. "I will notify my physician if my baby's temperature is greater than 101°F (38.3°C)." 4. "I will rock and cuddle my infant frequently to promote a sense of trust."

1

Several hours after an oxytocin (Pitocin) infusion is started, the client's contractions are sustained over two minutes. Which of these nursing actions is MOST important? 1. Discontinue the IV Pitocin. 2. Administer oxygen. 3. Reposition the client. 4. Decrease the IV Pitocin rate.

1

The home care nurse visits a client with a diagnosis of Addison's disease. The nurse determines that teaching is effective when the client makes which of the following statements? 1. "I'll take hydrocortisone (Cortef) in the morning." 2. "I'm glad that I will not have to change my dose of hydrocortisone (Cortef)." 3. "I'll increase my potassium by eating more bananas." 4. "This medicine probably won't affect my blood pressure."

1

The nurse assesses a child diagnosed with cystic fibrosis. The nurse is MOST concerned if which of the following is observed? 1. The child is expectorating thick, yellow mucus. 2. There is increased mucus production with postural drainage. 3. Exertional dyspnea increases during the day. 4. The child complains about difficulty breathing.

1

The nurse cares for a 4-year-old child diagnosed with a closed head injury. The nurse is reassured by which of the following observations? 1. The child is able to state his name when asked who he is. 2. The child reaches for a stuffed animal brought from home. 3. The child maintains himself in opisthotonos. 4. The child withdraws from mildly painful stimuli.

1

The nurse cares for a client after a thyroidectomy. The nurse is MOST concerned if which of the following is observed? 1. Tension and muscle spasm of the hand when a blood pressure cuff is applied to the arm and inflated. 2. Absence of facial movement when the muscles of the facial nerve or branches of the nerve are tapped. 3. Pain in the neck when pulling self to a sitting position or with sudden head movements. 4. Blood pressure readings that remain 10 points below the preoperative readings.

1

The nurse cares for a client in hypovolemic shock. Which of the following indicates a therapeutic response to volume replacement? 1. Urine output increases to 40 ml/hour. 2. Blood glucose of 180 mg/dL, serum potassium of 4.0 mEq/L. 3. CVP of 5 cm water, pupils equal and reactive. 4. Pulse rate of 110 with no dysrhythmias.

1

The nurse cares for a client with a three-chamber water-seal drainage system (Pleur-evac). While the nurse assists the client from the bed to the chair, the drainage tubing becomes disconnected from the Pleur-evac. The nurse should take which of the following actions? 1. Insert the tubing in a container of sterile saline solution. 2. Cut the tubing 2 in from the end, and clamp securely. 3. Reconnect the tubing to the Pleur-evac container. 4. Connect the tubing to a new Pleur-evac container.

1

The nurse cares for a patient following an appendectomy. Several hours after surgery, the nurse finds the knee gatch on the patient's bed elevated. The patient says it feels better with the knee gatch elevated. The nurse should take which of the following actions? 1. Check to see when the patient last received pain medication. 2. Lower the knee gatch, and place two pillows behind his knees. 3. Check to make sure that the knee gatch is not elevated more than 20°. 4. Help the patient turn on the side, and support the back with blankets.

1

The nurse cares for a patient one day after a thoracotomy. The patient is receiving 40% humidified oxygen. Arterial blood gas (ABG) results are PaO2 90 mm Hg, PaCO2 49 mm Hg, pH 7.30, HCO3 26 mEq/L. Which of the following nursing actions is BEST? 1. Position in high Fowler's, and encourage coughing and deep breathing; evaluate airway patency. 2. Place in prone position, and request respiratory therapy to perform postural drainage and percussion therapy. 3. Call the physician to advise about the arterial blood gas report; anticipate increase in oxygen percentage. 4. Administer antianxiety agent, and assist the patient with a rebreathing device to increase oxygen levels.

1

The nurse cares for a woman with pregnancy-induced hypertension (PIH) treated with magnesium sulfate. The nurse is MOST concerned if which of the following is observed? 1. Urine output decreased from 70 to 30 ml/hour. 2. Respiratory rate increased from 14 to 18/minute. 3. Hypertonic patellar reflexes. 4. Blood pressure increased from 150/90 to 170/100.

1

The nurse cares for clients in the outpatient clinic. After instilling atropine sulfate (Isopto Atropine) eyedrops, the nurse should instruct the client to take which of the following actions? 1. Hold pressure on the inner canthus for one minute. 2. Keep the eyes opened, and blink frequently to disperse the medication. 3. Roll the eyes in all directions to enhance the action of the medication. 4. Close the eyes tightly to prevent leakage of the medication.

1

The nurse cares for clients in the prenatal clinic. The nurse is MOST concerned if a diabetic client in the third trimester makes which of the following statements? 1. "I am taking less insulin now than I did two months ago." 2. "I am eating a large bedtime snack." 3. "I walk 15 minutes after lunch every day." 4. "I check my blood sugar two hours after each meal."

1

The nurse cares for clients in the same-day surgery unit. It is MOST important for the nurse to further investigate which of the following client statements? 1. "I take an herbal dietary supplement to lose weight." 2. "I had acute glomerulonephritis 10 years ago." 3. "I perform yoga and walk on my treadmill every day." 4. "I took my blood pressure medication 3 hours ago."

1

The nurse evaluates care in the long-term care facility. Which of the following provides the best evidence that the nursing intervention to deal with a client's self-care deficit in relation to feeding is effective? 1. The client eats at least one-half of all meals and drinks a minimum of 2,000 ml/day. 2. The client's dentures have been replaced, and he is able to chew. 3. The client will eat without verbalizing suspicions when a particular nurse sits with him. 4. The client appears to have increased energy to complete grooming activities.

1

The nurse instructs a client about how to understand and deal with hallucinations. Which of the following indicates to the nurse that teaching is successful? 1. The client reports that he is feeling anxious and requests his radio and headphones in anticipation of "the voices." 2. The client sleeps during the day and avoids going to his assigned activities. 3. The client requests PRN medication between the two regularly scheduled doses. 4. The client reports that he is angry and wishes to leave the hospital immediately.

1

The nurse is caring for clients on the postpartum unit. A client receiving heparin for the treatment of deep vein thrombosis (DVT) says to the nurse, "I am so upset that I can't breastfeed my infant." Which of the following statements, is made by the nurse, is BEST? 1. "You will be able to breastfeed your baby." 2. "Why do you think that it will be a problem?" 3. "We will check your baby's clotting times." 4. "We will give the baby protamine sulfate."

1

The nurse is the leader of a group of developmentally disabled adults. The nurse instructs the group members to ignore another client whenever the client interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should take which of the following actions? 1. Measure improvement by counting the number of times the client succeeds. 2. Measure improvement by counting the number of interruptions. 3. Assess the ability of the group to control the client's interruptions. 4. Count the number of tokens and earned privileges given for interruptions.

1

The nurse knows that which of the following information in a client's history places the client at greatest risk for suicide? 1. Two previous suicide attempts and increased use of alcohol. 2. Verbal threats without a specific plan. 3. Choice of a method that includes going to sleep and not waking up. 4. A specific plan but with ambivalence verbalized.

1

The nurse observes a student nurse administer a Dulcolax suppository. Which of the following actions, if performed by the student nurse, requires an intervention by the nurse? 1. The client is instructed to hold his breath during insertion of the suppository. 2. The suppository is positioned to touch the wall of the patient's rectum. 3. The suppository is inserted 3 to 4 inches into the patient's rectum. 4. Lubricant is applied to the tip of the suppository before insertion.

1

The nurse obtains a health history from the mother of a child diagnosed with failure to thrive. Which of the following assessments provides the MOST pertinent data to the nurse? 1. Weight and height. 2. Urine output. 3. Type of feedings. 4. Mother/child interactions.

1

The nurse performs a health screening at a senior citizen facility. A client has been taking oral iron supplements for a month and complains of constipation. The nurse should adapt a diet plan to include which of the following? 1. Oatmeal, green beans, and celery. 2. Strawberries and mushrooms. 3. Grits, orange juice, and cheddar cheese. 4. Pasta, buttermilk, and bananas.

1

The nurse performs a home visit on a client diagnosed with progressive multiple sclerosis (MS). The physician orders cyclophosphamide (Cytoxan) and adrenocorticotropic hormone (ACTH). It is MOST important for the nurse to take which of the following actions initially? 1. Advise the client to purchase a wig or a hairpiece. 2. Instruct the client to decrease fluid intake. 3. Test the client's serum glucose concentration. 4. Observe for indications of gastrointestinal bleeding.

1

The nurse performs dietary teaching for a client diagnosed with asymptomatic diverticular disease. The nurse determines further teaching is required if the client states which of the following? 1. "I'm glad that I can eat the tomatoes from my garden." 2. "I eat baby carrots as a snack almost every day." 3. "I mix several different kinds of lettuce for my evening salad." 4. "I only eat whole-wheat bread for my lunch sandwich."

1

The nurse performs teaching on a client diagnosed with Bell's palsy. It is MOST important for the nurse to include which of the following instructions? 1. Use artificial tears four times per day. 2. Wear sunglasses at all times. 3. Avoid sudden movements of the head. 4. Change the pillowcase daily.

1

The nurse reviews client care documentation. Which of the following statements BEST indicates to the nurse that the staff requires additional instruction about documentation? 1. "Patient is very sad about the death of his daughter." 2. "Patient states, 'I just can't get over my daughter's death.'" 3. "Patient frequently verbalizes about his daughter's death." 4. "Patient presents a sad face, stooped posture, and tear-streaked eyes."

1

The nurse supervises a nurse's aide administer a soapsuds enema to a patient prior to abdominal surgery. Which of the following actions, if performed by the aide, requires an intervention by the nurse? 1. The aide holds the irrigation set 30 inches above the patient's rectum. 2. The aide inserts the irrigation tube 3 inches into the patient's rectum. 3. The aide positions the patient in Sims' position. 4. The aide warms the water to 105°F (40°C).

1

The nurse supervises a student nurse administer a tube feeding to a client with a tracheostomy. The nurse should intervene if which of the following is observed? 1. The student nurse places the client in a supine position. 2. The student nurse aspirates and returns the residual stomach contents. 3. The student nurse checks the pH of the gastric content. 4. The student nurse checks the bowel sounds for five minutes in each quadrant

1

The parents of a newborn diagnosed with a meningocele have been grieving the loss of their perfect child. After three days of grieving, the progress in their emotional status is indicated to the nurse by which of the following comments? 1. "When will it be safe for us to hold our baby?" 2. "We would rather that you feed our baby." 3. "What did we do to cause this problem?" 4. "When do you anticipate our baby going home?"

1

The school nurse notes that one of the children has a copious watery discharge from the left eye, and the eye is red. Which of the following actions, if taken by the nurse, is BEST? 1. Contact the child's parents to pick up the child. 2. Instruct the child to use a clean tissue each time he wipes his eye. 3. Contact the child's physician. 4. Obtain the child's temperature.

1

A client awakens during the night with dyspnea, severe anxiety, jugular vein distention (JVD), and frothy pink sputum. After the nurse begins oxygen at 4 liters per nasal cannula, which of the following actions is MOST appropriate? 1. Place two pillows behind the head, and elevate the legs. 2. Notify the physician about the change in the client's condition. 3. Increase IV fluids to liquefy the secretions. 4. Dim the lights, and provide privacy.

2

A client diagnosed with tertiary syphilis is admitted to a nursing unit. The client exhibits signs of marked dementia and disorientation. Which of the following actions should the nurse take FIRST? 1. Place the nurse call bell within reach. 2. Frequently observe the client's behavior. 3. Apply a vest-type restraint. 4. Provide an around-the-clock sitter.

2

A client recently admitted to labor and delivery states that she is having severe discomfort with contractions. The nursing assessment reveals that the client is 3 cm dilated. The nurse assists the client through guided imagery. Ten minutes later the client is more agitated. The nurse should take which of the following actions? 1. Reteach the exercise. 2. Reposition the client. 3. Turn on the television. 4. Ambulate the client.

2

A client undergoes a total laryngectomy because of carcinoma. The nurse instructs the client and spouse how to suction the laryngectomy tube. Which of the following actions indicates to the nurse that teaching is effective? 1. The man selects a Yankauer tonsil tip catheter to suction the laryngectomy tube. 2. The man takes several deep breaths before the suction catheter is inserted. 3. The man applies suction as he introduces the sterile catheter into the stoma. 4. The wife suctions the man's mouth and then the laryngectomy tube.

2

A man is hospitalized with a fractured pelvis following an automobile accident. A female nurse is administering routine morning care when the patient tells the nurse that he finds her extremely attractive and would like her to come back to visit him that evening after work. Which of the following responses by the nurse is BEST? 1. "I appreciate the compliment you paid me, but why did you ask me that?" 2. "That kind of interaction is not appropriate. Why don't you finish shaving?" 3. "It is interesting that you feel that way. Do I remind you of someone?" 4. "You seem to be attracted to me, but I don't feel the same way."

2

A permanent demand pacemaker, set at a rate of 72, is implanted in a client for persistent third-degree block. The nurse is MOST concerned if which of the following is observed? 1. Pulse rate 88 and irregular. 2. Apical pulse rate regular at 68. 3. Blood pressure 110/88, pulse at 78. 4. Skin warm and dry to touch.

2

A spica cast is applied to a 14-month-old with developmental dysplasia of the hips. Which of the following is MOST appropriate for the nurse to teach the parents? 1. Change diapers frequently to prevent cast soiling. 2. Inspect the skin around the cast. 3. Turn the client by using the abduction stabilizer bar. 4. Keep small toys out of the client's reach.

2

An elderly client is diagnosed with a vitamin K deficiency because of dietary malabsorption. Which of the following is an appropriate nursing intervention for this client? 1. Encourage the client to remain in bed. 2. Carefully check the client's arm after taking the blood pressure. 3. Increase dietary intake of fruits and fiber. 4. Observe the client for signs of angina or cardiac dysrhythmia.

2

An elderly patient undergoes a colonoscopy. During the postprocedure period, it is MOST important for the nurse to monitor for which of the following? 1. Patient's ability to move the legs. 2. Fluid and electrolyte balance. 3. Characteristics of the patient's stool. 4. Level of pain the patient experiences.

2

During a nonstress test (NST), the nurse observes several late decelerations. Which of the following nursing actions is MOST appropriate? 1. Reposition the client on her right side. 2. Notify the physician for further evaluation. 3. Document these results in the nurse's notes. 4. Stop the oxytocin (Pitocin) immediately.

2

During a well-baby checkup, the nurse evaluates the reflexes of a 6-month-old child. The nurse is MOST concerned if which of the following is observed? 1. Presence of a positive Babinski reflex. 2. Extrusion reflex when feeding. 3. Able to grasp objects voluntarily. 4. Rolls from abdomen to back at will.

2

Four days after a client has an abdominal perineal resection, which of the following signs is MOST important for the nurse to report to the physician? 1. Moderate amount of serosanguineous drainage on the abdominal dressing. 2. Nausea, vomiting, and increased abdominal distention. 3. Moderate amount of yellow-green nasogastric drainage and decreased urine output. 4. Urinary output via Foley catheter 120 ml over a 4-hour period.

2

Polyethylene glycol-electrolyte solution (GoLYTELY) is ordered for a client before a colonoscopy. The physician's office nurse explains to the client how to take the solution. Which of the following statements, if made by the client, indicates the need for further instruction? 1. "I need to drink 4 liters of the solution." 2. "If I drink it ice cold, it won't taste as bad." 3. "Once I finish drinking the solution, I can drink only water." 4. "I can use tap water to reconstitute the powder."

