NCLEX 3000

Which of the following signs and symptoms should the nurse expect to find in a client with angina? Select all that apply: 1. Chest tightness 2. General muscle aching 3. Chest pressure 4. Jaw pain 5. Slowed respiratory rate 6. Bradycardia.

1, 3, 4. RATIONALES: Chest tightness, chest pressure, and jaw pain are all symptoms of angina. General muscle aching is not associated with angina. Respirations and heart rate typically increase, not decrease, with anginal attacks.

A 64-year-old client has just had total hip replacement surgery. The physician orders heparin 8,000 units to be administered subcutaneously. The label on the heparin vial reads: "Heparin 10,000 units/ml." How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose?

0.8 RATIONALES: The following formula is used to calculate drug dosages: dose on hand/quantity on hand = dose desired/X. In this example, the equation is as follows: 10,000 units/ml = 8,000 units/X; X = 0.8 ml.

The nurse transcribes the following physician's order onto the client's medication record: September 15, 2005 Administer 10 gtt of timolol maleate (Timoptic) ophthalmic solution AU daily. John Bloom, MD Which components of the medication order should the nurse question? Select all that apply: 1. Number of drops 2. Route 3. Type of medication 4. Signature 5. Frequency of administration 6. Date

1, 2. RATIONALES: To ensure that medication errors don't occur, the nurse must follow the "six rights" of safe medication administration: right drug, right dose, right route, right time, right client, and right documentation. The number of drops is too great to be instilled into the eye. The medication wouldn't be effective because the dose is too large and would run out. Normally, the physician orders 1 or 2 drops to be instilled into the eye. As the order is written, the eye medication would be administered in both ears (AU). Abbreviations should be avoided when possible to prevent medication errors.

One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond? 1. "Atropine decreases salivation and gastric secretions." 2. "Atropine controls the heart rate and blood pressure." 3. "Atropine improves ventilation by increasing the respiratory rate." 4. "Atropine enhances the effect of anesthetic agents."

1. "Atropine decreases salivation and gastric secretions." RATIONALES: When used as preanesthesia medications, atropine and other cholinergic blocking agents reduce salivation and gastric secretions, thus helping to prevent aspiration of secretions during surgery. Atropine increases the heart rate and cardiac contractility, decreases bronchial secretions, and causes bronchodilation. No evidence indicates that the drug enhances the effect of anesthetic agents.

Which assessment finding would be most supportive of the nursing diagnosis, Impaired skin integrity? 1. Heart rate of 88 beats/minute 2. Wound healing by first intention 3. Area of skin with persistent redness 4. Dry and intact wound dressing

3. RATIONALES: A stage I pressure ulcer presents as a defined area of persistent redness in clients with light skin. It's a defining characteristic of the nursing diagnosis Impaired skin integrity. A heart rate of 88 beats/minute, healing by first intention, and a dry, intact dressing are normal assessment findings.

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement by the client indicates an understanding of appropriate ways to deal with this deficit? 1. "I'll play card games with my friends." 2. "I'll take a long trip to visit my aunt." 3. "I'll bowl with my team after discharge." 4. "I'll eat lunch in a restaurant every day."

1. "I'll play card games with my friends." RATIONALES: During chemotherapy, playing cards is an appropriate diversional activity because it doesn't require a great deal of energy. To conserve energy, the client should avoid such activities as taking long trips, bowling, and eating in restaurants every day. However, the client may take occasional short trips and can dine out on special occasions.

Which statement indicates that a family of a dying 4-year-old child may be ready to consider organ donation? 1. "My wife and I feel that our real daughter has moved on even though her body is still functioning." 2. "Those physicians aren't doing everything they can for our daughter. I know she's still in there." 3. "When will our daughter wake up and be with us?" 4. "How can some parents allow their children to be cut up like a piece of meat and given away?"

1. "My wife and I feel that our real daughter has moved on even though her body is still functioning." RATIONALES: Statements indicating that the family has accepted the grave condition of their child is a green light for approaching them about organ donation. Statements that represent the family's nonacceptance of the child's prognosis, the lack of understanding of treatments that are being given, or the misunderstanding of organ and tissue donation are indications that the family isn't ready to be approached or to make a decision.

The nurse can document that her client's bowel sounds are absent after listening for how long in each quadrant? 1. 5 minutes 2. 4 minutes 3. 3 minutes 4. 2 minutes

1. 5 minutes RATIONALES: The nurse can document that bowel sounds are absent after listening for 5 minutes in each quadrant.

