Level 2 Practice Quiz

The nurse is assessing a 13 year old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? A) "Have you lost any weight in the last month?" B) "Are you experiencing any type of nervousness?" C) "When was the last time you took your synthroid?" D) "Are you having any problems with your vision?"

"Are you experiencing any type of nervousness?" Rationale: Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyper excitability, and palpitations are signs of hyperthyroidism.

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

"At what time do you take your medication?" Rationale: The nurse needs to first determine at what time of the day the client takes the Lasix. Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia.

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

"How can I help?" Rationale: Offering self shows empathy and caring and is the best of the choices provided.

An IV infusion of 0.9% normal saline 500 ml with ammonium chloride 0.2 mEq/ml is prescribed for a client who was admitted for an amphetamine overdose. How many mEq of ammonium chloride should the nurse use to prepare the solution?

100

An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac (Toradol) 30 mg IV q6h. Which action should the nurse implement? A) administer both medications according to the prescription B) hold the ketorolac to prevent an antagonistic effect C) hold the morphine to prevent an additive drug interaction D) contact the healthcare provider to clarify the prescription

Administer both medications according to the prescription Rationale: Morphine and ketorolac (Toradol) can be administered concurrently and may produce an additive analgesic effect, resulting in the ability to reduce the dose of morphine, as seen in this prescription.

A 2 year old with gastro esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A) invite other children home to share meals B) accept that he will eat when he is hungry C) reward the child with a nap after eating D) consistently follow a set mealtime routine

Consistently follow a set mealtime routine Rationale: A 2 year old child is comforted by consistency.

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

Continue gabapentin Rationale: Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management.

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

Describe the diet changes that can improve the management of her diabetes Rationale: Diet modifications are effective in managing type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client.

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

Global confusion and inability to recognize family members Rationale: Delirium tremens (DT) or alcohol withdrawal delirium usually peaks 2 to 3 days (48 to 72 hours) after cessation or reduction of intake (although it can occur later) and lasts 2 to 3 days. The risk of DT carries a 2-5% mortality rate, so the critical syndrome of alcohol withdrawal, manifested as global confusion and an inability to recognize family members is life-threatening and requires emergency medial intervention.

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

Help the client to determine ways to increase his fluid intake Rationale: The nurse should suggest creative methods to increase the intake of fluids, such as having disposable fruit juices readily available. Clients with COPD should have at least 3 liters of fluids a day. These clients often reduce fluid intake because of shortness of breath.

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

Increased thyroid stimulating hormone (TSH) Rationale: The healthcare provider should be notified of immediately. An increased TSH suggests a low thyroxine level because the TSH is trying to stimulate thyroxine production, and hypothyroidism symptoms mimic those of depression.

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

Interpersonal and intrapersonal skills Rationale: Interpersonal and intrapersonal intelligence form one's personal intelligence or "emotional quotient," so the nurse should focus inquiries on social skills.

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? A) loss of thirst, weight gain B) dependent edema, fever C) polydipsia, polyuria D) hypernatremia, tachypnea

Loss of thirst, weight gain Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hr, and dilutional hyponatremia. Other indications of SIADH are loss of thirst, weight gain, irritability, muscle weakness, and decreased level of consciousness.

A client with osteoarthritis receives a new prescription for celecoxib (Celebrex) orally for symptom management. The nurse notes the client is allergic to sulfa. Which action is most important for the nurse to implement prior to administering the first dose? A) review the client's hemoglobin results B) notify the healthcare provider C) inquire about the reaction to sulfa D) record the client's vital signs

Notify the healthcare provider Rationale: Celebrex contains a sulfur molecule, which can lead to an allergic reaction in individuals who are sensitive to sulfonamides, so the healthcare provider should be notified of the client's allergies.

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

Prepare a set up for an endotracheal intubation Rationale: Diazepam causes respiratory depression, so preparation for intubation to protect the airway is the priority intervention at this time.

The nurse is triaging a child with a fever brought to the emergency department by the parents. Which findings requires the nurse's immediate intervention? A) prolonged exhalations B) thick yellow rhinorrhea C) frequent nonproductive cough D) oxygen saturation is 95% by pulse oximeter

Prolonged exhalations Rationale: Prolonged exhalation indicates breathing difficulty, and intervention for this should be taken immediately.