2

The home health nurse makes home visits to follow the progress of a 2-year-old diagnosed with tetralogy of Fallot. When the nurse visits the home, the child is diaphoretic and short of breath. What should the nurse do FIRST? 1. Give the boy oxygen at 2 liters via nasal cannula. 2. Place the boy in the knee-chest or squatting position. 3. Administer morphine 0.1 mg/kg SQ to the boy. 4. Lay the boy in bed flat with his head elevated.

2

The mother of a child diagnosed with type 1 diabetes calls to discuss the child's self-monitoring blood glucose (SMBG) home readings. The child is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings, the blood sugar readings were 220 mg/dL and 210 mg/dL. The nurse should advise the mother to take which of the following actions? 1. Continue the child's medication regime. 2. Check the blood sugar during the night. 3. Give the NPH insulin later in the evening. 4. Serve the bedtime snack earlier in the evening.

2

The nurse cares for a 23-year-old college student from China awaiting arthroscopic knee surgery. Which of the following observations suggests to the nurse that the client is anxious? 1. The client's skin is cool and dry. 2. The client shifts his position in bed frequently. 3. The client's pulse is 74 and BP is 104/66. 4. The client answers questions appropriately.

2

The nurse cares for a child after a tonsillectomy. The nurse is MOST concerned if which of the following is observed? 1. Heart rate of 88 beats per minute. 2. Expectorating bright red secretions. 3. Thirty milliliters of dark brown secretions. 4. Infrequent swallowing.

2

The nurse cares for a client in active labor. As labor progresses, the client becomes irritable and complains of feeling increasingly uncomfortable. The nurse notes that the client is 8 cm dilated. Which of these actions should the nurse take FIRST? 1. Notify the physician of the patient's complaints. 2. Coach the patient in proper breathing and relaxation techniques. 3. Administer the standing order for meperidine (Demerol). 4. Reposition the fetal monitor to allow the patient to change positions.

2

The nurse cares for a client receiving total parenteral nutrition. Lab values are glucose 72 mg/dL, chloride 98 mEq/L, sodium 138 mEq/L, potassium 3.0 mEq/L. Which of the following nursing actions is MOST appropriate? 1. Discontinue the TPN administration. 2. Notify the physician. 3. Administer IV glucose. 4. Check the client's vital signs.

2

The nurse cares for a client scheduled for surgery. Immediately before transporting the client to the surgical area, the nurse should take which of the following actions? 1. Check the client's vital signs. 2. Check the client's identification bracelet. 3. Ask the client to sign the operative permit. 4. Administer the preoperative medications.

2

The nurse cares for a client with a radium implant. It is MOST important for the nurse to take which of the following actions? 1. Evaluate the position of the applicator every two hours. 2. Place the client on a low-residue diet to decrease bowel movements. 3. Encourage the use of the bedside commode every one to two hours. 4. Decrease fluid intake to decrease radiation in the bladder.

2

The nurse cares for a patient admitted to the unit three days ago with deep partial thickness and full thickness burns over 30% of the body. It is MOST important for the nurse to report which of the following observations to the next shift? 1. CVP reading of 12 cm water pressure. 2. General muscle weakness and lethargy. 3. Heart rate of 100 beats per minute. 4. Systolic blood pressure of 105.

2

The nurse cares for patients on the pediatric unit. An 8-year-old patient with deep partial thickness and full thickness burns on the right thigh is admitted. The nurse should assign the new patient with which of the following roommates? 1. A 2-year-old with chickenpox. 2. A 4-year-old with asthma. 3. A 9-year-old with acute diarrhea. 4. A 10-year-old with methicillin-resistant Staphylococcus aureus (MRSA).

2

The nurse enters the room and discovers that the client has slurred speech, right-sided paralysis, and unequal pupils. Which of the following actions should the nurse take FIRST? 1. Call the physician. 2. Assess the respiratory status. 3. Determine the level of consciousness. 4. Perform a complete neurological evaluation.

2

The nurse is caring for a client with a bleeding duodenal ulcer. The nurse would be MOST concerned if the patient reported taking which of the following medications? 1. Ranitidine hydrochloride (Zantac) 150 mg PO. 2. Metoclopramide hydrochloride (Reglan) 15 mg PO. 3. Sucralfate (Carafate) 1 gm PO. 4. Famotidine (Pepcid) 20 mg PO.

2

The nurse performs teaching for a client being discharged on dexamethasone (Decadron) 0.75 mg PO daily. The nurse determines teaching successful if the client makes which of the following statements? 1. "I will take my medication with orange juice in the morning." 2. "I will take my medication with breakfast." 3. "I will take my medication three hours after eating." 4. "I will take my medication before I eat breakfast."

2

The nurse prepares to examine the client's thyroid gland. Which of the following statements, if made by the nurse, is BEST? 1. "Would you like a Band-Aid?" 2. "Here is a glass of water." 3. "I will be using this tape measure." 4. "Please use this specimen cup."

2

The nurse prepares to insert a Foley catheter into a patient. It is MOST important for the nurse to take which of the following actions? 1. Place all supplies close to the edge of the table. 2. Keep the field holding the supplies in front of the nurse. 3. Set up the field below the nurse's waist level. 4. Add only clean supplies to the field.

2

The nurse reviews the record for a patient with a chest tube attached to a Pleur-evac system. The nurse evaluates which of the following nursing actions is appropriate? 1. "Chest tube was clamped." 2. "Pleur-evac next to bed." 3. "Suction decreased to 15 cm." 4. "Chest tube disconnected from the Pleur-evac."

2

The nurse sees clients in a pediatric clinic. The nurse receives a phone call from the mother of a 3-year-old saying that her child has vomited several times today. Which of the following instructions by the nurse is BEST? 1. "Offer your child some ice cream." 2. "Give your child some apple juice." 3. "Offer your child orange juice." 4. "Make some pudding for your child."

2

To coordinate community placement for a client diagnosed with schizophrenia and alcoholism who is homeless, the nurse should take which of the following actions? 1. Collaborate with members of the client's family to explore placement options. 2. Collaborate with the health care team and the client to schedule a predischarge visit to a residential placement facility. 3. Visit the placement facility alone to make an independent decision about the facility, and report to the client and family. 4. Review with the client specific rules of the facility.

2

Which nursing action is MOST appropriate when an infant is admitted for fever, poor feeding, irritability, and a bulging fontanel? 1. Perform neurological checks every four hours. 2. Place the client on droplet precautions. 3. Monitor the client's urine output closely. 4. Encourage fluid intake.

2

Which of the following statements by an adult client indicates to the nurse the need for further teaching regarding care of a sigmoid colostomy? 1. "I hope to be able to go without a pouch soon." 2. "I'm irrigating my colostomy after each meal." 3. "My stoma is looking better all the time." 4. "It's not hard to change my pouch every several days."

2

A 12-year-old client is admitted to the pediatric unit in vaso-occlusive crisis from sickle cell anemia. As the nurse prepares the plan of care, which of the following orders should the nurse question? 1. Bedrest with bathroom privileges. 2. Two liters oxygen via nasal cannula. 3. Maintain IV at keep-open rate. 4. Administer analgesics as ordered.

3

A 4-month-old infant who had a temperature of 103°F (39.4°C) following the last DTaP (diphtheria, tetanus, and pertussis) vaccine is seen in the clinic for another immunization administration. Prior to the nurse's administering the DTaP, which of the following should be the nurse's priority? 1. Withhold the immunization. 2. Give half the dose in this injection. 3. Consult the physician about giving pediatric DT (diphtheria and tetanus). 4. Instruct the parents to give acetaminophen following administration of the full dose of DTaP.

3

A child is admitted to the pediatric unit with a suspected diagnosis of Haemophilus influenzae meningitis. As the nurse explains care to the parents, they ask how long their child will need to be in a room by herself. Which response by the nurse is MOST appropriate? 1. "It depends on the results of her blood counts." 2. "Patients like her are usually in isolation for a couple of days or so." 3. "Isolation can usually be stopped 24 hours after the start of antibiotic therapy." 4. "When your child has been afebrile for 48 hours, we will move her."

3

A client complains of hearing loss. While the nurse is irrigating the client's ear to remove cerumen for better observation of the tympanic membrane, the client complains of dizziness. Which of the following actions should the nurse take FIRST? 1. Notify the physician immediately. 2. Monitor for changes in intracranial pressure. 3. Warm the irrigant, and resume the procedure. 4. Explore the canal with a cotton applicator.

3

A client diagnosed with peripheral vascular disease (PVD) states that he experiences leg pain frequently when walking, and he asks the nurse in the clinic what he should do. The nurse should advise him to take which of the following actions? 1. Lie down with his feet elevated above his heart when he experiences pain. 2. Apply a heating pad to his legs for 15 minutes before walking. 3. Walk until he experiences pain, then rest, and then resume walking. 4. Perform stretching exercises 20 minutes before starting to walk.

3

A client is admitted to the emergency room with complaints of crushing chest pain, shortness of breath, and left arm pain. Which of the following actions, if taken by the nurse, is BEST? 1. Administer oxygen. 2. Place in a semi-Fowler's position. 3. Administer morphine sulfate. 4. Administer lidocaine.

3

A client is experiencing a severe panic attack and has threatened to hurt another client on the unit. The nurse would expect to administer which of the following PRN medications as ordered? 1. Chlorpromazine (Thorazine). 2. Lithium carbonate (Lithane). 3. Haloperidol (Haldol). 4. Phenytoin (Dilantin).

3

A client is scheduled for a myelogram because of complaints of severe lumbar pain. Which of the following nursing interventions is MOST important for this procedure? 1. Inform the client about being NPO prior to the test. 2. Encourage ambulation after the test. 3. Encourage fluids prior to and after the test. 4. Instruct the client to remain prone for 24 hours.

3

A client receives prochlorperazine maleate (Compazine) 10 mg IM before repair of a hernia under general anesthesia. The nurse is MOST concerned if which of the following is observed six hours after surgery? 1. An IV of 0.9% NaCl is infusing at 100 ml/hour. 2. The patient is sleepy but able to be aroused. 3. The patient has not voided since surgery. 4. There is a moderate amount of serosanguineous drainage on the abdominal dressing.

3

A client returns to the recovery room at the outpatient surgery center after cataract surgery. The nurse notes that the IV site in the client's left hand appears reddened and warm. Which of the following actions, if performed by the nurse, is BEST? 1. Call the physician to obtain an order to remove the IV cannula. 2. Apply cool compresses, and continue to assess the IV insertion site. 3. Stop the IV infusion, and remove the IV cannula. 4. Apply antibiotic ointment to the site, and change the IV dressing.

3

A client with sudden onset of deep vein thrombosis (DVT) is started on IV unfractionated heparin. Which of the following orders should the nurse question? 1. Warm, moist packs to the affected leg. 2. Elevate the foot of the bed 6 inches. 3. Commode privileges without weight bearing. 4. Elastic stockings on unaffected leg.

3

A client with urinary frequency, burning, and a temperature of 102°F (38.8°C) is instructed by the nurse to collect a urine specimen for culture and sensitivity. The nurse knows that teaching is successful if the client states which of the following? 1. "I will call the lab before I collect my urine." 2. "I will drink several glasses of water before I collect my urine." 3. "I will collect the specimen using an aseptic technique." 4. "I will discard my first voiding in the morning."

3

A woman diagnosed with hepatitis B is scheduled for an abdominal hysterectomy. It is MOST important for the nurse to check which of the following lab results before the patient goes to surgery? 1. Potassium. 2. Sodium. 3. Prothrombin time. 4. Hemoglobin.

3

A young Hispanic client who speaks little English is admitted to a medical-surgical unit with an increased temperature. Prior to the nurse performing a physical assessment, which of the following is the MOST appropriate nursing action? 1. Attempt to prepare the client with hand signals. 2. Show the client pictures of the physical exam process. 3. Contact an employee who speaks Spanish to translate. 4. Speak slowly to explain the physical assessment.

3

After termination of preterm labor, the nurse confirms the ability of a client to monitor herself at home for fetal well-being if she can do which of the following? 1. Count uterine contractions. 2. Measure her urine output. 3. Count fetal kicks. 4. Weigh herself daily.

3

An 8-year-old child is brought to the physician's office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The child complains of headache and nausea and has a temperature of 103°F (39.3°C). The nurse observes the child has a petechial rash on the trunk of the body. Which of the following assessments is MOST important for the nurse to perform? 1. Grasp the child's hands, and ask him to squeeze the nurse's hands. 2. Stroke the plantar surface of the child's foot with a reflex hammer. 3. Gently flex the child's head and neck onto the chest. 4. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.

3

During a health history, a teenaged girl tells the nurse, "I have no appetite, and I've lost 4 lb this week." It is MOST important for the nurse to take which of the following actions? 1. Notify the physician. 2. Weigh the client. 3. Continue with the interview. 4. Examine the abdomen.

3

During the discharge planning session for a chronically ill infant, the nurse observes that the single mother nervously paces most of the time while bouncing the infant in her arms. Which of the following suggestions by the nurse is BEST? 1. "See your obstetrician for a prescription for a mild tranquilizer." 2. "Buy a commercially made 'baby bouncer' infant seat." 3. "Enroll in a Volunteers of America parenting class." 4. "Investigate hiring a live-in nanny."

3

Four days ago the physician prescribed lithium carbonate (Lithobid) 600 mg tid for a client. The client returns to the outpatient clinic for evaluation. What teaching regarding the medication is MOST important for the nurse to reinforce with the client and the client's spouse? 1. The client should check for ankle swelling and decreased urinary output. 2. The client should keep a log of the time of day medication is taken and the way he is feeling. 3. The client should call the clinic if tremors, muscular weakness, or ataxia develops. 4. Because of the medication, the client should be experiencing remission of the symptoms.

3

The nurse admits a client with possible Haemophilus influenzae meningitis. It is MOST important for the nurse to take which of the following actions? 1. Place the client on airborne precautions for 24 hours. 2. Perform neurological checks every four to six hours. 3. Dim the lights in the room, and minimize environmental stimuli. 4. Encourage PO fluids during the day to decrease fever.

3

The nurse assesses the emotional support available to a client who is starving herself. Which of the following questions is MOST important for the nurse to ask in the assessment interview? 1. "What do you consider your ideal weight to be?" 2. "How does your eating pattern change when you are around other people?" 3. "What happens at home when you express opinions that are different from those of your parents?" 4. "What do you think about your present weight?"

3

The nurse cares for a client recovering from streptococcal pneumonia who has a chest x-ray that reveals a higher degree of atelectasis in the right lower lobe. Which of the following nursing interventions is MOST appropriate? 1. Instruct the client to take deep breaths more frequently. 2. Reposition the client every hour to the right side. 3. Increase the frequency of incentive spirometry. 4. Change respiratory treatment to every two hours.

3

The nurse cares for a patient after a craniotomy. The patient's history reveals breast cancer with metastatic lesions to the brain, and the patient has received chemotherapy for one month. Postoperatively, the nurse is MOST concerned if which of the following is observed? 1. Urine is foul smelling, and the urine specific gravity is 1.035. 2. The client's 24-hour fluid intake is 3,000 ml. 3. The client's 24-hour urinary output is 4,000 ml. 4. The client has diarrhea and excoriation of the anal area.

3

The nurse cares for a patient three days after a spinal cord injury at the level of T5. The patient complains of a pounding headache, and the nurse notes profuse sweating on the patient's forehead. Which of the following actions should the nurse take FIRST? 1. Determine the patency of the Foley catheter. 2. Place ice packs on the neck and head. 3. Elevate the head of the bed. 4. Apply a rigid cervical collar.

3

The nurse cares for clients in a rehabilitation facility. To support the client learning self-care, the nurse should take which of the following actions FIRST? 1. Provide instructions to complete an activity. 2. Observe client progress with an activity. 3. Establish the goal of the activity with the client. 4. Allow the client to complete as much self-care as desired.