An elderly client becomes extremely agitated and attempts to remove his endotracheal tube. The physician orders physical restraints. Which action indicates that the nurse has applied the restraints correctly? 1. A quick-release knot is used to tie the restraint. 2. The restraint is attached to the side rails. 3. Leather restraints are applied. 4. The hands are restrained tightly and can't be moved.

1. A quick-release knot is used to tie the restraint. RATIONALES: A quick-release knot is always used when fastening a restraint to allow the restraint to be removed quickly in an emergency. Restraints should be fastened to the bed frame only, not the side rails. Soft restraints should be used — not leather — to prevent client injury. Restraints should be applied as loosely as possible to allow movement but tight enough to ensure client safety.

Which measurement can best be used to monitor the respiratory status of a client with pulmonary edema? 1. Arterial blood gas (ABG) analysis 2. Pulse oximetry 3. Skin color assessment 4. Lung sounds

1. Arterial blood gas (ABG) analysis RATIONALES: ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy. The use of pulse oximetry is unreliable, especially in the case of severe vasoconstriction as is present in pulmonary edema. Although assessment of skin color and lung fields can be used to detect pulmonary changes, these options often are subject to interpretation by practitioners.

A client in labor is receiving oxytocin (Pitocin). During oxytocin therapy, why must the nurse monitor the client's fluid intake and output closely? 1. Because oxytocin causes water intoxication 2. Because oxytocin causes excessive thirst 3. Because oxytocin has a diuretic effect 4. Because oxytocin is toxic to the kidneys

1. Because oxytocin causes water intoxication RATIONALES: Oxytocin has an antidiuretic effect; prolonged I.V. infusion may lead to severe water intoxication, resulting in seizures, coma, and even death. Excessive thirst results from the work of labor and lack of oral fluids, not oxytocin administration. Oxytocin isn't toxic to the kidneys.

A client who's pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing: 1. Braxton Hicks contractions. 2. back labor. 3. fetal distress. 4. true labor contractions.

1. Braxton Hicks contractions. RATIONALES: Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout pregnancy, they're most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3 to 4 months in multiparous clients. With Braxton Hicks contractions, the cervix is closed, thick, and posterior, rather than dilated and thin as in true labor. Back labor refers to pain that typically starts in the back. Fetal distress doesn't cause contractions, although it may cause sharp abdominal pain. Decreased or absent fetal movements, green-tinged or yellowish green-tinged fluid, or port-wine-colored fluid may also indicate fetal distress. Pain from true labor contractions typically starts in the back and moves to the front of the fundus as a band of pressure that peaks and subsides in a regular pattern.

A client reports experiencing vulvar pruritus. Which finding may indicate that the client has an infection caused by Candida albicans? 1. Cottage cheese-like discharge 2. Yellow-green discharge 3. Gray-white discharge 4. Discharge with a fishy odor

1. Cottage cheese-like discharge RATIONALES: The symptoms of C. albicans include itching and a scant white discharge that has the consistency of cottage cheese. Yellow-green discharge is a sign of Trichomonas vaginalis. Gray-white discharge and a fishy odor are signs of Gardnerella vaginalis.

A client with a history of drug and alcohol abuse is concerned that the hospital will divulge her history to her employer without her knowledge. What response by the nurse would be appropriate? 1. "Your personal health information can't be disclosed to your employer without your permission." 2. "Your employer has the right to this information." 3. "You should give your employer the information before the hospital notifies him." 4. "Only the physician can inform your employer about your history of drug and alcohol abuse."

1. RATIONALES: No one can legally divulge this information without the client's permission. Doing so violates the client's right to confidentiality. The employer doesn't have the right to private health care information without the client's permission. The physician can't divulge health care information without the client's permission.

A client with a serum glucose level of 618 mg/dl is admitted to the facility. He's awake and oriented. He has hot, dry skin and the following vital signs: a temperature of 100.6° F (38.1° C), a heart rate of 116 beats/minute, and a blood pressure of 108/70 mm Hg. Based on these findings, which nursing diagnosis takes highest priority? 1. Deficient fluid volume related to osmotic diuresis 2. Decreased cardiac output related to elevated heart rate 3. Imbalanced nutrition: Less than body requirements related to insulin deficiency 4. Ineffective thermoregulation related to dehydration

1. Deficient fluid volume related to osmotic diuresis RATIONALES: A serum glucose level of 618 mg/dl indicates hyperglycemia, which causes polyuria and deficient fluid volume. In this client, tachycardia is more likely to result from deficient fluid volume than from decreased cardiac output because his blood pressure is normal. Although the client's serum glucose is elevated, food isn't a priority because fluids and insulin should be administered to lower the serum glucose level. Therefore, a diagnosis of Imbalanced nutrition: Less than body requirements isn't appropriate. A temperature of 100.6° F isn't life-threatening, which eliminates ineffective thermoregulation as the top priority.