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

Schedule specific times on a written calendar to review 2 charts per day Rationale: Creating a disciplined approach by scheduling time periods for each issue is the most effective time management strategy.

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

Serum albumin Rationale: Serum albumin has a long half life and is the best long term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness.

A 43 year old female client is receiving thyroid replacement hormone following a thyroidectomy. What adverse effects associated with thyroid hormone toxicity should the nurse instruct the client to report promptly to the healthcare provider? A) tinnitus and dizziness B) tachycardia and chest pain C) dry skin and intolerance to cold D) weight gain and increased appetite

Tachycardia and chest pain Rationale: Thyroid replacement hormone increases the metabolic rate of all tissues, so common signs and symptoms of toxicity include tachycardia and chest pain.

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

Teens create psychological distance from parents in order to separate from them Rationale: Although a mutually respectful parent adolescent relationship is important, an adolescent may use critical and fault finding behavior as a mechanism to separate from the parent.

When conducting a hygiene class for adolescent girls, it is important for the nurse to include which instruction about preventing toxic shock syndrome? A) wash your hands before inserting a tampon B) use super absorbent tampons C) wear cotton underwear D) douche every month following menstruation

Wash your hands before inserting a tampon Rationale: The single most effective means of preventing infection is hand washing.

The nurse is teaching the parents of a 5 year old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand? A) "Perform postural drainage before starting the aerosol therapy." B) "Give respiratory treatments when the child is coughing a lot." C) "Administer aerosol therapy followed by postural drainage before meals." D) "Ensure respiratory therapy is done daily during any respiratory infection."

"Administer aerosol therapy followed by postural drainage before meals." Rationale: Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and before meals. or at least 1 hour after eating to prevent nausea and vomiting.

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

"Dental caries can be prevented though fluoridation of public water." Rationale: Dental caries can be prevented through fluoridation of public water.

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

"The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her." Rationale: The baby is at 35% which is much more than room air (21%) and at this time the baby should not be moved from under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant.

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply) A) vaginal stimulation B) an increased level of stress C) decreased duodenal inhibition D) hypersecretion of hydrochloric acid E) an increased number of parietal cells

- Vaginal stimulation - Decreased duodenal inhibition - Hypersecretion of hydrochloric acid - An increased number of parietal cells Rationale: Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids.

A 9 month old infant receives a prescription for digoxin 40 mcg PO daily. Digoxin Oral Solution, USP 50 mcg (0.05 mg) per ml is available. How many ml should the nurse administer?

0.8

The nurse plans to administer labetalol hydrochloride (Trandate) 0.3 grams PO to a client with hypertension. Trandate is available in 200 mg scored tablets. How many tablets should the nurse administer?

1.5

A client who has congestive heart failure with paroxysmal atrial tachycardia is receiving digoxin (Lanoxin) 0.45 mg IV as the initial digitalizing dose. The pharmacy provides 0.25 mg/ml. How many ml should the nurse administer?

1.8

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

14 lb Rationale: Infancy growth spurts double the birthweight by 4 to 6 months and triple it by one year.

A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer?

2

A client with hypertension receives a prescription for carteolol (Cartel) 7.5 mg PO daily. The drug is available in 2.5 mg tablets. How many tablets should the nurse administer?

3

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

4 to 6 years of age Rationale: The second booster of the MMR vaccine is recommended by the CDC for routine immunization at 4 to 6 years of age, which is commonly required prior to entrance into elementary school.

Which pediatric client requires immediate intervention by the nurse? A) a 2 year old with a twenty-four hour urinary output of 500ml B) a 3 year old with several episodes of nocturnal enuresis C) a 4 year old with an easily palpable bladder and frequency D) a 5 year old with diuresis following furosemide (Lasix) administration

A 4 year old with an easily palpable bladder and frequency Rationale: Frequency and bladder distention are indications of urinary retention, which requires immediate Intervention by the nurse.

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

A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." Rationale: A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness is at the highest risk for stress related health problem.

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

A tympanic measurement of temperature will provide the most accurate reading Rationale: A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management -- sterile procedures should be assigned to licensed personnel.