3

The nurse determines which of the following diversional activities is most appropriate for a 10-year-old female client recovering from a sickle cell crisis? 1. Walking in the hall 20 minutes twice a day. 2. Watching the cartoon channel all day. 3. Collecting pictures of favorite stars from magazines. 4. Putting together large-pieced wooden puzzles.

3

The nurse finds a client unresponsive and making funny sounds. The client's arms and legs are stiff and jerking, and there is no verbal response. Which of the following actions should the nurse take FIRST? 1. Open the client's mouth, and place a tongue blade between the teeth. 2. Position the client on his back, open the airway, and assess respiratory status. 3. Remain with the client, and prevent him from injuring himself or falling out of bed. 4. Restrain the client's extremities, and determine the neurological status.

3

The nurse in a small town is called to a neighbor's house in the middle of a blizzard. The neighbor woman states that she is at 39 weeks' gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse assists with the delivery of the infant. Once the head is delivered, it is MOST important for the nurse to take which of the following actions? 1. Instruct the woman to bear down and push. 2. Turn the infant's head in a clockwise direction. 3. Check the infant's neck for the umbilical cord. 4. Ask the woman to pant through her mouth.

3

The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and is given four phone messages. Which of the following phone messages should the nurse return FIRST? 1. A client who has an indwelling Foley catheter and is complaining of foul-smelling urine. 2. A client who had a 9 lb infant 3 days ago and is complaining of painful breasts. 3. A client who had a cataract lens extraction 4 days ago and has not had a bowel movement in 3 days. 4. A client states that he had abdominal cramping and diarrhea after eating a large meal.

3

The nurse monitors a client diagnosed with cholecystitis. The nurse is MOST concerned if which of the following is observed? 1. Nausea. 2. Frequent belching. 3. Jaundice. 4. Right upper abdominal pain.

3

The nurse overhears a conversation in the cafeteria between two nurses regarding a client's home situation. Which of the following actions is the MOST appropriate? 1. Report the incident to the nurse manager. 2. Join the conversation with the nurses. 3. Suggest that the nurses continue their conversation in private. 4. Ignore the incident because the nurse is not involved.

3

The nurse performs a home care visit for the family of a toddler. The nurse is MOST concerned if which of the following is observed? 1. A bruise on the toddler's knee. 2. The toddler cries and is fearful when the parents leave. 3. The toddler's immunizations are not up to date. 4. The toddler throws a temper tantrum during an injection.

3

The nurse prepares a client for an intravenous pyelogram (IVP). Which of the following statements, if made by the client to the nurse, indicates teaching is effective? 1. "I may feel a fluttery sensation when the catheter is inserted." 2. "The test may cause spasms and shooting pains in my back." 3. "I may experience a hot feeling, and my skin may become flushed." 4. "I may become light-headed and have a desire to cough."

3

The nurse prepares a client for insertion of a subclavian triple lumen catheter to be used for administration of total parenteral nutrition (TPN). The nurse should position the client in which of the following positions? 1. High-Fowler's position with the client's head in a neutral position. 2. Semi-Fowler's position with the client's head extended. 3. Supine with the client's head low and turned away from the insertion site. 4. Left lateral with the client's head turned toward the insertion site.

3

The nurse supervises a nurse's aide transferring a client from the bed to the chair after a right total hip replacement. The nurse should intervene if which of the following is observed? 1. The nurse's aide helps the woman to a sitting position. 2. The nurse's aide positions the chair at a 90° angle to the bed. 3. The nurse's aide stands on the same side of the bed as the patient's unaffected side. 4. The nurse's aide pivots the patient on the unaffected leg.

3

The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients? 1. A client 1 day postoperative after an internal fixation of a fractured left femur. 2. A client receiving diltiazem (Cardizem) and phenytoin (Dilantin). 3. A client ordered to receive 2 U of packed cells prior to an upper endoscopy procedure. 4. A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.

3

The physician adds cholestyramine (Questran) 4 gm PO ac and hs to the medication regimen for an older client. The client is also taking digoxin (Lanoxin) 0.125 mg PO qd and hydrochlorothiazide (Esidrix) 25 mg PO qd. The nurse assists the client to set up a medication schedule. Which of the following medication schedules is BEST? 1. Give the 3 meds at 8am, and Questran also at12,5 and hs 2. 3. 4.

3

The school nurse interviews an adolescent. The nurse is MOST concerned if the adolescent states which of the following? 1. "I am so busy all the time, and at the end of the day, I am tired." 2. "Once in a while, I fall over my feet when I am just walking around." 3. "I'm glad I don't get as sweaty as my friends when I work out." 4. "It is important that I wear clothes that are similar to what my friends wear."

3

Which of the following actions, if performed by the nurse, is considered negligence? 1. Inserting a 16 Fr NG tube and aspirating 15 ml of gastric contents. 2. Administering Demerol IM to a patient prior to his using the incentive spirometer. 3. Administering ferrous sulfate (Feosol) 325 mg with coffee. 4. Initially administering blood at 5 ml/minute for 15 minutes.

3

Which of the following questions BEST aids the nurse in assessing the orientation of a client on the psychiatric unit? 1. "Who is the president of the United States?" 2. "Do you remember my name?" 3. "What is your name?" 4. "What time is it?"

3

Which of the following statements, if made by a client diagnosed with Buerger's disease to the nurse, indicates that teaching is effective? 1. "I should avoid taking analgesics if I become uncomfortable." 2. "The medication I am taking will prevent this disease from recurring." 3. "I should inspect my fingers and toes every day." 4. "I should keep track of how much fluid I drink during the day."

3

Which statement, if made by the client diagnosed with Cushing's syndrome, indicates to the nurse the need for further teaching? 1. "I realize I'll have to gradually begin an exercise program." 2. "I'm going to have to keep a close eye on my blood pressure." 3. "I'm not really worried about getting pneumonia this winter." 4. "I'll be eating foods low in carbohydrates and salt."

3

While checking the patency of a Salem sump tube, the nurse finds stomach contents draining from the air vent. Which of the following nursing actions is MOST appropriate? 1. Insert water through the air vent. 2. Pull the sump tube back 2-3 inches. 3. Insert 30 ml of air through the air vent. 4. Insert a new nasogastric tube.

3

A 20-year-old, gravida 1, para 0 woman comes to the clinic for her first routine prenatal exam. During the physical assessment, the client informs the nurse that she is unsure of the date of her last menstrual period. Which of the following assessments would best assist the nurse in determining her expected date of confinement (EDC)? 1. The presence of Hegar's sign. 2. A positive pregnancy test. 3. The presence of quickening. 4. Auscultation of the fetal heartbeat.

4

A client at 38 weeks' gestation is admitted in active labor. The nursing assessment reveals a decrease in the client's blood pressure to 90/50, and the fetal heart rate (FHR) is 130 and regular. Which of the following nursing actions is MOST important? 1. Contact the physician. 2. Elevate the head of the bed. 3. Check the client's blood pressure and FHR every 30 minutes. 4. Place the client on her left side.

4

A client is to receive peritoneal dialysis through a catheter inserted through a trocar. Which of the following nursing interventions is ESSENTIAL for the nurse to perform? 1. Maintain the client in a supine position during the procedure. 2. Weigh the client during the procedure and again 24 hours later. 3. Change the dwell time according to the client's tolerance during the procedure. 4. Check the client's BP and apical and radial pulses before the procedure.

4

A father brings his 15-month-old son to the well-baby clinic for a routine checkup. The father confides to the nurse that he is concerned that his son still crawls and does not walk. Which of the following responses, if made by the nurse to the father, is BEST? 1. "I will refer you to a pediatric specialist if he doesn't start walking soon." 2. "Have you noticed any signs of paralysis or weakness in your son?" 3. "Try standing him on his feet several times a day." 4. "Children frequently set their own pace for development."

4

A patient receives gentamycin (Garamycin) 500 mg q 8 hours IV for a Pseudomonas infection of the leg. When the nurse walks into the patient's room, the patient is sitting in a chair with his back to the door, looking out the window. When the patient does not respond to the nurse's greeting, the nurse touches him on the shoulder. The patient jumps and acts startled. Which of the following actions, if performed by the nurse, is MOST important? 1. Ask the patient what he is thinking. 2. Monitor the color and sensation in the patient's leg. 3. Obtain the patient's temperature, pulse, and blood pressure. 4. Check the patient for tinnitus and hearing loss.

4

A staff member working in the newborn nursery complains to the nurse that even though he doesn't feel bad, he has been having loose stools for the last couple of days. Which of the following responses by the nurse is BEST? 1. "Make sure you wash your hands after going to the bathroom." 2. "Are you drinking plenty of fluids?" 3. "Describe to me how you are feeling." 4. "I'm going to reassign you to the orthopedics."

4

A young adult comes to the outpatient clinic with complaints of vaginal itching. Which of the following recommendations, if given to the client by the nurse, is MOST appropriate? 1. "Supplement your diet with yogurt and dairy products." 2. "Douche with an over-the-counter preparation." 3. "Wash the area with soap and water several times a day." 4. "Wear underwear that is lined with a cotton crotch."

4

A young woman comes to the prenatal clinic, pregnant for the first time. The client states that she participates in a regular exercise program and asks the nurse if she should continue to do this during her pregnancy. Which of the following is the BEST response by the nurse? 1. "You should limit your exercise because it may interfere with your ability to carry the child to term." 2. "You should restrict your exercise to taking brisk walks twice a day." 3. "You can exercise as much as you want, but you should cut back on your other activities." 4. "You can continue your regular exercise program, but you should rest when you are tired."

4

An elderly client has had a subtotal gastrectomy. The client received meperidine (Demerol) 75 mg and hydroxyzine hydrochloride (Vistaril) 50 mg IM. The nurse is MOST concerned if which of the following was observed? 1. Tachypnea. 2. Lethargy. 3. Hypertension. 4. Disorientation.

4

An elderly client is very confused and disoriented when admitted to the hospital from a long-term care facility. Which of the following is a priority nursing assessment? 1. Determine the client's level of mobility when walking. 2. Evaluate the client's teeth, and determine an appropriate diet. 3. Determine if a family member can remain at the bedside. 4. Assess the respiratory status, and evaluate for hypoxia.

4

In caring for a client with dementia, the nurse should give highest priority to which of the following goals? 1. Keep the client alive. 2. Ensure that the client has an adequate fluid intake. 3. Return the client to a functional role in the community. 4. Maintain an optimal level of functioning.

4

The clinic nurse returns a phone call from a client diagnosed with type 1 diabetes who has been vomiting for 24 hours. It is MOST important for the nurse to instruct the client to take which of the following actions? 1. Take half of the regular insulin dose. 2. Attempt to maintain the regular diabetic diet. 3. Limit intake of sweets and sugar. 4. Drink liquids as often as possible.

4

The home care nurse makes a follow-up visit to a client recently diagnosed with AIDS. Which of the following activities, if performed by the client, indicates that the nurse's teaching has been effective? 1. The patient uses a firm toothbrush once a day to brush her teeth. 2. The patient eats a large lunch at noon and a small dinner at 6 PM. 3. The patient changes the litter in her cat's litter box every day. 4. The patient takes docusate sodium (Colace) 300 mg once a day.

4

The home care nurse visits a client is taking carbidopa-levodopa (Sinemet) for tremors, shuffling gait, and rigidity. Which of the following statements, if made by the home health aide to the nurse, indicates that the medication is effective? 1. "The client's weight increased by 2 lb." 2. "The client is getting over an upper respiratory infection." 3. "There is an increase in the fine motor tremors." 4. "The client seems to be more ambulatory."

4

The home care nurse visits a client taking diazepam (Valium) to help deal with the anxiety experienced due to nightmares and flashbacks about the war. During a visit, the home care nurse observes the client is ataxic, confused, has slurred speech, and complains of dizziness. Which of the following nursing actions is MOST appropriate? 1. Give the client a relaxation tape, and send the client to a quiet room. 2. Sit quietly with the client because the client is having a flashback. 3. Recommend to the physician that the client be given medication for sleep. 4. Recommend that the physician evaluate the client's excessive use of the drug diazepam.

4

The nurse cares for a client diagnosed with dissociative disorder. Which of the following is a priority nursing action? 1. Assist the client to understand the relationship between anxiety and dissociation. 2. Assess the client's level of and reason for memory loss. 3. Assist the client to incorporate the dissociated material into conscious memories. 4. Establish an honest, nonjudgmental, and safe relationship with the client.

4

The nurse cares for a client in alcohol withdrawal. The nurse expects the physician to order which of the following oral medications to assist the client in decreasing the severity of the symptoms? 1. Amitriptyline (Elavil). 2. Trazodone (Desyrel). 3. Fluphenazine (Prolixin). 4. Chlordiazepoxide (Librium).

4

The nurse conducts a class at a senior citizen center on the changes associated with aging. The nurse is MOST concerned if a client states which of the following? 1. "I seem to get colds more often now than I did years ago." 2. "I'm about an inch shorter now than I was when I was working." 3. "I don't mind cooking, but eating doesn't appeal to me much anymore." 4. "I've been sleeping with fewer blankets over me lately."

4

The nurse performs a diet history on a client diagnosed with AIDS hospitalized for a cytomegalovirus (CMV) infection of the gastrointestinal tract that has resulted in diarrhea. Which of the following food choices indicates a need for the nurse to do further teaching? 1. A cup of beef bouillon, steamed white rice, and strawberry gelatin. 2. Clear chicken broth, two slices of white toast, and a serving of applesauce. 3. A cup of apple juice, cottage cheese, and three unsalted crackers. 4. Plain tea, a fresh fruit salad, and chocolate ice cream.

4

The nurse performs health screening at a shelter for the homeless. Which of the following nursing observations most likely indicates the need for teaching about personal hygiene? 1. Fruity breath odor. 2. Foul-smelling stools. 3. Vaginal itching. 4. Red, swollen gums.

4

The nurse questions the family of a patient admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNK). The nurse should expect which of the following information to be contained in the patient's history? 1. The patient was diagnosed with type 1 diabetes four years ago. 2. The patient has a history of 3+ ketones in his urine. 3. The patient is 20 lb overweight and smokes a pack of cigarettes a day. 4. The patient is 66 years old and takes propranolol (Inderal) 20 mg PO tid.

4

The physician orders an analgesic to be administered to a woman in labor who is 9 cm dilated and is having contractions every 3 minutes, lasting for 50 seconds. Which of the following nursing actions is MOST important? 1. Identify the client prior to administering medication. 2. Calculate the amount of medicine to be administered. 3. Hold the medication, and document the order in nursing notes. 4. Notify the physician regarding the status of the contractions.

4

The physician prescribes hydrochlorothiazide (Oretic) 50 mg PO daily for a client. The client also takes dexamethasone (Decaspray) 2 sprays in each nostril bid. The nurse should encourage the client to increase the intake of which of the following foods? 1. Chicken and low-fat meats. 2. Dairy products and eggs. 3. Whole grain breads and fresh vegetables. 4. Citrus fruits and green, leafy vegetables.

4

The public health nurse cares for a child diagnosed with impetigo. The nurse is MOST concerned if which of the following is observed? 1. White patches on the buccal mucosa. 2. Hearing loss. 3. Respiratory wheezes. 4. Periorbital edema.

4

To best evaluate home compliance with metoclopramide (Reglan) for a 3-month-old, the nurse should take which of the following actions? 1. Observe the mother feeding the infant. 2. Ask the mother about the infant's retention of feedings. 3. Ask the mother how many wet diapers the baby has each day. 4. Weigh the baby, and compare to baseline weight.

4

When doing an admission assessment for a client diagnosed with herpes zoster (shingles), it is important for the nurse to determine which of the following? 1. When the client developed this allergic reaction and how long it has lasted. 2. If the client has eaten any new foods within the past 24 hours. 3. If the client has a history of fever blisters or canker sores. 4. If the client comes in contact with anyone with chickenpox.