A client with mild diarrhea, fever, and abdominal discomfort is being evaluated for inflammatory bowel disease (IBD). Which statement about IBD is true? 1. Diarrhea is the most common sign of IBD. 2. Transmural inflammation with fistula formation occurs in ulcerative colitis, one form of IBD. 3. Abscesses may occur in IBD because poor nutrition causes breakdown of cells in the GI tract. 4. Bowel cancer is common in clients with a history of Crohn's disease, one form of IBD.

1. Diarrhea is the most common sign of IBD. RATIONALES: IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. The pathophysiology of ulcerative colitis involves vascular congestion, hemorrhage, and edema — usually affecting the rectum and left colon. Although abscesses may occur in IBD, they result from buildup of lymphocytes and cellular debris in crypts, which may serve as abscess sites. Only about 3% of clients with a long history of Crohn's disease develop bowel cancer.

Which intervention should the nurse perform as soon as possible when caring for a 21-week-old anencephalic neonate? 1. Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets. 2. Place the neonate in a warmer and initiate neonatal resuscitation efforts. 3. Swaddle the neonate and attempt feedings. 4. Transfer the neonate to the neonatal intensive care unit.

1. Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets. RATIONALES: Anencephaly is the congenital absence of the brain and spinal cord, which isn't compatible with life. The nurse needs to provide palliative care to the neonate and family by promoting physical comfort, and providing emotional support. Attempts to normalize the neonate's appearance and provide warmth meets the needs of the neonate and family. The other interventions are inappropriate for a client with a terminal diagnosis.

The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include? 1. Encourage a high-calorie, high-protein diet. 2. Restrict fluids to 1,500 ml per day. 3. Limit salt intake to 2 g per day. 4. Encourage foods high in vitamin B.

1. Encourage a high-calorie, high-protein diet. RATIONALES: The child should eat a high-calorie, high-protein diet. In cystic fibrosis, the enzymes from the pancreas (lipase, trypsin, and amylase) become so thick that the ducts become plugged. Without these enzymes, the duodenum isn't able to digest fat, protein, and some sugars; therefore, the child can become malnourished. Because fats aren't easily tolerated, they may need to be restricted. The child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are necessary because the inability to absorb fats results in a deficiency of these vitamins. Clients with cystic fibrosis don't have a problem absorbing water-soluble vitamins such as vitamin B.

Which nursing action is most appropriate when trying to diffuse a client's impending violent behavior? 1. Helping the client identify and express feelings of anxiety and anger 2. Involving the client in a quiet activity to divert attention 3. Leaving the client alone until he can talk about his feelings 4. Placing the client in seclusion

1. Helping the client identify and express feelings of anxiety and anger RATIONALES: In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statements as "What happened to get you this angry?" may help the client verbalize feelings rather than act on them. Close interaction with the client in a quiet activity may place the nurse at risk for injury should the client suddenly become violent. An agitated and potentially violent client shouldn't be left alone or unsupervised because the danger of the client's acting out is too great. The client should be placed in seclusion only if other interventions fail or the client requests this. Unlocked seclusion can be helpful for some clients because it reduces environmental stimulation and provides a feeling of security.

Twenty-four hours after birth, a neonate hasn't passed meconium. This may indicate which condition? 1. Hirschsprung's disease 2. Celiac disease 3. Intussusception 4. Abdominal wall defect

1. Hirschsprung's disease RATIONALES: Failure to pass meconium is an important diagnostic indicator for Hirschsprung's disease. The other options aren't associated with failure to pass meconium.

The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed? 1. Irrigate continuously until the solution becomes clear or all of the solution has been used. 2. Moisten the area around the wound with normal saline after the irrigation. 3. Apply a wet-to-dry dressing to the wound after the irrigation. 4. Rapidly instill a stream of irrigating solution into the wound.