Which client should the nurse identify as being at highest risk for complications during the use of an opioid analgesic? A) an older client with type 2 diabetes mellitus B) a client with chronic rheumatoid arthritis C) a client with a open compound fracture D) a young adult with inflammatory bowel disease

A young adult with inflammatory bowel disease Rationale: The principal indication for opioid use is acute pain, and a client with inflammatory bowel disease is at risk for toxic megacolon or paralytic ileus related to slowed peristalsis, a side effect of morphine.

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

Accused of diversion Rationale: Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion, or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing.

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

Administer insulin per sliding scale to a client with a capillary glucose of 285 Rationale: The nurse should first administer the insulin per sliding scale to the client with hyperglycemia to prevent further elevation of the serum glucose levels.

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

Administer the medication Rationale: Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may Indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered since the client is not demonstrating any signs of toxicity.

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

Agoraphobia Rationale: Agoraphobia is the fear of crowds or being in an open place.

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

Allow time for the ritualistic behavior, then redirect the client to other activities Rationale: Initially, the nurse should allow time for the ritual to prevent anxiety.

Which rationale best supports an older client's risk of complications related to a dysrhythmia? A) an older client usually lives alone and cannot summon help when symptoms appear B) an older client is more likely to eat high fat diets which predisposes to heart disease C) cardiac symptoms, such as confusion, are more difficult to recognize in an older adult D) an older client is intolerant of decreased cardiac output which may cause dizziness and falls

An older client is intolerant of decreased cardiac output which may cause dizziness and falls Rationale: In an older client, cardiac output is decreased and a loss of contractility and elasticity reduces systemic and cerebral blood flow, so dysrhythmias, such as bradycardia or tachycardia is poorly tolerated, and increases the client's risk for syncope, falls, transient ischemic attacks, and possibly dementia.

The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose? A) syrup B) applesauce C) orange juice D) formula or milk

Applesauce Rationale: In order to prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications.

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

Ask the child if he / she has had a cold, runny nose, or any ear pain lately Rationale: More information is needed to interpret these findings. The tympanic membrane is normally not pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of history and related symptoms is indicated for accurate interpretation of the findings.

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

Ask the client if this decision has been discussed with his healthcare provider Rationale: Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider.

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

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

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

Avoid using jargon, such as coeshot, when giving care Rationale: Using positive terms and avoiding words that have frightening connotations assist the preschool age child in coping with an emergency room experience.

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)? A) update the nutrition needs in the plan of care B) bathe an unconscious client with decubitus ulcers C) teach insulin self administration for a client with type 1 diabetes D) evaluate goal attainment for a client with a below the knee prosthesis

Bathe an unconscious client with decubitus ulcers Rationale: Delegation requires determining which staff member is capable of performing what tasks. Basic hygiene is within the role of the UAP.

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

Begin humidified oxygen via hood Rationale: An oxygen saturation of less than 90% requires oxygen administration.

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

Begin one on one supervision immediately Rationale: One on one supervision ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations.

Which change in data indicates to the nurse that the desired effect of the angiotensin II receptor antagonist valsartan (Diovan) has been achieved? A) dependent edema reduced from +3 to +1 B) serum HDL increased from 35 to 55 mg/dl C) pulse rate reduced from 150 to 90 beats/minute D) blood pressure reduced from 160/90 to 130/80

Blood pressure reduced from 160/90 to 130/80 Rationale: Diovan is an angiotensin receptor blocker, prescribed for the treatment of hypertension. The desired effect is a decrease in blood pressure.

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

Call for an ECG to be performed immediately Rationale: Clients over the age of 40 and / or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before.

The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? A) anemia B) cardiac dysrhythmias C) gastrointestinal reflux D) heightened neurologic reflexes

Cardiac dysrhythmias Rationale: An adolescent with bulimia who purges by frequent self induced vomiting, diuretic or laxative abuse can experience potassium depletion, which increased the risk for cardiac dysrhythmias.

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

Children of this age are comfortable with ritualism and display global thinking Rationale: A 2 year ld is ritualistic and wants consistency and routine, so changes in the toddler's environment or schedule is upsetting. Another mark of the toddler's sensitivity to change is global thinking and the 2 year old's equanimity disintegrates.