4

Which of the following statements by the client indicates to the nurse that the client has an accurate understanding of the cause of anxiety? 1. "When I get overly tired from working too hard, I begin to have severe headaches and nausea." 2. "I'm losing my mind. I can't think straight." 3. "My chest pounds and I can't catch my breath. I must be having a heart attack." 4. "Now that my mother has died, I've been thinking a lot about the way she abused me. I feel very tense and sick."

4

The nurse in the labor and delivery unit receives report about four clients in active labor. In which order does the nurse see the clients?

Show/hide explanation Strategy: Determine who is the least stable client. 1) see first; end of transition phase of labor and delivery quick for many multiparas 2) see second; second phase of labor nulliparas usually have a longer second stage than multiparas, approximately 2 hours 3) see third; cesarean delivery for transverse presentation; next highest priority for fetal risk 4) see last; most stable, labor has not progressed very far

The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST? 1. A 2-day-old infant, lying quietly alert, heart rate of 185 bpm. 2. A 1-day-old infant, crying, and the anterior fontanel is bulging. 3. A 12-hour-old infant held by the mother, respirations 45 and irregular. 4. A 5-hour-old infant, sleeping, hands and feet are blue bilaterally.

Show/hide explanation Strategy: Using unstable through stable. (1) See first: Unstable, Unexpected, Respiratory. Newborn respiratory rates while quiet are 30-50 bpm and abdominal. Requires immediate assessment. (2) See second; Unstable, Unexpected, Cardiac. infant has tachycardia; normal resting rate is 120-160 bpm; requires further investigation (3) See third; Unstable, Unexpected, Neurological. the anterior fontanel should be flat when the infant is at rest. May indicate increased fluid in the cranium. The fontanel may bulge with crying as a normal finding. (4) See last; Stable; acrocyanosis is normal for two to six hours post delivery.

The client has been placed on phenelzine sulfate 11 mg PO daily to assist in treating depression. The nurse determines that teaching is effective if the client makes which statements? Select all that apply. 1. "I will call my health care provider and stop taking the medication if I begin to have severe headaches." 2. "I can drink wine, but I should avoid alcoholic beverages that contain high levels of alcohol." 3. "I know I am going to feel better in a couple of days. I am so glad that I finally got some medication." 4. "I can take the over-the-counter (OTC) cold medications that contain pseudoephedrine." 5. "I will carefully watch my diet."

Strategy: "Effective teaching" means you are looking for correct statements. 1) CORRECT — medication is an MAO inhibitor; hypertensive crisis may be precipitated by foods containing tyramine; client should be taught to report problems associated with hypertension 2) wine is contraindicated; it contains tyramine 3) takes up to two weeks for the medication to be effective 4) cold medications with pseudoephedrine are contraindicated due to possible hypertensive problems 5) CORRECT — foods containing tyramine interact with this medication

A client undergoes peritoneal dialysis at home. The home care nurse notices the fluid outflow is inadequate. Which of the following actions should the nurse take FIRST? 1. Turn the client from side to side. 2. Check for kinks in the tubing. 3. Close the clamp to the drainage tubing for one half hour, and then reopen. 4. Milk the drainage tubing firmly every 20 minutes.

Strategy: "FIRST" indicates priority. (1) correct—facilitates drainage (2) second action (3) all clamps should be open (4) not best first action; done carefully as needed if fibrin clot has formed

The physician prescribes estrogen (Premarin) daily for a middle-aged woman. Which of the following statements, if made by the client to the nurse, indicates further teaching is necessary? 1. "There may be a change in my libido because of this medication." 2. "I may have a change in my weight while taking this medication." 3. "I may have some difficulty wearing my contact lenses because of the medication." 4. "It is unnecessary for me to perform routine self-breast exams while I am taking this medication." 5. "I am glad I do not have to stop smoking."

Strategy: "Further teaching is necessary" indicates that wrong information. (1) common side effect (2) common side effect (3) causes dryness of eyes (4) correct—should continue to perform monthly self-breast exams (5) correct—smoking and this medication can increase risk of CV complications. Client should be encouraged to stop smoking.

The home care nurse visits a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed? 1. "I have been very careful to wash my hands after I go to the bathroom." 2. "I have had to take Tylenol several times this week for this sinus infection I have." 3. "I have been very careful not to handle my child's toys or eating utensils." 4. "My husband has been preparing all of the meals since I've been sick." 5."My spouse had the Hep B vaccine so they are safe." 6."I have to sleep in a separate room from my spouse."

Strategy: "Further teaching is needed" indicates you are looking for an incorrect response. (1) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others' mouths (2) correct—client should be cautioned about taking any drugs not approved by the health care provider; may become dangerous because of the liver's inability to detoxify and excrete them (3) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others' mouths (4) because hepatitis A is spread by the oral-rectal route, it is important to protect others by practicing good hand-washing techniques and avoiding contact with items that will be placed in others' mouths (5) correct—The Hep B vaccine is not helpful to a Hep A exposure. (6) correct—This is not a requirement for Hep A.

The nurse explains the use of transcutaneous electrical nerve stimulation (TENS) to a client diagnosed with sciatica. Which of the following actions, if performed by the patient, indicates to the nurse that further teaching is necessary? 1. The client applies a conducting gel before applying the electrodes. 2. The client places the electrodes on the side of the body opposite from the painful area. 3. The client turns up the voltage until they feels a prickly "pins and needles" sensation. 4. The client adjusts the voltage based on the relief of pain she/he experiences. 5. The client turns up the voltage until mild twitching of the extremity begins. 6. The client turns on the unit before applying the electrodes.

Strategy: "Further teaching" indicates an incorrect response. (1) gel is used; should rotate sites to prevent irritation of skin (2) correct—should be over, above, or below the painful area (3) uses battery-operated device to deliver small currents to skin and underlying tissues (4) used for localized pain, such as low back pain (5) correct—a "pins and needles" sensation is the max voltage. twitching would be too high (6) correct—The client applies all electrodes and set the parameters then turns on the machine.

The nurse plans care for a client with Graves' disease. The nurse should intervene if the client drinks which of the following fluids? 1. Iced coffee. 2. Diet cola. 3. Orange juice. 4. Hot tea. 5. Apple juice. 6. Milk.

Strategy: "Intervenes" indicates a wrong action. 1) CORRECT — stimulant that would increase metabolic rate 2) CORRECT — stimulant that would increase metabolic rate 3) not limited for Graves' disease 4) CORRECT — stimulant that would increase metabolic rate 5) not limited for Graves' disease 6) not limited for Graves' disease

The nurse in the pediatrician's office instructs the parents of a toddler about a scheduled magnetic resonance imaging (MRI). The nurse tells the parents the child should be sedated using chloral hydrate (Noctec) prior to the MRI. The parents ask if they can administer the medication at home so that the toddler will be asleep when they arrive at the hospital. Which of the following responses by the nurse is MOST appropriate? 1. "I will ask the physician if it is permissible." 2. "The medication should be administered at the hospital." 3. "The child should be awake when arriving at the hospital." 4. "Are you sure you can handle your sedated toddler?"

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) chloral hydrate causes paradoxical excitation in children; administer at facility where MRI is scheduled (2) correct—chloral hydrate, a sedative, can have the opposite effect on a toddler, causing excitability; child should be continuously monitored after medication is administered (3) safety of toddler is most important (4) medication should not be given at home prior to coming to facility

The nurse performs an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed? 1. Redness or inflammation of the tissue. 2. Mottling or graying of the tissue. 3. The client states that she feels a burning and tingling sensation in the area. 4. The client states that she feels a numbness and a cold sensation in the area.

Strategy: "MOST concerned" indicates a complication. (1) indicates inflammation (2) correct—site should be observed every five minutes for signs of tissue intolerance, including blanching, mottling, or graying (3) usually indicates ischemia or sensorineural impairment (4) expected outcome of numbness, which would lead to decreased pain perception

The nurse evaluates care for a client diagnosed with depression. The nurse is MOST concerned if which of the following is observed? 1. The LPN/LVN teaches the client deep breathing and relaxation techniques. 2. The staff allows the client to verbalize thoughts when he tries to sleep. 3. The staff encourages the client to express his feelings more clearly. 4. The LPN/LVN administers flurazepam hydrochloride (Dalmane) 15 mg hs.

Strategy: "MOST concerned" indicates an incorrect action. (1) therapeutic intervention to help the client learn how to create an environment conducive to sleep (2) therapeutic intervention to help the client learn how to create an environment conducive to sleep (3) therapeutic intervention to help the client learn how to create an environment conducive to sleep (4) correct—medication that produces dependence should be a last resort; used only if other nursing measures and antidepressant medications have not worked and the client is exhausted

While a client is receiving TPN, it is MOST important for the nurse to monitor which of the following? 1. Vital signs and level of consciousness. 2. Arterial blood gases and liver enzymes. 3. Serum glucose and electrolytes. 4. Skin turgor and daily weights.

Strategy: "MOST important" indicates a priority question. (1) most common complications involve fluid and electrolytes (2) abnormalities in liver function may occur, but most common complications involve fluid and electrolytes (3) correct—hyperglycemia can cause diuresis and excessive fluid loss; should check fingerstick blood sugar every 6 hours, check serum electrolytes (sodium, potassium, calcium, magnesium, phosphates) several times a week (4) not most important; should assess skin turgor to check for dehydration and weigh daily

The nurse prepares a client for a laparoscopic cholecystectomy for treatment of cholelithiasis. It is MOST important for the nurse to ask which of the following questions? 1. "Tell me about your sleep patterns." 2. "Who is going to help you at home during the next couple of days?" 3. "Have you noticed an intolerance to fatty foods?" 4. "Have you had difficulty maintaining your weight?"

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) not the priority question; information required for health promotion (2) correct—client usually discharged the day of surgery or the next day; ensure that client has help at home for first 24-48 hours (3) should maintain nutritious diet and avoid excessive fats; more important to determine if client has help at home (4) due to fat intolerance, may have lost weight; if obese, health care provider may recommend a weight loss program

A client is diagnosed with a tumor of the pituitary gland and has a transsphenoidal hypophysectomy. The nurse plans care for the patient two days after surgery. It is MOST important for the nurse to monitor which of the following? 1. Complete blood count (CBC). 2. Temperature. 3. Specific gravity of urine. 4. Intracranial pressure.

Strategy: "MOST important" indicates this is a priority question. Determine what each assessment measures and how it relates to the situation. 1) not affected by surgery 2) controlled by the hypothalamus, not the pituitary 3) CORRECT—lack of ADH from pituitary will cause diabetes insipidus and diuresis with very low specific gravity 4) surgery performed through nose; does not affect cerebral pressure

A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a "dry labor." Which of the following responses by the nurse is MOST appropriate? 1. "The amniotic fluid provides only minimal lubrication for the labor process." 2. "The amniotic sac may impede the progress of labor and is often ruptured artificially." 3. "Labor is only slightly more difficult with early rupture of the amniotic sac." 4. "Because there is limited amniotic fluid, additional fluids will be supplied."

Strategy: "MOST" indicates there may be more than one attractive answer. (1) amniotic fluid cushions fetus, allows freedom of movement for musculoskeletal development, facilitates symmetrical growth, maintains constant body temperature, is a source of oral fluids, and collects wastes (2) correct—sometimes done to assist or induce labor (3) does not make labor more difficult (4) no additional fluids will be supplied

The client is diagnosed with myasthenia gravis. The nurse instructs the client about the disease. Which statement, if made by the client to the nurse, indicates the need for further teaching? Select all that apply. 1. "I should have a glass of wine every night." 2. "I should not go places that are crowded." 3. "I should try to stay calm." 4. "I should use my hot tub daily." 5. "I should do all my work in the morning." 6. "I will change to an all thin liquid diet."

Strategy: "Need for further teaching" indicates you are looking for an incorrect statement. (1) correct—should be avoided (2) may cause infection (3) emotional extremes can cause exacerbations (4) correct—should avoid heat (sauna, hot tubs, sunbathing) (5) correct—activities should be spread out to decrease fatigue (6) correct—thicker liquids are easier to swallow than thin

The nurse evaluates care given to clients by the nursing assitive personnel (NAP) in the client home. The nurse should intervene in which situation? 1. The NAP walks a client 15 ft with a walker. 2. The NAP uses a spoon to feed a client with blindness. 3. The NAP administers the client's medication. 4. The NAP performs catheter care for the client.

Strategy: "Nurse would intervene" indicates an incorrect action. (1) appropriate action; standard, unchanging procedure (2) appropriate action; standard, unchanging procedure (3) correct—care not within the scope of a NAP (4) appropriate action

The nurse observes care given to a client who vigorously follows several rituals daily, including frequent hand washing. The client's hands are now reddened and sensitive to touch. The nurse should intervene if which of the following is observed? 1. The staff administers special skin care to the client. 2. The staff gives positive reinforcement for nonritualistic behavior. 3. The staff limits the amount of time the client may use to wash hands. 4. The staff protects the client from ridicule by other clients on the unit.

Strategy: "Should intervene" indicates that you are looking for incorrect behavior. Don't lose the question. (1) appropriate nursing action (2) appropriate nursing action (3) correct—will only increase the client's anxiety and need for the rituals; limits must be gradually instituted (4) appropriate nursing action

The nurse observes the psychiatric staff interact with a client exhibiting manipulative behavior. The nurse should intervene in which of the following situations? 1. The staff discusses with the client the consequences of the manipulative behavior. 2. The staff collaborates to establish limits on the manipulative behavior. 3. The staff clarifies the consequences of the client's manipulative behavior. 4. The staff decreases demands placed on the client that trigger the manipulative behavior.

Strategy: "The nurse would intervene" means you are looking for an incorrect response. (1) appropriate and effective strategy for intervening with a manipulative client (2) appropriate and effective strategy for intervening with a manipulative client (3) appropriate and effective strategy for intervening with a manipulative client (4) correct—can foster a sense of entitlement along with underfunctioning; establishing realistic, achievable goals and activities is necessary to build self-esteem

A client is seen in the physician's office for follow-up after treatment for renal calculi. The nurse discusses methods to prevent a recurrence of the problem. Which of the following instructions by the nurse is MOST beneficial? 1. "Drink at least 3,000 mL of fluid a day." 2. "Increase the amount of milk in your diet." 3. "Increase the amount of whole grains that you eat." 4. "You should eat a diet low in sodium." 5. "Increase your fluids in warm or hot environments." 6. "Limit your intake of coffee."

Strategy: "beneficial" indicates correct instruction. Determine the outcome of each answer choice. Is it desired? 1) CORRECT — prevention program: diet, medications, fluids 3,000 to 4,000 mL/day 2) not recommended even if the composition of the calculi is known 3) not specific to creation of urinary tract calculi 4) CORRECT — high sodium intake increases calcium excretion; increasing risk for calculi formation 5) CORRECT — dehydration is a risk factor for calculi formation 6) CORRECT — intake of colas, coffee, and tea increase risk of calculus formation

A client is treated for deep vein thrombosis with IV unfractionated heparin. The nurse is MOST concerned if which of the following is observed? 1. Increased anxiety. 2. Decreased heart rate. 3. Increased activated partial thromboplastin time (aPTT). 4. Decreased level of consciousness. 5. Ginkgo is taken to increase memory. 6. Small pinpoint red marks are noted on the client's arms.