1. RATIONALES: To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area around the wound; moistening it promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, rather than a wet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues.

The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply: 1. Illness in one family member can affect all members. 2. Family roles don't change because of illness. 3. A family member may have more than one role at a time in a family. 4. Children typically aren't affected by adult illness. 5. The effects of an illness on a family depend on the stage of the family's life cycle. 6. Changes in sleeping and eating patterns may be signs of stress in a family.

1. Illness in one family member can affect all members. 3. A family member may have more than one role at a time in a family. 5. The effects of an illness on a family depend on the stage of the family's life cycle. 6. Changes in sleeping and eating patterns may be signs of stress in a family. RATIONALES: Illness in one family member can affect all family members, including children. Each member of a family may have several roles to perform. A middle-aged woman, for example, may have the roles of mother, wage-earner, wife, and housekeeper. Families move through certain predictable life cycles (such as birth of a baby, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family may depend on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress. When one family member can't fulfill a role due to illness, the roles of the other family members are affected.

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest? 1. Infection 2. Dehiscence 3. Hemorrhage 4. Evisceration

1. Infection RATIONALES: Infection produces such signs as redness, swelling, induration, warmth, and possibly drainage. Dehiscence, which refers to the separation of a wound, may cause unexplained fever and tachycardia, unusual wound pain, and prolonged paralytic ileus. Hemorrhage can result in increased pulse and respiratory rate, decreased blood pressure, restlessness, thirst, and cold, clammy skin. Evisceration produces visible protrusion of organs, usually through an incision.

A client receives an epidural block for pain relief during labor. Which interventions by the nurse are important when caring for a client with an epidural block? Select all that apply: 1. Make sure oxygen is available. 2. Keep the client positioned on her left side. 3. Monitor vital signs frequently. 4. Maintain I.V. fluid at a keep-vein-open rate. 5. Monitor fetal heart rate and contractions closely.

1. Make sure oxygen is available. 3. Monitor vital signs frequently. 5. Monitor fetal heart rate and contractions closely. RATIONALES: The nurse should make sure that oxygen is available in case hypotension occurs. I.V. fluid should be infusing to prevent dehydration, which might cause hypotension. The client should be positioned on her side and her position should be alternated from side to side every 30 to 60 minutes. Fetal heart rate and contractions must be monitored closely because the client may be unaware of changes in the strength of contractions or the descent of the presenting part.

A client is prescribed digoxin (Lanoxin) 0.125 mg by mouth now. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes she has administered the wrong dose. How should the nurse proceed? 1. Obtain vital signs and notify the physician and nursing supervisor immediately of the error. 2. Obtain a copy of the physician's order and inform the pharmacy of their dispensing error. 3. Immediately inform the pharmacist of his dispensing error and document the incident. 4. Inform the pharmacist and the nursing supervisor of the error and document the incident.

1. Obtain vital signs and notify the physician and nursing supervisor immediately of the error. RATIONALES: The nurse should obtain vital signs and notify the physician and nursing supervisor of the error. An incident report should then be completed to document the occurrence. The nurse administering the drug is legally responsible for ensuring that she calculates and administers the correct dose. She shouldn't immediately inform the pharmacist. The incident will be shared with the pharmacy supervisor after completion of the incident report.

The nurse is caring for a client who exhibits pinpoint pupils and decreased blood pressure, pulse, respirations, and temperature. These signs may indicate which disorder? 1. Opiate intoxication 2. Amphetamine intoxication 3. Cannabis intoxication 4. Alcohol intoxication

1. Opiate intoxication RATIONALES: Opiates such as morphine or heroin cause pinpoint pupils and decreased blood pressure, pulse, respirations, and temperature. Amphetamines cause pupils to dilate. Cannabis intoxication causes dry mouth, tachycardia, and increased appetite. Alcohol intoxication causes unsteady gait, incoordination, nystagmus, and a flushed face.

A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased respiratory rate, and a decreased oxygen saturation level. Which of the following should be the nurse's first action? 1. Suction the tracheostomy. 2. Turn the child to a side-lying position. 3. Administer pain medication. 4. Perform chest physiotherapy.

1. RATIONALES: Diaphoresis, increased heart rate, increased respiratory effort, and decreased oxygen saturation are signs that mucus is partially occluding the airway. The child needs suctioning immediately to prevent full occlusion. Turning the child to a side-lying position won't remove mucus from the airway. The child may require pain medication after his airway has been cleared if his condition warrants it. Chest physiotherapy will help drain excess mucus from the lungs but not from a tracheostomy.