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

Chlorodiazepoxide (Librium) Rationale: Librium, an antianxiety drug, as well as other benzodiazepines, is used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal.

The nurse is assessing an 8 month old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? A) bradycardia B) machinery murmur C) weak pedal pulses D) clubbed fingers

Clubbed fingers Rationale: Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes due to tissue hypoxia.

A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What action should the nurse take? A) commend the client for selecting a high biologic value protein B) remind the client that protein in the diet should be avoided C) suggest that the client also select orange juice, to promote absorption D) encourage the client to attend classes on dietary management of CKD

Commend the client for selecting a high biologic value protein Rationale: Foods such as eggs and milk are high biologic proteins which are allowed because they are complete proteins and supply essential amino acids that are necessary for growth and cell repair.

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

Confusion and tachycardia Rationale: The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate.

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

Delayed growth and development Rationale: This child does not demonstrate gross motor or psychosocial skills typical of an 18 month old toddler, which best supports delayed growth and development.

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

Demonstrate feeding strategies and infant cues that indicate hunger and satiation Rationale: NFTT most often occurs due to inadequate parent knowledge or a disturbance in maternal child attachment, but the first goal for infants with NFTT is to provide nutrition to promote "catch up" growth. The nurse should demonstrate positive feeding strategies that reduce parent and infant frustration, such as recognizing the infant's cues indicated by vigorous sucking and satiation.

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

Determine the time the client last voided Rationale: Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided should be determined next.

The charge nurse working in a long term facility is informed by the LPN that a client's son is unhappy with the care his mother is receiving. What action should the nurse take first? A) ask the family member to come to the nurses' station to discuss the concerns B) provide the son with a complaint form and ask him to describe the situation C) discuss with the LPN the son's concerns about his mother's care. D) notify the administrator of the long term care facility about the son's discontent

Discuss with the LPN the son's concerns about his mother's care Rationale: The nurse should first obtain information about the nature of the complaint and ask the LPN to describe what he / she knows of the situation.

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hr. The client's eight hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) notify healthcare provider and request to change the IV infusion to hypertonic D10W B) decrease in the infusion rate of the current IV and report to the healthcare provider C) document in the medical record that these normal findings are expected outcomes D) obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV

Document in the medical record that these normal findings are expected outcomes Rationale: The results are all within normal range.

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

Drugs taken in last 7 days Rationale: Use of prescribed, over the counter, and illicit drugs is the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations.

The nurse is assessing a client who is experiencing anaphylaxis from an insect sting. Which prescription should the nurse prepare to administer this client? A) dopamine B) ephedrine C) epinephrine D) diphenhydramine

Epinephrine Rationale: Epinephrine is an adrenergic agent that stimulate beta receptors to increase cardiac automaticity in cardiac arrest and relax bronchospasm's in anaphylaxis.

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

Evaluate the effectiveness of narcotic analgesics Rationale: Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled.

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

Excessive CNS stimulation will be reduced Rationale: Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal.

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

Experiencing culture shock Rationale: An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock describes feelings or discomfort and disorientation when adapting to new cultural settings.

The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? A) facilitates transport of glucose into the cells B) stimulates function of beta cells in the pancreas C) increases intracellular receptor site sensitivity D) delays carbohydrate digestion and absorption

Facilitates transport of glucose into the cells Rationale: Glucose moves across the cell membrane by using an active transport mechanism. Insulin acts as the carrier of glucose and is the only hormone that decreases blood glucose levels by facilitating transport of glucose into the cells.

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)? A) accompany the healthcare provider during client visits B) determine a client's response to pain C) observe a client's central venous catheter site D) feed a client with minimal dysphagia

Feed a client with minimal dysphagia Rationale: Delegation of client care is delineated by state boards of nursing practice and include specific guidelines regarding which tasks are within the scope of practice for each level of care provider and include the components of delegation to the UAP. Feeding a client is a basic client care measure that is within the scope of practice for a UAP.

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

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

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

He visits his diabetic brother who just had surgery to amputate an infected foot Rationale: The loss of a limb by a family member will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease.