Strategy: "concerned" indicates a complication. 1) anxiety not related to heparin 2) change in heart rate not related to heparin 3) desired response to therapy 4) CORRECT — major adverse effect is bleeding; decrease in level of consciousness indicates possible intracranial bleeding 5) CORRECT — ginkgo is a herbal supplement that can extend clotting times 6) CORRECT — petechiae are of concern in a client on heparin

The nurse believes a coworker is diverting narcotics for personal consumption. The nurse approaches the nurse manager to report the suspicions. Which of the following statements by the nurse is BEST? 1. "After my coworker has been on duty, the patients often need repeated doses of pain medication. I have seen her/him sleeping on duty three times." 2. "I saw my coworker downtown after work. She/he was acting really strange, like she/he didn't even recognize me." 3. "I think my coworker is stealing narcotics because she/he is always acting euphoric and seems high." 4. "My coworker is hanging around with drug dealers, and I think I saw tracks on her/his arms."

Strategy: All answers are assessment. Determine how each relates to the situation. (1) correct—report objective information that can be verified; clues to possible substance abuse by staff include memory lapses, frequent absences from the floor, increased number of clients reporting unrelieved pain or insomnia (2) subjective observation (3) subjective observation (4) "hanging around with drug dealers" is subjective

A 76-year-old woman has a medical history that includes hypertension with cardiac involvement. A public health nurse visits this client regularly and on each visit records her vital signs. Which of the following findings should the nurse expect for this client? 1. Pulse 110 2. Blood pressure 120/80. 3. Temperature 99.8°F (37.7°C) 4. Temperature 98.6°F (37°C) 5. Pulse 80 6. Blood pressure 150/85

Strategy: All answers are assessments. Determine how each relates to the situation. Determine if this is expected or unexpected in a hypertensive elderly client (1) pulse too high for the elderly (2) would expect with younger client without history of hypertension (3) temperature elevated; not expected with elderly clients (4) correct—temperature is usually lower due to decrease in BMR (5) correct—normal pulse rate. (6) correct—BP expected with history of hypertension

The nurse cares for a client with a complete heart block. The nurse should question which of the following orders? 1. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute. 2. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia. 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix 10 ml of 1:5,000 solution of isoproterenol (Isuprel) in 500 ml D5W for sustained bradycardia below 30.

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) CORRECT — in complete heart block, the AV node blocks all impulses from the SA node, so the atria and ventricles beat independently; because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response; cardiac depressants are contraindicated in the presence of complete heart block 2) appropriate treatment 3) appropriate treatment 4) appropriate treatment

The nurse in the outpatient clinic plans care for an older client with left-sided weakness due to a cerebral vascular accident (CVA). The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to increase which of the following? 1. Calcium in the daily diet. 2. Vitamin D in the daily diet. 3. Time of exposure to sunlight. 4. Activities that involve weight bearing.

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) diet should have adequate calcium; client should increase intake in middle age to protect against skeletal demineralization; not most important 2) adequate serum levels of vitamin D are needed for calcium to be absorbed from gastrointestinal tract, should increase intake in middle age to protect against skeletal demineralization; not most important 3) vitamin D is synthesized in the skin with exposure to sunshine; not most important for this client 4) CORRECT — weight bearing and exercise are primary ways to develop high-density bones; decrease bone resorption, and stimulate bone formation; would also help maintain mobility with left-sided weakness

A client has received cimetidine (Tagamet) 300 mg qid for several weeks. During an office visit, the physician gives the client an additional prescription for aluminum hydroxide (Amphojel) 600 mg qid. Which of the following instructions, if given by the nurse, is BEST? 1. Take the Tagamet and Amphojel together after meals and hs for combined effect. 2. Take the Amphojel with meals and before bed, and take the Tagamet one hour after meals and before bed. 3. Take the Tagamet two hours before meals and before bed, and take the Amphojel two hours after meals and at bedtime. 4. Take the Tagamet with meals and one hour before bed, and take the Amphojel two hours after meals and hs.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antacids interfere with absorption of cimetidine; administration should be separated by one hour (2) aluminum hydorxide should be given one hour after meals and cimetidine with meals (3) cimetidine should be given with meals and aluminum hydroxide one hour after meals (4) correct—give cimetidine with meals (causes more consistent therapeutic effect) and hs; antacids interfere with absorption; separate administration by one hour, give aluminum hydroxide one hour after meals and hs (separate administration by one hour)

An elderly client constantly comes to the nurse's station with varying complaints and requests. Which of the following actions by the nurse is BEST? 1. Speak to the client only when the client calls the nurse. 2. Address and manage each specific complaint and request. 3. Redirect the client to other activity. 4. Interact with the client at consistent intervals.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) can escalate his feelings of abandonment (2) not the best action and would not serve to reduce the behavior (3) can escalate his feelings of abandonment (4) correct—client is probably fearful of being abandoned; interacting with the client at consistent intervals when he is not complaining will begin to reduce the calling, requesting, and reporting behaviors

A client had a mitral valve replacement three days ago. It is MOST important for the nurse to take which of the following actions? 1. Maintain the client in the supine position to prevent tension on the mediastinal suture line. 2. Encourage deep breathing but discourage coughing because of increased central venous pressure. 3. Decrease fluids to prevent fluid retention and development of congestive heart failure. 4. Encourage early activity to promote ventilation and improve quality of circulation.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is maintained in semi-Fowler's position (2) coughing and deep breathing should be encouraged (3) fluids are encouraged unless there is evidence of cardiac failure (4) correct—postoperative open heart clients should be encouraged to be out of bed and ambulating as soon as possible, frequently one to two days after surgery

Prior to helping a client out of bed on the first day after an anterior cervical fusion, the nurse should take which of the following actions? 1. Remove the client's cervical collar. 2. Raise the head of the bed. 3. Position the client supine at the edge of the bed. 4. Ask the client to fold both arms across his chest.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) contraindicated; collar offers additional support for the neck (2) correct—raising head of bed decreases the effort for the client and the nurse (3) inconvenient and would cause undue strain on the client (4) does not allow the client to assist in the transfer

During the initial prenatal visit, the physician orders an iron supplement to be taken throughout the client's pregnancy. It is MOST important for the nurse to include which of the following instructions?" 1. "The medication should be taken with orange juice." 2. "Take the medication with antacids to decrease gastric distress." 3. "Drinking 8 oz of water will enhance absorption of the medication." 4. "Notify the physician if your stools become dark or loose."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—vitamin C facilitates absorption of iron (2) antacids will decrease absorption of the iron (3) client needs increased fluids; fluids will not affect absorption (4) stools will turn dark, but there is no need to notify the health care provider

The nurse prepares to discharge the client after an abdominal cholecystectomy. The client will go home with a T tube in place. Which statement, if made by the client to the nurse, indicates a need for further teaching? Select all that apply. 1. "It will be great to finally get home, take a shower." 2. If the amount of drainage increases over the next several days, I should call my health care provider." 3. "I can resume swimming laps three times a week." 4. "I will check the skin around the tube once a day." 5. "I will call my health care provider if I have green drainage." 6. "I am glad I can lift whatever I want."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) maintains personal hygiene (2) increase in bile drainage is sign of obstruction, should continue to decrease (3) correct—should avoid strenuous exercise and do not immerse T tube in water (4) should check for signs of inflammation (5) correct—This is a normal finding do not need to call HCP (6) correct—light lifting only for approximately 5 weeks

The nurse cares for a client three days after an above-knee amputation (AKA). The client complains about phantom limb pain in the lower leg. Which of the following nursing responses is BEST? 1. "It should improve within a year." 2. "I'll call the physician." 3. "Keep your leg on this pillow." 4. "Staying active will help decrease the episodes."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) majority of clients feel pain for several months; minimizes what client is feeling (2) passing the buck (3) contraindicated after 24 hours because of possibility of causing contractures (4) correct—activity helps reduce frequency and degree of phantom pain

A client who had an appendectomy four days ago complains of severe abdominal pain. During the initial assessment he states, "I have had two almost-black stools today." Which of the following nursing actions is MOST important? 1. Start an IV with D5W at 125 ml/hour. 2. Insert a nasogastric tube. 3. Notify the physician. 4. Obtain a stool specimen.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) outcome desired, but priority is to notify HCP (2) outcome desired, but priority is to notify HCP (3) correct—development of black, tarry stool in the presence of abdominal pain could represent gastrointestinal bleeding; should be reported to HCP as soon as possible (4) outcome desired, but priority is to notify HCP

After abdominal surgery, a client complains of gas pains in her abdomen. It is MOST important for the nurse to take which of the following actions? 1. Offer the client fresh fruits. 2. Ambulate the client frequently. 3. Teach the client how to splint the abdomen during activity. 4. Position the client on her right side. 5. Provide bisacodyl suppositories prn.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should not be encouraged until the bowel sounds have returned and client is able to eat; will help prevent constipation but will not prevent gas pains (2) correct—ambulation promotes the return of peristalsis and facilitates expulsion of flatus (3) does nothing to increase peristalsis, which is needed after surgery (4) correct—positioning on the right side aids in the release of gas in the colon (5) correct—bisacodyl suppositories stimulate peristalsis and expulsion of gas.

The nurse performs hypertension screening at the local grocery store. It is MOST important for the nurse to complete which of the following tasks? 1. Use a blood pressure cuff that overlaps the arm at least 4 inches. 2. Support the client's arm above the level of the heart. 3. Take two readings at least five minutes apart. 4. Take the blood pressure after the client has exercised for 10 minutes.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary (2) arm should be supported at the level of the heart (3) correct—recognition of adult hypertension should be done after two readings taken at least five minutes apart (4) unnecessary

A client receives thiethylperazine maleate (Torecan) 10 mg IM after surgery for repair of a hernia. The ordered activity is up ad lib. One half hour after administration of the medication, the patient has to void. The nurse should take which of the following actions? 1. Accompany the patient to the bathroom. 2. Place the patient on the bedpan. 3. Obtain a bedside commode for the patient to use. 4. Obtain an order to catheterize the patient.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) after a preoperative medication is administered, the client should stay in bed because of the risk of lightheadedness or dizziness 2) CORRECT — necessary for client safety 3) should stay in bed after getting preoperative medication because of possible orthostatic hypotension 4) unnecessary invasive procedure

When using palpation techniques during the physical assessment of an adult female with abdominal pain, which of the following actions should the nurse take FIRST? 1. Instruct the client to take a deep breath and hold it. 2. Inform the client to breathe slowly. 3. Use bimanual palpation technique. 4. Apply light palpation in the area.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) holding a deep breath is done during palpation of the liver 2) CORRECT — breathing slowly will enhance relaxation of the abdominal muscles 3) bimanual palpation shouldn't be used for a client with abdominal pain 4) prior to the abdominal palpation, instruct client to breathe slowly because client is likely to protect the abdomen when in pain

The nurse cares for a patient with a head injury. Appropriate nursing interventions for minimizing the risk of increasing intracranial pressure include which of the following? 1. Turn the client every hour. 2. Keep the head of the bed flat. 3. Maintain the head of the bed elevated at 90°. 4. Keep the client's head from flexing. 5. Elevate the head of the bed 30°. 6. Avoid frequent suctioning.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) moving the client frequently increases risk of ICP; change position gently 2) head of bed elevated 30 degrees 3) appropriate only if client is awake and alert; too high for any extended period of time 4) CORRECT — flexing inhibits venous return and increases cerebral edema 5) CORRECT — promotes drainage from the head, decreases ICP; greater than 30 degrees decreases cranial circulation 6) CORRECT — suctioning is done on a PRN basis only; suctioning can increase ICP

A client is given an aminophylline (Somophyllin) capsule four hours too early. This incident is discovered 30 minutes after administration of the medication. The nurse should take which of the following actions? 1. Document the event on an incident report form 2. Change the time for the next medication administration. 3. Assess pulse 4. Notify the physician.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? Determine the outcome of each answer choice. use most important action to prioritize (1) first assessment of client status is necessary tachycardia is a side effed (2) second implementation notification for orders from HCP is 2nd priority (3) third, timing of this medication is important, do not want next dose give 4 hour late unless you have an order from the HCP (4) last documentation on the incident report is important but focus on client care is the priority

A client begins taking haloperidol (Haldol) 5 mg tid. It is MOST important for the nurse to share which of the following with the client? 1. "Do not eat aged cheese, beer, or red wine." 2. "Rise slowly when standing." 3. "Suck on hard candy." 4. "Avoid pretzels, potato chips, and carbonated beverages."

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) appropriate for a monoamine oxidase (MAO) inhibitor (2) correct—side effect of haloperidol is hypotension; moving slowly to a standing position will decrease the problem with orthostatic hypotension (3) medication does not have anticholinergic effects (4) salt does not have any effect on the medication

A client has been receiving chlorpromazine (Thorazine) 400 mg/day for four weeks. He experiences an oral temperature of 105°F (40.5°C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which of the following actions? 1. Administer PRN benztropine mesylate (Cogentin) immediately. 2. Hold the chlorpromazine, and notify the medical staff stat. 3. Place the client in isolation on bedrest in semi-Fowler's position. 4. Administer acetaminophen 500 mg, and place the client on a cooling mattress.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) bromocriptine or dantrolene is used for CNS toxicity (2) correct—client is experiencing neuroleptic malignant syndrome; fatal in about 15-20% of cases; is toxic effect of antipsychotic medication (3) isolation is unnecessary (4) is not most important; cooling blanket is used for fever, IV fluids for hydration, airway if necessary, frequent monitoring of vital signs

An adolescent is admitted for insertion of a Harrington rod due to scoliosis. In preparation for the immediate postoperative care, the nurse should include which of the following in a teaching plan for this client? 1. Take 10 deep breaths every 2 hours. 2. Get on the bedpan by lifting the hips. 3. Soft diet as tolerated. 4. Elevate legs 10 times every 4 hours.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—clients must be monitored closely for the first 48-72 hours for respiratory problems; bowel and urinary problems need to be assessed along with neurological problems in the extremities (2) client will have a catheter (3) client may have a nasogastric tube connected to low suction (4) not appropriate for the situation

The nurse is caring for a client in a manic phase of bipolar disorder. It is MOST important for the nurse to offer which of the following meals? 1. Tuna salad sandwich and orange slices. 2. Bologna sandwich and french fries. 3. Milkshake and banana. 4. Fried chicken and tossed salad.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—clients with mania need nutritious finger foods; foods contain protein, carbohydrates, vitamin C, and fiber (2) finger foods but little nutritive value (3) finger foods but not as balanced (4) too difficult to eat in manic phase

A client has an order for hydrochlorothiazide (HydroDIURIL) 50 mg qd. The nurse knows that teaching is successful if the client states which of the following? 1. "I should not operate heavy machinery." 2. "I should drink five glasses of liquid per day." 3. "This medication will cause my urine to turn orange." 4. "I should eat dried apricots each day." 5. "I should take this medication on an empty stomach

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—medication does not cause drowsiness (2) correct—there are no specific restrictions on fluid at this time (3) correct—does not occur (4) continued use of this diuretic may cause a loss of potassium; dietary intake of foods such as bananas or dried apricots, which are high in potassium, should be encouraged (5) correct—This medication should be taken with food because it causes GI upset.

A client visits the rape-crisis clinic one week after being assaulted. The client is currently taking alprazolam (Xanax) 0.25 mg PO q 6 hours for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication? 1. "I can take it whenever I feel upset." 2. "I should not take this with anything but water." 3. "I guess I need to stop drinking white wine." 4. "This medication will help me forget and go on."

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—needs to be withdrawn slowly under supervision. (2) indicates a need for further medication teaching (3) correct—antianxiety, should not be taken with alcoholic beverages (4) indicates a need for further medication teaching (5) indicates a need for further medication teaching

The physician prescribes ciprofloxacin (Cipro) for a client. Which of the following instructions is MOST important for the nurse to include when instructing the client about this medication? 1. "Drink plenty of fluids." 2. "You may take this medication with your multivitamin." 3. "Eliminate dairy products from your diet." 4. "Always take this medication with meals." 5. "You should avoid exposure to the sun while on this medication" 6. "Try to avoid caffeine while you take this medication."