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? 1. Respiratory rate of 22 breaths/minute 2. Dilated and reactive pupils 3. Urine output of 40 ml/hour 4. Heart rate of 100 beats/minute

1. RATIONALES: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

Which symptom reported by an adolescent's parents indicates that the adolescent is abusing amphetamines? Select all that apply: 1. Restlessness 2. Fatigue 3. Excessive perspiration 4. Talkativeness 5. Watery eyes 6. Excessive nasal drainage.

1. Restlessness 3. Excessive perspiration 4. Talkativeness RATIONALES: Amphetamines are central nervous system stimulants. Symptoms of amphetamine abuse include marked nervousness, restlessness, excitability, talkativeness, and excessive perspiration.

A 42-year-old client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis? Select all that apply: 1. Severe, deep pain around the thorax 2. Red, nodular skin lesions around the thorax 3. Fever 4. Malaise 5. Diarrhea

1. Severe, deep pain around the thorax 2. Red, nodular skin lesions around the thorax 3. Fever 4. Malaise RATIONALES: Shingles, also called herpes zoster, is an acute unilateral and segmental inflammation of the dorsal root ganglia. It's caused by infection with the herpes virus varicella-zoster, the same virus that causes chickenpox. It commonly causes severe, deep pain along a peripheral nerve on the trunk of the body and red, nodular skin lesions. Fever and malaise typically accompany these findings. Diarrhea doesn't commonly occur with shingles.

Which response should alert the nurse caring for a preschooler who underwent surgery that the child is experiencing pain? 1. The child begins clutching at his parents. 2. The child appears to be holding back tears. 3. The child is exhibiting controlling behavior. 4. The child is exhibiting demanding behavior.

1. The child begins clutching at his parents. RATIONALES: A normal response to pain in a preschool-age child is clinging to or clutching the parents for comfort. Holding back tears and exhibiting controlling or demanding behaviors are responses that might be seen in an older child or adult in response to pain but not in a preschool-age child.

A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of: 1. how well the neonate tolerated labor. 2. how well the neonate tolerated vitamin K administration. 3. how well the neonate tolerated the birth. 4. gestational age of the neonate.

1. how well the neonate tolerated labor. RATIONALES: Apgar scores, given at 1 and at 5 minutes after delivery, indicate how well the neonate tolerated labor and how well he made the transition to extrauterine life. These scores also provide the foundation for additional nursing interventions, if needed. Apgar scores aren't used to determine the gestational age of the neonate or how well the neonate tolerated vitamin K administration.

In an individual with Sjögren's syndrome, nursing care should focus on: 1. moisture replacement. 2. electrolyte balance. 3. nutritional supplementation. 4. arrhythmia management.

1. moisture replacement. RATIONALES: Sjögren's syndrome is an autoimmune disorder leading to progressive loss of lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is the mainstay of therapy. Though malnutrition and electrolyte imbalance may occur as a result of Sjögren's syndrome's effect on the GI tract, it isn't the predominant problem. Arrhythmias aren't a problem associated with Sjögren's syndrome.

The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: 1. progressively deeper breaths followed by shallower breaths with apneic periods. 2. rapid, deep breaths with abrupt pauses between each breath. 3. rapid, deep breaths and irregular breathing without pauses. 4. shallow breaths with an increased respiratory rate.

1. progressively deeper breaths followed by shallower breaths with apneic periods. RATIONALES: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

A client in the emergency department expresses suicidal ideation and feelings of worthlessness. He has a family history of suicide. The nurse is collecting data on the client. The most important factor to consider is: 1. whether the client has an active suicide plan and the means to carry it out. 2. whether the client made a previous suicide attempt. 3. the client's religion and social status. 4. the client's social support and marital status.

1. whether the client has an active suicide plan and the means to carry it out. RATIONALES: The presence of an actual suicide plan would require a restrictive environment for the client. Although a previous suicide attempt and the client's marital and social support status can increase the risk of suicide, the presence of a serious plan is the primary concern for the nurse.

Before discharge, which instruction should the nurse give to a client receiving digoxin (Lanoxin)? 1. "Take an extra dose of digoxin if you miss one dose." 2. "Call the physician if you have a rapid heart rate." 3. "Call the physician if your pulse drops below 80 beats/minute." 4. "Take digoxin with meals."