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

Hepatitis B Rationale: Multiple sexual contacts are associated with the risk for Hepatitis B.

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

Increase in abdominal fat deposits Rationale: An increase in the abdominal girth may be indicative of the onset of metabolic syndrome, which places the client at risk for cardiac disease and requires further assessment.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? A) large amounts of expelled flatus with mucus B) tympanic abdomen and hyperactive bowel sounds C) increased abdominal pain with rebound tenderness D) complaint of feeling weak with watery diarrheal stools

Increased abdominal pain with rebound tenderness Rationale: Positive rebound tenderness may be an indication of peritonitis or perforation and needs follow up immediately.

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

Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia Rationale: Care of a stage IV pressure ulcer is a complex, sterile procedure that requires assessment of the wound, and evaluation of the effectiveness of the treatment plan, and should be performed by the RN.

The healthcare provider prescribes high protein, high fat, low carbohydrate diet with limited fluids during meals for a client who is recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? A) it is quickly digested B) it does not cause diarrhea C) it does not dilate the stomach D) it is slow to leave the stomach

It is slow to leave the stomach Rationale: This type of diet is slowly digested and is slow to leave the stomach because of its density from proteins and fats, and then reduction of fluids with the meal, the possibility of dumping syndrome is reduced.

An antacid (maalox) is prescribed for a client with Peptic Ulcer Disease. The nurse knows that the purpose of this medication is to A. decrease production of gastric secretions B. produce an adherent barrier over the ulcer C. maintain a gastric pH of 3.5 or above D. decrease gastric motor activity

Maintain a gastric pH of 3.5 or above. Rationale: The objective of antacids is to neutralize gastric acids and keep pH of 3.5 or above.

A client who was prescribed atorvastatin (Lipitor) one month ago calls the triage nurse at the clinic complaining of muscle pain and weakness in his legs. Which statement reflects the correct drug specific teaching the nurse should provide to this client? A) increase consumption of potassium rich foods since low potassium levels can cause muscle spasms B) have serum electrolytes checked at the next scheduled appointment to assess hyponatremia, a cause of cramping C) make an appointment to see the healthcare provide, because muscle pain may be an indication of a serious side effect D) be sure to consume a low cholesterol diet while taking the drug to enhance the effectiveness of the drug

Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect Rationale: Myopathy, suggested by the leg pain and weakness, is a serious, and potentially life threatening, complication of Lipitor, and should be evaluated immediately by the healthcare provider.

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

Normal growth curve of a breast fed infant Rationale: When plotting weights and heights on a standard growth chart used for both breast fed and formula fed infants, the breast def infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast fed infant is leaner and has less body fat than a formula fed infant. Normal patterns of infants who are breast fed differ from those who are formula fed.

The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? A) the xray procedure may last for several hours B) a nasogastric tube (NGT) is inserted to instill the barium C) enemas are given to empty the bowel after the procedure D) nothing by mouth is allowed for 6 to 8 hours before the study

Nothing by mouth is allowed for 6 to 8 hours before the study Rationale: The client should be NPO for at least 6 to 8 hours before the UGI.

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

Notify family members of the client's condition Rationale: The nurse's first priority is to notify the family of the resident's impending death.

An elderly resident of a long term care facility is no longer able to perform self care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) reaffirm the client's desire for no resuscitative efforts B) transfer the client to a hospice inpatient facility C) prepare the family for the client's impending death D) notify the healthcare provider of the family's request

Notify the healthcare provider of the family's request Rationale: The nurse should first communicate with the healthcare provider. Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider.

A healthcare provider prescribes cefadroxil (Duricef) for a client with a postoperative infection. It is most important for the nurse to assess for what additional drug allergy before administering this prescription? A) penicillins B) aminoglycosides C) erythromycins D) sulfonamides

Penicillins Rationale: Cross allergies exist between penicillins and cephalosporins, such as cefadroxil (Duricef), so checking for penicillin allergy is a wise precaution before administering this drug.

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

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

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A) sodium B) antidiuretic hormone C) potassium D) glucose

Potassium Rationale: Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (hypokalemia) -- hypertension is the most prominent and universal sign.