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) correct—prevents crystalluria and stone formation (2) do not take within 6 hours before ciprofloxacin (3) do not take with milk or yogurt alone, decreases the absorption of ciprofloxacin; can ingest dietary sources of calcium (4) may take with meals if gastric irritation occurs (5) correct—this medication makes skin exposure a risk. (6) correct—caffeine consumption increase caffeine effects while on this medication

Which nursing action is MOST appropriate after intubating a postoperative client who had a respiratory arrest? 1. Soak the intubation equipment in concentrated Betadine solution. 2. Place the intubation blade in a bag, and arrange for gas sterilization. 3. Soak the intubation blade in Cidex solution. 4. Wash the equipment with soap and water and allow to air-dry.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate action (2) correct—sterilization of equipment after exposure to body fluids of a client is protocol (3) inappropriate action (4) inappropriate action

The nurse cares for a client with a long leg cast on the right leg. The nurse notes that the right foot is pale and cool to the touch, and the client continues to complain of pain even though an analgesic was administered 45 minutes ago. What is the FIRST action the nurse should take? 1. Apply a heating pad to the client's right toes. 2. Repeat the dose of the analgesic stat. 3. Remove the cast immediately. 4. Notify the physician immediately.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate response to the symptoms observed (2) although no time frame for administration is specified, it is not likely that the analgesic was ordered q 45 minutes; is only palliative (3) is the action that probably will be done by the health care provider (4) correct—symptoms of compartmental syndrome; document observations and secure health care provider's intervention immediately

A client had a thoracotomy three hours ago. For the past two hours, there has been 100 ml/hour of bloody chest drainage. Which of the following actions should the nurse take FIRST? 1. Increase the IV fluid rate. 2. Administer oxygen at 5 L/minute per oxygen mask. 3. Elevate the head of the bed. 4. Advise the physician of the amount of drainage.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) may be appropriate after the HCP is notified (2) may be appropriate after the HCP is notified (3) may be appropriate after the HCP is notified (4) correct—chest drainage of 100 ml/hour is abnormal; HCP should be notified

A psychiatric patient admitted involuntarily asks the nurse to mail a letter to the President. The patient states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST? 1. Accept the letter and place it in the patient's medical record. 2. Read the patient's letter and decide if it is appropriate to mail. 3. Call the patient's psychiatrist and inform him of the letter. 4. Discourage the patient from sending the letter, but mail it if patient insists.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) psychiatric clients do not forfeit their civil rights (2) client has the right to send and receive unopened mail (3) has the right to mail the letter (4) correct—retains the right to communicate with elected officials

A client diagnosed with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to take which of the following actions? 1. Suction the patient frequently. 2. Provide an air mattress. 3. Turn the patient every two hours. 4. Give the patient frequent baths.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? 1) decreases oxygen levels, is uncomfortable and unnecessary 2) equipment is not most important 3) CORRECT - prevents complications such as skin breakdown 4) will dry out the skin and cause chilling

During administration of oral medications to an elderly, confused client, the client states, "These pills look funny. They belong to the lady down the hall." Which of the following is the BEST response by the nurse? 1. "Your physician has ordered new medications for you. They will help you get well." 2. "Remember yesterday when I brought your medications? They look the same." 3. "I'll explain why you are receiving these medications." 4. "I'll be back after I check your medications again."

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? 1) unsafe action 2) unsafe action 3) unsafe action 4) CORRECT — even a confused client should have his/her medications rechecked when there is any possibility of an error; always observe the six rights of medication administration

At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. Which of the following actions by the nurse is BEST? 1. Refer the client to a physician for appropriate medication. 2. Refer the client to the dietitian. 3. Obtain a diet history. 4. Recheck the cholesterol level in two years.

Strategy: Answer choices are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation; levels higher than 250 mg/dL (6.5 mmol/L) may require medication if diet therapy is not effective (2) implementation; passing the buck (3) correct—assessment; total cholesterol level for an adult male should be under 200 mg/dL (5.2 mmol/L); higher levels require a low-fat diet; obtain diet history before instructing on a low-fat diet (4) assessment; blood level should be checked earlier than two years

The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia? 1. Adequately hydrate the client. 2. NPO client for at least 12 hours. 3. Assess the client for any allergies to Betadine or iodine preparations. 4. Determine the specific gravity of the urine.

Strategy: Answers are a mix of assessments and implementations. Do the assessments make sense? No. (1) correct—implementation; important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated (2) implementation; unnecessary for client to be NPO for 12 hours (3) assessment; unnecessary, as iodine dyes are not used (4) assessment; irrelevant to the procedure

On the morning after surgery to repair a fractured hip, the nurse finds an older client struggling to get out of bed. The client tells the nurse, "I have to clean the kitchen now." Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Obtain blood gas studies. 2. Instruct the client to remain in bed. 3. Take the client's blood pressure. 4. Ask the family to remain with the client.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment; fat embolism is common with fractures of long bones, results in pulmonary or cerebral emboli, interferes with adequate circulation; confusion is first symptom (2) need to assess first (3) assessment; need to obtain ABG, start oxygen (4) implementation; doesn't address the fat embolism

The nurse cares for clients in a rehabilitation facility. The nursing team reports a client recovering from a hip fracture has repeatedly "transferred herself to the floor." Which of the following actions, if taken by the nurse, is BEST? 1. Place the call light within the client's reach. 2. Remove the footrests from the wheelchair. 3. Observe the client rise from a sitting to a standing position. 4. Place a Posey vest restraint on the client.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; assumes that client can't reach the call light (2) implementation; assumes that client is tripping on the footrest (3) correct—assessment; nurse can determine if client is safe to perform this activity (4) implementation; must exhaust all other interventions before restraining clientStrategy:

A school-aged child informs the school nurse that his right knee "doesn't feel right." Which of the following actions should the nurse take FIRST? 1. Instruct the child to extend the right leg. 2. Put both of the child's legs through range of motion. 3. Advise the child to soak the right knee in warm water. 4. Compare the appearance of the right knee with the left knee.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) will not help determine if the knee is edematous (2) inspection first step of physical assessment (3) implementation; need to assess to determine the problem (4) correct—should compare corresponding joints for symmetry and to determine normal parameters

After the anesthesiologist administers an epidural to a woman in labor, which of the following nursing actions has the HIGHEST priority? 1. Decrease IV fluids. 2. Assess the fetal heart monitor. 3. Place the mother on her right side. 4. Obtain the blood pressure.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. 1) implementation; client must be well hydrated before and after the procedure 2) assessment; may be done as ongoing management but is not a priority 3) implementation; laboring client would be placed on left side to promote uterine perfusion 4) CORRECT — assessment; adverse effect of an epidural is hypotension from the vasodilation that occurs

A 41-year-old woman was brought to the emergency room by two police officers after she had been standing barefoot in the rain for more than two hours. The police officers report that the woman had to be restrained after she resisted and became agitated. The intake nurse's FIRST action should be which of the following? 1. Complete a physical examination. 2. Maintain a safe environment. 3. Ascertain the client's mental status. 4. Orient the client to place and time.

Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the best implementation. (1) assessment; should not be first action (2) correct—implementation; major priority of the nurse is to provide and maintain safety for the client who is unable to provide for herself; safe environment will generate trust and rapport; will decrease resistance to doing preliminary physical exam, which includes orienting client and doing a mental status exam (3) assessment; should not be first action (4) implementation; should not be first action

A client comes to the clinic for a glycosylated hemoglobin assay (HbA1c). The result is 6%. The nurse should take which of the following actions? 1. Document the findings in the chart. 2. Call the physician about orders to adjust the insulin dosage. 3. Give the client 15 g of carbohydrates. 4. Ask the client to list the foods he has eaten in the last 24 hours.

Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer choice. (1) correct—results normal, indicates good control of diabetes (2) no adjustments need to be made (3) does not reflect hypoglycemia (4) no adjustment needs to be made in diet; result is not altered by intake day before test

One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. Which of the following actions should the nurse take FIRST? 1. Notify the physician. 2. Call the lab for a blood glucose level. 3. Offer the client milk and crackers. 4. Administer glucagon.

Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) action should be taken prior to notifying the health care provider (2) does not require validation, implementation required (3) correct—onset of action for regular insulin is 30-60 minutes; assessment indicates a problem with hypoglycemia; foods such as milk and crackers should be given if blood sugar is around 40-60 mg/dL3 (2.2 - 3.3 mmol/L); if orange juice or simple sugar is given, it should be followed with a meal or with protein intake (4) unnecessary, unless client is unresponsive

The nurse cares for a patient who is lethargic but responsive to verbal commands. The nurse now observes that the client is responding to noxious stimuli by withdrawing. Which of the following actions by the nurse is MOST appropriate? 1. Reassess the client in one hour. 2. Notify the physician. 3. Place the client in Trendelenburg's position. 4. Contact the family.

Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of the implementations. (1) validation not required (2) correct—withdrawing from pain is a sign of deterioration in client's condition; helath care provider should be notified (3) will increase the cranial pressure (4) health care provider should be notified immediately

The nurse cares for a teenaged boy in Buck's traction. It is MOST important for the nurse to take which of the following actions? 1. Check the pin sites for bleeding or infection. 2. Apply topical or antibiotic ointment as ordered. 3. Assess that the elastic bandages are not too loose or too tight. 4. Remove the bandages daily to lubricate the skin.

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? Yes. (1) Buck's traction is a type of skin traction; there are no pins (2) Buck's traction is a type of skin traction; there is no need for topical ointment (3) correct—nurse needs to assess the client to make sure circulation is not being compromised (4) skin is not lubricated under the bandages

The nurse cares for a client diagnosed with a CVA with right-sided paralysis. It is MOST appropriate for the nurse to take which of the following actions? 1. Insert a Foley catheter. 2. Assist the client to ambulate three times per day. 3. Determine if assistance is needed with feeding. 4. Position the client on the right side.

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? Yes. (1) not required unless complications occur (2) need to assess first (3) correct—difficulty eating causes the CVA client severe anxiety (4) positioning stipulations are not required unless complications occur

The nurse learns that a staff member providing care to a client diagnosed with cytomegalovirus is in early pregnancy. Which of the following actions, if taken by the nurse, is BEST? 1. Reassign the pregnant staff member to care for other patients. 2. Instruct the staff member to contact her physician. 3. Ask the staff member how she is feeling about her pregnancy. 4. Ensure that the staff member follows standard precautions.

Strategy: Answers are a mix of assessments and implementations. Is validation required? No. Determine the outcome of each implementation. 1) all personnel, whether pregnant or not, should use standard precautions 2) passing the buck 3) will discuss nurse's feelings about caring for high-risk clients but is not the priority 4) CORRECT — make pregnant personnel aware of the risks; CMV is fetotoxic

An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST? 1. Observe the child at mealtime. 2. Inquire about the child's eating patterns. 3. Weigh the baby each month. 4. Attempt to feed the baby for the mother.

Strategy: Answers are a mix of assessments and implementations. Is validation required? Yes. (1) correct—assessment; will provide the most information (2) assessment; may or may not secure an accurate picture (3) assessment; weight should be obtained more often or on each visit (4) implementation; need to assess before determining appropriate interventions

Which of the following actions should the nurse instruct the client to complete FIRST to establish a normal urinary pattern? 1. Urinate every two hours. 2. Record each time the client urinates. 3. Keep a record of daily fluid intake. 4. Stay near a bathroom.

Strategy: Answers are all implementations. Determine the outcome of each answer. Is it desired? (1) client should start voiding every two hours and gradually progress to three to four hours (2) second thing to do (3) correct— client needs to know how much and when fluid is ingested (4) appropriate but not the first thing to do

The father of a 1-day-old son works the evening shift (3 PM to 11 PM) at another hospital. Which of the following plans is a priority to meet the needs of this father? 1. Encourage the father to call his wife after work. 2. Instruct the father about visiting policy and suggest AM visitation. 3. Adjust visiting hours to meet the new parents' needs. 4. Present a change of visiting hours to the appropriate hospital committee.

Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired? (1) inflexible (2) inflexible (3) correct—role of nurse is to be a family and client advocate; this provides individualized care (4) not a priority, although it may be an appropriate long-range goal

A client at 16 weeks' gestation has a blood sample drawn for rubella antibody screening. The test results reveal a low titer. When discussing the results with the client, the nurse should take which of the following actions? 1. Arrange for the client to have an MMR immunization immediately. 2. Explain to the client that the results are expected and nothing needs to be done. 3. Explore options with the client about whether to terminate the pregnancy. 4. Encourage the client to receive the rubella immunization immediately after delivery.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) active immunization should not be administered (2) should not be done in this situation (3) should not be done in this situation (4) correct—with a low rubella titer, the client is at risk for developing rubella; immediately after delivery, within early postpartum period, she needs to receive an immunization

The parents of a child just diagnosed with a chronic illness share with the nurse that they are concerned about the sibling's sudden change in behavior. Which of the following is the BEST response by the nurse? 1. "Our other child is feeling left out right now, but we plan to include them in the care of their sibling." 2. "Our other child is just feeling left out right now, but they will start acting normal soon." 3. "Our other child is worried about our sick child and is just reacting to fear." 4. "Our other child is going through a normal developmental stage."

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—total family participation is accomplished when the nurse includes the sibling (2) may be appropriate but does not help the family adjust to a child with a chronic illness (3) may be appropriate but does not help the family adjust to a child with a chronic illness (4) inaccurate

Which of the following interventions should be the priority during the nursing care of a 2-month-old infant after surgery? 1. Minimize stimuli for the infant. 2. Restrain all of the infant's extremities. 3. Encourage the parents to stroke the infant. 4. Demonstrate to the parents how they can assist with their infant's care.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would lead to further deprivation (2) would lead to further deprivation (3) correct—tactile stimulation is imperative for an infant's normal emotional development; after the trauma of surgery, sensory deprivation can cause failure to thrive (4) does not address the emotional needs of the infant

The nurse teaches the client about the incentive spirometer. Which observations indicate the need for further teaching? Select all that apply. 1. The client exhales with the spirometer in the mouth. 2. The client inhales with the spirometer in the mouth. 3. The client splints the incision before using the spirometer. 4. The client raises the head of the bed before using the spirometer. 5. The client's breath rate is 20/minute while using the spirometer. 6. The client exhales and holds the breath for two to three seconds.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) CORRECT — incentive spirometry is designed to promote lung expansion by encouraging sustained maximal inspirations 2) benefits the postoperative client during use of spirometry 3) benefits the postoperative client during use of spirometry 4) benefits the postoperative client during use of spirometry 5) CORRECT — rate should not exceed 20 breaths/minute 6) CORRECT — should hold breath at end of maximal inspiration

A client who is terminal is on a unit with limited visiting hours that restrict children younger than 12 years of age from visiting. Which nursing action has the HIGHEST priority? 1. Explain the visiting hours to the client's family. 2. Propose a policy change to the medical and nursing staff. 3. Allow flexibility with family members' visitation. 4. Encourage the family to call the unit between visiting hours.

Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired? (1) does not address the client's needs (2) not highest priority (3) correct—role of the nurse is to function as client advocate; is important to individualize care with all clients (4) does not address the client's needs

When working with an adolescent diagnosed with hypertension and obesity, it is MOST important for the nurse to make which of the following suggestions? 1. Avoid participating in organized sports. 2. Join an adolescent weight reduction support group. 3. Limit socialization with friends of normal weight. 4. Adhere to a 1,000-calorie low-fat diet.

Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired? (1) properly supervised physical activity is desirable, not to be avoided (2) correct—excellent means of obtaining information and support for the client (3) isolation from peers should be avoided (4) does not supply enough calories for an adolescent

The nurse plans care for a client who had surgery for an ileal conduit 2 days ago. It is MOST important for the nurse to take which of the following actions? 1. Remove the appliance regularly, and clean the skin with antiseptic solution. 2. Apply a close-fitting drainage bag to the stoma. 3. Massage the skin around the stoma with an emollient. 4. Expose the area around the stoma to air twice a day.

Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired? 1) nurse should use soap and water, not an antiseptic solution, to clean the skin 2) CORRECT— primary preventative measure to prevent urine from contacting the skin 3) would hinder the application of the bag for urine collection 4) unnecessary; would not help prevent skin breakdown

The nurse cares for clients at the student health clinic. Which signs and symptoms should cause the nurse to suspect cocaine abuse in the college student? Select all that apply. 1. Frequent sneezing. 2. Paranoia. 3. Fatigue. 4. Reports of insomnia. 5. Rhinorrhea. 6. Tachycardia.

Strategy: Determine how each answer choice relates to current cocaine use. (1) If snorted, most common method of use, decreased stimulation of the nares occurs. (2) euphoria is more common. Paranoia is seen in phase 2 of withdrawal. (3) current use presents with hyperactivity in the user (4) correct—cocaine stimulates with current users insomnia occurs. (5) correct—associated with cocaine use by inhalation; nose is most common route for administration (6) correct—cardiac stimulant.

The nurse cares for a patient after a surgical procedure. The patient is a 23-year-old exchange student from Japan. Which of the following observations by the nurse suggests the patient is experiencing pain? 1. The patient's pulse is 74, BP 104/66. 2. The patient's dressing has a small amount of serosanguinous drainage. 3. The patient repeatedly rubs his hands together. 4. The patient's skin is cool and dry.

Strategy: Determine how each answer choice relates to pain. (1) would expect BP and pulse to increase in response to pain (2) no relationship with drainage from incision and pain (3) correct—nurse should assess for nonverbal cues to pain, such as increased confusion, restlessness, aggressive behaviors (4) would expect client to be diaphoretic in response to pain

A primipara is admitted in early labor, and her membranes rupture. Which of the following assessments by the nurse is MOST important? 1. Determine the pH of the amniotic fluid. 2. Evaluate the mother's blood pressure. 3. Check the monitor for decelerations. 4. Assess for a prolapsed cord.

Strategy: Determine how each answer choice relates to the rupture of membranes. 1) amniotic fluid is important to check to differentiate it from urine; pH will be acidic if it is urine 2) client's blood pressure is not affected by rupture of the membranes 3) nurse should look for variable decelerations if cord is prolapsed 4) CORRECT — initial assessment is to check for a prolapsed cord

The nurse obtains a health history from a client in the medical clinic. The client states, "I think I have an ulcer." Which of the following responses by the nurse is BEST? 1. "Do you have a burning pain in the epigastric region?" 2. "Do you have sharp pain in your lower abdomen?" 3. "Do you have right shoulder pain with vomiting?" 4. "Do you have heartburn when you lie down?"

Strategy: Determine how each answer relates to an ulcer. (1) correct—peptic ulcer pain is often referred to as a "boring pain in the back" or a "burning, gnawing" feeling in the midepigastric area (2) may indicate intestinal perforation (3) often associated with gallbladder disease or with irritation of the diaphragm, most often caused by free air in abdominal cavity (a postoperative complication) (4) describes indigestion or possible hiatal hernia

The nurse cares for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment is successful if which of the following is observed? 1. The client's output is 1,500 ml of clear, straw-colored urine. 2. The client is unable to state his name. 3. The client denies numbness and tingling. 4. The client loses 3 lb in 1 week.

Strategy: Determine how each answer relates to hypoparathyroidism. (1) important to monitor but is not top priority (2) confusion and decreased memory are symptoms of hypercalcemia (3) correct—tetany is major sign of hypoparathyroidism (4) most frequently observed with hyperparathyroidism

The nurse performs teaching for a client receiving isoniazid (INH) 300 mg PO daily. The nurse identifies that teaching is successful if the client states which of the following? 1. "My urine will turn brown." 2. "I will take this medication for two weeks." 3. "I shouldn't take any other medication while taking this drug." 4. "I should not drink any alcoholic beverages."

Strategy: Determine how each answer relates to isoniazid. (1) untrue statement (2) untrue statement (3) untrue statement (4) correct—alcohol consumption while on isoniazid therapy has been reported to increase isoniazid-related hepatitis; clients should be cautioned to restrict consumption of alcoho

The nurse cares for a neonate diagnosed with an infection. The nurse is MOST concerned if which of the following is observed? 1. Heart rate of 150 bpm. 2. Axillary temperature of 96°F (35.5°C). 3. Weight increase of 4 oz. 4. Respiratory rate of 65 at rest.

Strategy: Determine how each answer relates to neonatal infection. (1) is within the normal range (2) axillary temperature is less than tympanic membrane or rectal temperature in neonate (3) neonates normally experience a 5-10% loss of weight within the first few days of life (4) correct—normal respiratory rate of a neonate is 30-50; tachypnea is a sign of sepsis or hypoxia in a neonate

A client is diagnosed with otosclerosis and is admitted for a stapedectomy. It is MOST important for the nurse to ask which of the following questions? 1. "Have you noticed fluid draining from your left ear?" 2. "Have you had problems hearing for your entire life?" 3. "Did you require speech therapy when you were a child?" 4. "When did you notice that your hearing was impaired?"

Strategy: Determine how each answer relates to otosclerosis. (1) describes ruptured tympanic membrane, not relevant to otosclerosis (2) hearing impairment may begin in the early adult years, but not at birth (3) speech is not affected by hearing loss (4) correct—otosclerosis occurs gradually over many years; often client is not aware of it until the impairment is significant

The nurse cares for a client receiving chemotherapy. The client has a WBC count of 1,200/mm3. Which of the following nursing actions should the nurse take FIRST? 1. Check temperature q4h. 2. Monitor urine output. 3. Assess for bleeding gums. 4. Obtain an order for blood cultures.

Strategy: Determine how each assessment relates to a low white count. (1) correct—important to monitor for infection, which would be evidenced by an elevated temperature in a client with a low WBC (2) important because of problems of increased uric acid excretion from chemotherapeutic drugs but should not be done first (3) would be associated with a low platelet count (4) would be done if the temperature were elevated to determine the type of organism involved

The nurse cares for a client after dental surgery. The dentist prescribes ibuprofen (Motrin IB) 600 mg PO. The nurse is MOST concerned if the client makes which of the following statements? 1. "I was treated for a peptic ulcer two years ago." 2. "I had a transurethral resection of the prostate (TURP) last year." 3. "I attend Weight Watchers." 4. "I have been having problems with gout."

Strategy: Determine how each statement relates to ibuprofen. (1) correct—side effects include epigastric distress, nausea, occult blood loss, peptic ulceration; use cautiously with history of previous gastrointestinal disorders (2) medication not contraindicated (3) medication not contraindicated (4) medication not contraindicated

A client on continuous mechanical ventilation desires to go home. In order to determine the client's ability for home care, the nurse should take which of the following actions? 1. Assess the ability of others in the home to be trained to provide appropriate care for the client. 2. Confer with the client's physician, and discuss the feasibility of the client's request. 3. Assess the number of people in the home and the adequacy of space to care for the client. 4. Examine the client's reasons for wanting to go home, and discuss the implications of home care.

Strategy: Determine how the assessment relates to home care. (1) correct—to ensure safety and to provide client with quality care at home, assessing ability of others in home is critical before proceeding with efforts to discharge the client (2) should occur, but ensuring that someone can care for the client should occur before consulting with the health care provider (3) may be appropriate after the home situation is evaluated (4) may occur but first determine if someone can care for the client

An order has been received to obtain a stool specimen and test for occult blood. The nurse is MOST concerned if the client makes which of the following statements? 1. "I take Feosol every day." 2. "My physician prescribed Vicodin." 3. "I've been taking Lomotil." 4. "I sometimes take Motrin."

Strategy: Determine the action of each drug and how it relates to a stool specimen. (1) correct—iron supplements can cause color of stool to resemble melena (2) opiate narcotic; would have little effect on stool specimen reliability (3) antidiarrheal; would have little effect on stool specimen reliability (4) nonsteroidal anti-inflammatory drug (NSAID); would have little effect on stool specimen reliability

The infant of a diabetic mother has a blood glucose of 90 mg/dL and a total serum calcium level of 7.0 mg/dL. The nurse should anticipate that which of the following medications would be administered IV? 1. Insulin. 2. Glucose. 3. Phenobarbital. 4. Calcium gluconate.

Strategy: Determine the action of each drug and how it relates to the lab values. (1) would be given for blood sugar problems (2) would be given for blood sugar problems (3) not appropriate for a neonate (4) correct—hypocalcemia causes tetany; calcium gluconate will replace the calcium

The nurse cares for the client in the clinic. The health care provider's orders read: "sulindac 200 mg PO bid for 14 days." The nurse should instruct the client to report which symptom to the health care provider? Select all that apply. 1. Urinary frequency. 2. Photophobia. 3. Ecchymosis of the extremities. 4. Slight edema of the feet. 5. Vomiting red streaked fluid. 6. Flank pain.

Strategy: Determine the cause of each answer and how it relates to sulindac. (1) not a side effect (2) not side effect (3) correct—should notify health care provider if easy bruising or prolonged bleeding occurs (4) not a side effect (5) correct—erosion of the gastric mucosa is a side effect that should be reported. (6) correct—flank pain may indicate nephrotoxcicity, should be reported.

A client has recently been placed on warfarin (Coumadin) for transient ischemic attacks (TIAs). The nurse is MOST concerned if the patient makes which of the following statements? 1. "I eat cantaloupe and bananas every day." 2. "I can eat potato chips and dill pickles." 3. "I eat strawberries and oranges every day." 4. "I have to eat more green salads and pork."

Strategy: Determine the nutrients contained in each answer and how they relate to warfarin. (1) high in potassium; would have no effect on the medication (2) high in sodium; would have no effect on the medication (3) high in vitamin C; would have no effect on the medication (4) correct—ingestion of large quantities of foods high in vitamin K content may antagonize the anticoagulant effect of warfarin

A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period? 1. Position the client on the right side with the head slightly elevated. 2. Place the client on the left side to protect the eye. 3. Perform sensory neurological checks every two hours. 4. Maintain complete bedrest for the first 48 hours. 5. Assess client's level of consciousness. 6. Assess client knowledge of home care.

Strategy: Determine the outcome of each answer choice. Is it desired? 1) CORRECT — should be positioned on back or unaffected side to prevent trauma to surgical eye 2) should be positioned on unaffected side 3) unnecessary for cataract clients 4) unnecessary for cataract clients 5) CORRECT — assessing the level of anesthesia is necessary immediately postop 6) this is not necessary until the anesthesia is cleared, so not immediately1

The adolescent is seen in the emergency department for an overdose of aspirin. Which actions does the nurse take? Select all that apply. 1. Determine when the client took the aspirin. 2. Administer protamine sulfate. 3. Administer vitamin K. 4. Obtain an arterial blood gas (ABG). 5. Obtain client's temperature.

Strategy: Determine the outcome of each answer. Answers are a mix of assessments and implementations. Does each answer apply to aspirin overdose? 1) CORRECT — charcoal, if given within two hours, will absorb particles of salicylate 2) antidote for heparin 3) vitamin K is used only when the clotting cascade is affected and bleeding is noted; antidote for warfarin not acetylsalicylic acid 4) CORRECT — severe acid/base disturbance can occur, so ABGs will be needed 5) CORRECT — hyperthermia is a sign of overdose; monitoring temperature is a correct action

The nurse obtains a health history from a client taking phenytoin sodium (Dilantin). It is MOST important for the nurse to report which of the following client statements to the physician? 1. "I've had several 'blackouts' in the past year." 2. "My mother has seizures, and this medication does not work for her." 3. "I don't know when I had my last menstrual period." 4. "I took this medicine several years ago but stopped when my urine turned pink."

Strategy: Determine the significance of each answer and how it relates to Dilantin. (1) not relevant to this medication (2) not relevant to this medication (3) correct—phenytoin sodium is in pregnancy risk category D; health care provider should be notified of the possibility of a pregnancy (4) pink urine is a normal occurrence when taking phenytoin sodium

A client has an order for aminophylline (Truphylline) PO. The nurse should withhold the medication and notify the physician if the client makes which of the following statements? 1. "I am allergic to neomycin." 2. "I am taking propranolol." 3. "I have trouble breathing when I exercise." 4. "I have had several urinary tract infections." 5. "I have been taking ciprofloxacin for the last 5 days." 6. "My seizure medication is just not working very well these days."

Strategy: Determine the significance of each answer choice and how it relates to aminophylline. (1) aminoglycosides are antibiotics and there is not problem with this medication (2) correct—may decrease metabolism and lead to toxicity (3) medication is given to treat airway problems (4) urinary tract infections are not a concern (5) correct—quinolones may decrease hepatic clearance of aminophylline causing risk of toxicity (6) correct—this medication is contraindicated in clients with poorly controlled seizure disorder

A client is treated for rheumatoid arthritis. Which of the following findings should assume the HIGHEST priority for the nurse when planning the client's care? 1. The client has subcutaneous nodules on the right and left forearms. 2. The client has a slight contracture of the right wrist. 3. The client has mild erythema of the finger joints. 4. The client has an area of ecchymosis approximately 3 mm in diameter on right forearm.

Strategy: Determine the significance of each answer choice and how it relates to rheumatoid arthritis. (1) expected symptom of disease (2) correct—sign of inadequate management; should be treated immediately to prevent further damage (3) redness expected symptom of disease (4) may be result of mild trauma, not highest priority

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings indicates to the nurse that the patient is improving? 1. The patient's fasting blood sugar decreased from 100 to 90 mg/dL. 2. The patient's prothrombin time (PT) increased from 20 to 25 seconds. 3. The patient's ammonia level decreased from 160 to 120 g/dL. 4. The patient's AST (SGOT) increased from 24 to 30 Units.

Strategy: Determine the significance of each assessment and how it relates to hepatic encephalopathy. (1) normal FBS 60-110 mg/dL (3.3-6.1 mmol/L), indicates glucose metabolism; usually altered with diabetes (2) normal PT 9.5 to 12 seconds, indicates blood coagulation; usually altered with cirrhosis or anticoagulant medications, would decrease if improving (3) correct—indicates a decrease in ammonia; normal ammonia 15 - 45 mcg/dL (11-33 mcmol/L); still elevated but improving (4) normal 10 to 40 Units (0.17-0.67 mckat/L), indicates liver damage; usually altered with acute pancreatitis and cirrhosis, indicates increased hepatic cell damage

The nurse cares for a client immediately after an abdominal aortic aneurysm repair. Vital signs are blood pressure 100/70, pulse 120, respirations 24, urine output 75 ml during the past three hours. Which of the following is a priority nursing action(s) for this client? 1. Weigh the client. 2. Obtain an EKG. 3. Decrease the rate of the IV fluids, and start nasal oxygen. 4. Maintain bedrest, and evaluate for a decrease in CVP readings.

Strategy: Determine what the problem is in the stem (shock). Determine how each answer relates to shock. (1) not a priority (2) an EKG will not determine cause of tachycardia (3) rate of IV fluids will most likely be increased (4) correct—client is at increased risk for development of hypovolemic shock; vital signs and urine output correlate with the early signs of shock; the nurse should compare the CVP with previous readings

The nurse cares for a client recovering from lower bowel surgery. The nurse determines that teaching is successful if the client selects which of the following menus? 1. Milk, green beans, whole-wheat bread. 2. Creamed chicken soup, broccoli, pudding. 3. Baked chicken, buttered rice, plain gelatin. 4. Cabbage salad, fried chicken, applesauce.

Strategy: Determine what type of diet is required. Select the menu that reflects the diet. (1) contains a high-residue food (2) contains a high-residue food (3) correct—low-residue diet will leave a relatively small amount of residue, or indigestible material, in the colon; all meats, fish, and poultry must be broiled or baked (4) contains a high-residue food

The nurse reading an EKG rhythm strip determines that there are 8 QRS complexes in 30 large squares for a 6-second strip. The nurse calculates the heart rate to be which of the following? 1. 60. 2. 70. 3. 80. 4. 120.

Strategy: Do the math. (1) inaccurate (2) inaccurate (3) correct—30 large squares on the EKG paper represent 6 seconds; multiply the number of QRS complexes found in 30 large squares by 10 (8 × 10 = 80 beats per minute) (4) inaccurate

The nurse on postpartum prepares four clients for discharge. It is MOST important for the nurse to refer which of the following clients for home care? 1. A 15-year-old who vaginally delivered a 7-lb male 2 days ago. 2. An 18-year-old multipara who delivered a 9-lb female by cesarean section 2 days ago. 3. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping. 4. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.

Strategy: Eliminate the most stable clients. (1) stable situation, no indication of problems with mother or baby (2) stable situation, no indication of problems with mother or baby (3) stable client, cramping due to uterine contractions (4) correct—unstable client, indicates urinary tract infection; requires follow-up

The nurse cares for a client who had a cholecystectomy. Which of the following observations is MOST important for the nurse to report to the next shift? 1. Resting after receiving IM pain medication. 2. No bowel sounds present. 3. IV infusing at 100 ml/h. 4. Breath sounds decreased in both lower lobes.

Strategy: Priority question. Remember Maslow and the ABCs. (1) psychosocial; not a priority (2) physical; expected finding after surgery due to decrease in peristalsis from anesthetic agents (3) physical; not a priority (4) correct—physical; incision for a cholecystectomy is high on the abdominal wall, which inhibits ventilatory movement; decreased breath sounds might indicate a complication of pneumonia

The nursing team includes three RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to which of the following clients? 1. A client with an appendectomy. 2. A client with infectious meningitis. 3. An immunosuppressed client. 4. A client who had a radical mastectomy.

Strategy: RN cannot delegate clients that require assessment, teaching, or nursing judgment. (1) correct—stable client with standard, unchanging procedures (2) requires assessment; RN should care for this client (3) requires skills of RN (4) requires assessment and teaching

The nurse supervises care of a group of children in a day care facility. The nurse should intervene in which of the following situations? 1. A 4-year-old is given paper to write to a pen pal. 2. A 7-year-old is playing with an electric train set. 3. A 9-year-old is performing magic tricks for his friends. 4. A 12-year-old discusses collecting canned goods for the holidays.

Strategy: Remember growth and development milestones. 1) CORRECT — task too advanced for a preschooler 2) appropriate for this age group 3) helps cognitive development of child 4) appropriate for this age group

The nurse cares for a patient following a right adrenalectomy. During the immediate postoperative period, it is MOST important for the nurse to observe for which of the following? 1. Fluid and electrolyte imbalance. 2. Temperature fluctuation. 3. Respiratory atelectasis. 4. Blood pressure alteration.

Strategy: Remember the ABCs. (1) severity of this complication is not as life-threatening as that of shock (2) severity of this complication is not as life-threatening as that of shock (3) severity of this complication is not as life-threatening as that of shock (4) correct—decrease in blood pressure may indicate shock

A 16-year-old is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, "My parents are mean and don't really care about me." Which of the following responses by the nurse is BEST? 1. "You feel your parents don't care about you?" 2. "Your parents brought you to the clinic, didn't they?" 3. "I am sure that your parents have your best interests at heart." 4. "Did you have a disagreement with your parents?"

Strategy: Remember the principles of therapeutic communication. (1) correct—uses therapeutic technique of reflecting; validates feelings without placing value judgment or giving approval or disapproval (2) negates client's feelings, blocks communication (3) negates client's feelings, blocks communication (4) yes/no question

A 74-year-old man is brought by his daughter to the emergency room. When asked his name, he is unable to remember it and appears to be disheveled, restless, and confused. His daughter says that she has been caring for him at home for the last year, but he "ran away" after they had an argument about his deteriorating personal hygiene. She found him several hours later sitting in the street. She confides to the nurse that she feels horrible about yelling at her father. Which of the following is the BEST response by the nurse? 1. "We all do things that we are sorry for later." 2. "Don't feel guilty because he is confused." 3. "Your father's illness must be difficult for both of you." 4. "The social worker will be able to help you with this problem."

Strategy: Remember therapeutic communication. (1) closed statement; doesn't encourage discussion of feelings (2) minimizes feelings and problems; nontherapeutic (3) correct—responds to feeling tone, encourages discussion of feelings (4) passing the buck; doesn't respond to feeling tone

The family members of an 85-year-old report to the nurse that they suspect that their father is masturbating. Which of the following responses by the nurse is BEST? 1. "I understand your concern because this is not a normal part of aging." 2. "Don't worry because I think that he will stop soon." 3. "This is considered a normal behavior for men." 4. "The best thing you can do is talk to your father about this behavior."

Strategy: Remember therapeutic communication. (1) inappropriate (2) inappropriate (3) correct—masturbation is an activity performed by some elderly men (4) would embarrass the father and cause him to have feelings of guilt and anxiety

The nurse encounters a client diagnosed with psychosis coming out of the room nude. Which of the following responses by the nurse is BEST? 1. "Come with me. You need to get dressed." 2. "Why are you coming into the hallway undressed?" 3. "Being naked in the hallway is inappropriate. Return to your room to get dressed." 4. "Do I need to get a male nurse to help you get dressed?"

Strategy: Remember therapeutic communication. (1) inappropriate behavior must be explained to client (2) don't ask "why" questions (3) correct—identifies inappropriate behavior and tells client what change must take place (4) yes/no question

A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, "I guess we just don't get along." Which of the following responses by the nurse is MOST appropriate? 1. "Your wife seems to be upset by the situation." 2. "Perhaps you should both go home now." 3. "Try to think about what precipitated her crying." 4. "The situation is difficult for both of you."

Strategy: Remember therapeutic communication. (1) nontherapeutic; emphasis is placed on wife, not the situation (2) nontherapeutic; closes off communication (3) nontherapeutic; appears to blame the husband for precipitating the wife's behavior, would cause him to react defensively (4) correct—therapeutic; avoids blaming, focuses on feelings of both husband and wife

A patient on suicide precautions asks for a razor to shave her legs. When the nurse tells the patient that she must remain with the patient, the patient responds, "Don't you trust me?" Which of the following responses by the nurse is BEST? 1. "It is against hospital policy to allow patients on suicide precautions to have razors unsupervised." 2. "I trust you, but your physician said a nurse has to watch you if you want to shave your legs." 3. "Wouldn't you rather wait until you are feeling better before you try to shave your legs?" 4. "You have been having thoughts about wanting to hurt yourself recently, so I'll stay with you."

Strategy: Remember therapeutic communication. (1) true statement but not the most therapeutic (2) passing the buck (3) yes/no question (4) correct—provides client with factual information in a caring manner

A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The client's vital signs are B/P 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders? 1. Theophylline (Somophyllin) 0.7 mg/kg/h IV. 2. Tetracycline hydrochloride (Sumycin) 250 mg IM qd. 3. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid. 4. Propranolol hydrochloride (Inderal) 40 mg PO bid.

Strategy: Select the incorrect order. Think about the action of each implementation. (1) drug of choice for acute asthma (2) broad spectrum antibiotic, not contraindicated (3) blocks parasympathetic stimulation and decreases mucus; used with asthma (4) correct—beta-blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation resulting in increased bronchoconstriction (5) correct—This rate of IV fluid will increase the risk of fluid volume overload.

A LPN/LVN contacts the nurse to say that she has shingles on her back. Which of the following statements by the nurse is BEST? 1. "You can't take care of clients for 14 days." 2. "Come to work as scheduled." 3. "You can't care for clients until the lesions are crusted." 4. "Please contact your physician."

Strategy: The topic of the question is unstated. Read answer choices for clues. (1) staff with localized lesions can care for non-high-risk clients (2) correct—able to care for non-high-risk clients; cover lesions should not care for pregnant women, premature infants, or immunocompromised clients (3) able to care for low risk clients if lesions are covered (4) passing the buck

A client diagnosed with acute lymphocytic leukemia is admitted with shortness of breath, anemia, and tachycardia. The MOST appropriately stated nursing diagnosis for this client is which of the following? 1. Altered protection, immunosuppression: leukemia. 2. Impaired gas exchange related to decreased RBCs. 3. Risk for infection related to altered immune system. 4. Risk of injury related to decreased platelets.

Strategy: Think about each answer choice. (1) incorrectly stated (2) correct—leukemia causes a decrease in all blood components; a gas exchange problem results from depletion of oxygen-carrying red cells (3) appropriately stated and relates to leukemia but is not supported by the assessment data in the question (4) appropriately stated and relates to leukemia but is not supported by the assessment data in the question

Which of the following indicates that a client is beginning to develop a trusting relationship with the nurse? 1. The client describes delusions to the nurse. 2. The client can describe his/her feelings to the nurse. 3. The nurse feels more comfortable with the client. 4. The client reports feeling less anxious.

Strategy: Think about each answer. Does the behavior indicate trust? (1) delusional system is indication of anxiety, delusions will increase with greater anxiety; trust of nurse is not related to an explanation of client's delusions (2) correct—client who is suspicious and delusional begins to demonstrate trusting behaviors when she/he shares feelings with the nurse (3) nurse's response can be an indication of transference/countertransference issues; is not indicative of client beginning to enter a trusting relationship (4) is beneficial that the client's anxiety level is becoming less intense; will facilitate development of a trusting relationship

A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN? 1. A 72-year-old patient with diabetes requiring a dressing change for a stasis ulcer. 2. A 55-year-old patient with terminal cancer being transferred to hospice home care. 3. A 42-year-old patient with cancer of the bone complaining of pain. 4. A 23-year-old patient with a fracture of the right leg asking to use the urinal.

Strategy: Think about the skill level involved in each client's care. (1) correct—stable client with an expected outcome (2) requires nursing judgment; RN is the appropriate caregiver (3) requires assessment; RN is the appropriate caregiver (4) standard unchanging procedure; assign to the nursing assistive personnel

The daughter of an elderly client diagnosed with Alzheimer's disease provides care for her parent in her home. The nurse knows that which of the following observations MOST likely represents caregiver burnout? 1. The child fails to get the parent into a wheelchair daily. 2. The home environment is extremely cluttered at each visit. 3. The child is always in nighttime clothes at the time of the nurse's visits. 4. The child's spouse is seen assisting with the parent-in-law's care. 5. The child states they have difficulty sleeping. 6. The client states the child never has friends over.

Strategy: Think about what the words mean. How do they relate to the caregiver? (1) may be impossible for the daughter to do alone (2) correct—cluttered environment may represent depression and burnout (3) may reveal the limited time the adult child has to take of themself (4) is very healthy and desirable (5) correct—disturbed sleep patterns more or less than normal can be sings of burnout (6) correct—Social isolation is a sign of burnout

The nurse completes discharge teaching for the new client who is breastfeeding the newborn. Which client statements indicate the need for further teaching? Select all that apply. 1. I will go to my health care provider and get fitted for a diaphragm. 2. I will ask my partner to use a condom. 3. I will get a combination oral contraceptive from my health care provider. 4. I will practice abstinence during my fertile time. 5. I will not ovulate as long as I am breastfeeding.

Strategy: Topic of question is unstated. Read answer choices for clues. 1) could be used and does not indicate a need for further teaching 2) could be used and does not indicate a need for further teaching 3) CORRECT — the combination oral contraceptive suppresses production of breast milk; while breastfeeding, another method of contraception should be used such as the progestin-only oral contraceptive 4) could be used and does not indicate a need for further teaching 5) CORRECT — breastfeeding is not a reliable method of contraception; return of ovulation can occur during breastfeeding

A nursing student with a history of breast cancer reports to the nurse on the unit that the nursing student has just developed shingles on her trunk. Which of the following actions by the nurse is BEST? 1. Suggest that the nursing student contact her physician. 2. Assign the nursing student to clients that are not high risk. 3. Inform the nursing student that she cannot care for clients. 4. Restrict the nursing student from performing invasive procedures.

Strategy: Topic of the question is unstated. Read answer choices to determine topic. (1) passing the buck; care of clients determined by the RN (2) can't care for any clients until lesions have crusted (3) correct—because student is immunocompromised, restrict from client contact until lesions have crusted (4) restricted from any client contact

The nurse performs diet teaching for a client with a spinal cord injury at S3. Which of the following meals, if chosen by the client, indicates to the nurse that teaching is effective? 1. Cheeseburger with tomato and onion. 2. Spaghetti with meat sauce and green beans. 3. Tuna fish sandwich with orange juice. 4. Grilled cheese sandwich and chocolate pudding.

Strategy: Type of diet needed by the client is unstated. Determine what type of diet is required and select the appropriate menu. (1) should have high-fiber, low-fat diet; this diet is high in fat (2) correct—high-fiber diet is an important part of bowel program; fiber helps prevent the complication of constipation; includes whole-grain foods, bran, fresh and dried fruits; increased fiber will facilitate defecation, especially with reduction in fat intake (3) should increase intake of fiber foods and decrease intake of fat (4) should have high-fiber, low-fat diet; this is a high-fat diet

The nurse screens an 8-month-old girl in a well-baby clinic. The nurse is MOST concerned if the infant's mother makes which of the following statements? 1. "My daughter has almost doubled her birth weight." 2. "When I walk in the room, my child smiles at me." 3. "When she is around her grandpa, my child cries." 4. "My daughter can't quite say "mama" yet." 5. "My child should be able to do a large piece puzzle by now." 6. "I will use a pillow to support her all the time."

Strategy: understands indicates you are looking for something correct. (1) weight should double by 5 months of age (2) correct—begins to recognize parents at 6 months of age (3) correct—begins to fear strangers at 6 months, increases until 9 months of age (4) correct—begins to say "dada" and "mama" with meaning at 10 months of age (5) outside the range of an 8 month old. (6) inappropriate for an 8 month old.

The nurse discusses symptoms of the onset of labor with a 26-year-old primipara. Which of the following statements, if made by the client to the nurse, indicates the need for further teaching? 1. "I will note an increase in fetal movement." 2. "I may feel a gush of fluid run down my legs." 3. "I may see some blood in my vaginal discharge." 4. "I may experience a low backache."

Strategy: understands the teaching indicates you are looking for correct response. (1) usually movement decreases with the onset of labor (2) correct—indicates rupture of membranes, symptom of labor (3) correct—bloody showis a common symptom of labor (4) correct— low back ache can be a symptom of labor (5) Contractions in labor are usually evenly spaced or regular but not always.

The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6 L/minute. Results show: pH 7.37, HCO3 26 mEq/L, PaCO2 42 mm Hg, PaO2 90 mm Hg. The nurse should take which of the following actions? 1. Increase the rate of oxygen flow that the patient is receiving. 2. Elevate the head of the bed. 3. Document the results in the chart. 4. Instruct the patient to cough and deep breathe.

The health care provider orders an arterial blood gas (ABG) for the client receiving oxygen at 6 L/minute. Results are pH 7.37, HCO3 26 mEq/L (26 mmol/L), PaCO2 42 mm Hg (5.59 kPa), and PaO2 90 mm Hg (11.97 kPa). Which action does the nurse take? 1. Increases the rate of oxygen flow that the client is receiving. 2. Elevates the head of the bed. 3. Documents the results in the medical record. 4. Instructs the client to cough and deep breathe. Show/hide explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) oxygen level normal 2) unnecessary, results normal 3) CORRECT — results normal, should be recorded 4) unnecessary, results normal