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

Potential for fluid volume deficit Rationale: All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern for any newborn infant.

Which action should the nurse implement first for a client experiencing alcohol withdrawal? A) apply vest or extremity restraints B) give an alpha-adrenergic blocker C) provide a diet high in protein and calories D) prepare the environment to prevent self injury

Prepare the environment to prevent self injury Rationale: Self-destructive or violent behavior provides a potentially immediate and life threatening risk to the client and others, so a safe environment should be provided by removing any potential objects that could inflict self injury.

In developing a teaching plan for a 5 year old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? A) food planning and selection B) administering insulin injections C) process of glucose testing D) drawing up the correct insulin dose

Process of glucose testing Rationale: Developmentally, a 5 year old has the cognitive and psychomotor skills to use a glucometer and to read the number.

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

Productive cough with grayish white sputum Rationale: Chronic bronchitis, one of the diseases compromising the diagnosis of COPD, is characterized by a productive cough with grayish white sputum, which usually occurs in the morning and is often ignored by smokers.

What is the expected outcome of esomeprazole (Nexium) when prescribed for a client with gastroesophageal reflux disease (GERD)? A) promotion of rapid tissue healing B) increased gastric emptying C) improved esophageal peristalsis D) neutralization of gastric secretions

Promotion of rapid tissue healing Rationale: Proton pump inhibitors, such as esomeprazole, act to inhibit gastric acid secretion and promote rapid healing of esophageal tissue.

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

Propanolol (Inderal) Rationale: Inderal is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility.

A client with type 2 diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take next? A) obtain a specimen for serum glucose level B) administer insulin per sliding scale C) provide cheese and bread to eat D) collect a glycosylated hemoglobin specimen

Provide cheese and bread to eat Rationale: Once blood glucose is greater than 70 mg/dL, the client should eat a regularly scheduled meal or a snack to prevent hypoglycemia from reoccurring.

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

Provide clean explanations while encouraging questions Rationale: Adolescents are capable of abstract thinking and understand explanations, so the opportunity to ask questions should be provided.

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

Question the healthcare provider's prescription Rationale: Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse.

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

Rash Rationale: Side effects of sulfisoxazole (Gantrisin), a sulfonamide antibiotic, include possible allergic response, manifested by skin rash and itching, which can progress to Stevens Johnson syndrome - erythema multiforme, a severe hypersensitivity reaction.

A client receives a new prescription for an angiotensin converting enzyme (ACE) inhibitor. What client history contraindicates its use? A) asthma B) heart failure C) renal artery stenosis D) coronary artery disease

Renal artery stenosis Rationale: Angiotensin converting enzyme (ACE) inhibitors can cause sever renal insufficiency in clients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney. ACE inhibitors should not be used during the second and third trimesters of pregnancy and should be used with caution in clients who are taking potassium sparing diuretics or who have hyperkalemia.

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? A) report the findings to the surgeon B) irrigate the indwelling urinary catheter C) apply manual pressure to the bladder D) increase the IV flow rate for 15 minutes

Report the findings to the surgeon Rationale: An adult who weighs 132 pounds should produce about 60 ml of urine hourly. Dark, concentrated, and low volume or urine output should be reported to the surgeon.

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

Review the night shift nurse's documentation with the charge nurse Rationale: The client's concern needs to be assessed immediately. This can be best accomplished by reviewing the documentation with administration, the charge nurse, to determine the client's needs and the night nurse's response.

Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? A) context B) self-analysis C) counter transference D) therapeutic self-disclosure

Self-analysis Rationale: Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs, so Self-analysis is a primary tool used by the nurse to establish therapeutic empathy and achieve authentic, open, and personal communication with a client.

A 46 year old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? A) serum creatinine B) blood urea nitrogen (BUN) C) sedimentation rate D) urine specific gravity

Serum creatinine Rationale: Creatinine is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. n elevated creatinine strongly indicates nephron loss, reducing filtration.

A client is being treated for osteoporosis with alendronate (Fosamax) and the nurse has completed discharge teaching regarding medication administration. Which morning schedule would indicate to the nurse that the client teaching has been effective? A) take medication, go for a 30 minute morning walk, then eat breakfast B) take medication, rest in bed for 30 minutes, eat breakfast, go for morning walk C) take medication with breakfast, then take a 30 minute morning walk D) go for a 30 minute morning walk, eat breakfast, then take medication

Take medication, go for a 30 minute morning walk, then eat breakfast Rationale: Alendronate (Fosamax) is best absorbed when taken 30 minutes before eating in the morning. The client should also e advised to remain in an upright position for at least 30 minutes after taking the medication to reduce the risk of esophageal reflux and irritation.

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

Take the medication when consuming food Rationale: With the loss of exocrine function for a client with chronic pancreatitis, replacement of pancreatic enzymes using pancrelipase becomes necessary.

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

Tell the client that therapy cannot take place while she is intoxicated Rationale: Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur because the client's judgement is altered.

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

Temperature Rationale: It is very important to check the client's temperature. Infection is the most common factor precipitating respiratory distress. Client's with COPD who are on maintenance doses of corticosteroids are particularly predisposed to infection.

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

The child should be given opportunities to achieve a sense of competency in an area he chooses Rationale: According to Erikson, the developmental stage "Industry vs Inferiority" builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in.

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

The client's consent may have been coerced Rationale: Informed consent requires that the choice is freely give. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced based on family pressure.

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

The dose must be tapered over the course of 7 to 10 days Rationale: To minimize the impact of adrenal insufficiency, withdrawal of exogenous glucocorticoids should be done by gradually decreasing the dosage over several days.

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

The heart develops in the thirst to fifth weeks after conception Rationale: The cardiovascular system is the first organ system to develop and function in the embryo. The blood vessel and blood formation begin in the third week, and the heart is developmentally complete in the fifth week.

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

The mother is slurring her words and is not attentive to discharge instructions Rationale: Having a responsible adult to make on going observations is the most important criteria for discharging anyone to their home after a head injury. The child (who needs observation) should not go home with an impaired adult.

After abdominal surgery, a male client is prescribed low molecular weight heparin (LMWH). During administration of the medication, the client asks the nurse why he is receiving this medication. Which is the best response for the nurse to provide? A) this medication is a blood thinner given to prevent blood clot formation B) this medication enhances antibiotics to prevent infection C) this medication dissolves any clots that develop in the legs D) this abdominal injection assists in the healing of the abdominal wound

This medication is a blood thinner given to prevent blood clot formation Rationale: Unfractionated heparin or low molecular weight heparin is an anticoagulant that inhibits thrombin-mediated conversion of fibrinogen and is given prophylactically to prevent postoperative venous thrombosis or to treat pulmonary embolism or deep vein thrombosis following knee and abdominal surgeries.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to provide care for a bedfast client needing total care, medications, and foley catheter irrigation. How should the RN assign the client's care? A) UAP: personal care, catheter irrigation, I&O RN: medications. B) UAP: personal care. RN: medications, catheter irrigation, I&O. C) UAP: catheter irrigation, I&O. RN: medications. Both provide personal care. D) UAP: personal care, I&O. RN: catheter irrigation, medications.

UAP: personal care, I&O. RN: catheter irrigation, medications. Rationale: The RN is responsible for medication administration and sterile procedures such as catheter irrigation. The UAP is qualified to provide personal care and measure I&O.

Which action by the nurse is most helpful in communicating with a preschool aged child? A) speak clearly and directly to the child B) use a doll to play and communicate C) approach when a parent is not present D) play a board game with the child

Use a doll to play and communicate Rationale: Communicating through play with a doll or other toy gives time for the child to feel comfortable with a stranger.

The nurse manager observes that a staff nurse consistently fails to complete assigned care for clients who are obese. When counseling this employee, what issue is the priority concern? A) violation of ethical principles B) poor time management skills C) dissatisfaction of coworkers D) reduction of client complaints

Violation of ethical principles Rationale: The priority concern is the lack of fair and equal treatment of obese clients assigned to this staff nurse for car. This reflects a violation of the ethical principle of justice.

What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A) wheezing becomes louder B) cough remains unproductive C) vesicular breath sounds decrease D) bronchodilators stimulate coughing

Wheezing becomes louder Rationale: In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder as air flow increases in the airways.