2. "Call the physician if you have a rapid heart rate." RATIONALES: The nurse should instruct the client to notify the physician if a rapid heart rate develops because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the client should be instructed never to take an extra dose of digoxin if a dose is missed. The nurse should show the client how to take her pulse and to call the physician if her pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. Digoxin shouldn't be administered with meals because doing so slows the absorption rate.

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. Which of the following would be the nurse's best response? 1. "I can see you're upset. Why don't we discuss this at a later time when you're feeling better." 2. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." 3. "Let me check with your physician and get you something that will help you relax." 4. "Pregnancy should be avoided until all of your tests are normal."

2. "I can see that you're upset; however, you must wait at least 1 year before becoming pregnant again." RATIONALES: Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 12 months by an experienced health care provider. Discussing this situation at a later time and checking with the physician to give the client something to relax ignore the client's immediate concerns. Telling her to wait until all tests are normal is vague and provides the client with little information.

The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? 1. "The client demonstrates the ability to care for the neonate completely by time of discharge." 2. "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." 3. "The client demonstrates an understanding of her physical needs related to labor and delivery." 4. "The client demonstrates an understanding of the neonate's physical needs related to labor and delivery."

2. "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." RATIONALES: Discussing the childbirth experience helps the client acknowledge and understand what happened during this event. The nurse should give the client a chance to ask questions about the event and seek clarification, if needed. After the client discusses the event, she may be able to shift the focus away from herself and begin the tasks that will help her assume the maternal role. The nurse must determine the client's understanding of her physical needs and those of her neonate after teaching and demonstrating care techniques; discussing the childbirth experience won't help her meet these needs.

The grandmother of a preschool-age child calls the clinic to report that the child has had a fever, has been fussy, and now has a rash that started on the neck and has spread to the rest of the child's body. The child was exposed to chickenpox about 3 weeks ago. What advice would be most important to give to the grandmother? 1. "Bring the child to the clinic immediately so we can confirm the diagnosis." 2. "You can help relieve the child's itching by giving him oatmeal baths." 3. "Make sure the child stays calm and limit the amount of time he spends watching television." 4. "The child should stay home until his fever is gone, then he can return to daycare."

2. "You can help relieve the child's itching by giving him oatmeal baths." RATIONALES: The most likely explanation for the child's illness is chickenpox. The nurse should review the treatment for chickenpox, which includes oatmeal baths and diphenhydramine (Benadryl) for itching. The nurse should also recommend measures to lower the child's temperature (if elevated), such as giving a tepid bath or administering antipyretics. Unless the child is severely ill or has complications, the child doesn't need to be seen in the clinic. In general, limiting a preschooler's television viewing is appropriate but it isn't the most important advice in this situation. Typically, children will limit their own activities as needed.

A pregnant client in her second trimester visits the health care practitioner for a regular prenatal checkup. The nurse weighs the client. She then compares the client's current and previous weights. During the second trimester, how much weight should the client gain per week? 1. 0.5 lb (0.23 kg) 2. 1 lb (0.45 kg) 3. 1.5 lb (0.68 kg) 4. 2 lb (.91 kg)

2. 1 lb (0.45 kg) RATIONALES: During the second and third trimesters, weight gain should average about 1 lb per week in a client with a single fetus. A woman with a multiple-fetus pregnancy should gain about 1.5 lb per week, on average, during the second half of pregnancy.

A client is admitted to the labor and delivery area. The nurse-midwife checks for fetal descent, flexion, internal rotation, extension, external rotation, and expulsion. What do these terms describe? 1. Phases of the first stage of labor 2. Cardinal movements of labor 3. Factors affecting labor 4. Factors that determine fetal position

2. Cardinal movements of labor RATIONALES: Cardinal movements of labor refer to the typical sequence of positions assumed by the fetus during labor and delivery. These positions are most commonly called descent, flexion, internal rotation, extension, external rotation, and expulsion. Phases of the first stage of labor include the latent, active, and transitional phases. Factors affecting labor include the passenger, passageway, powers, placental position and function, and psychological response. Factors that determine fetal position include the landmark of the fetal presenting part, whether the landmark faces the left or right side of the maternal pelvis, and whether the landmark faces the front, back, or side of the maternal pelvis.

The nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate? 1. Weak sucking response 2. Enlarged breast tissue 3. Soft skin 4. Vernix caseosa

2. Enlarged breast tissue RATIONALES: It's common to see enlarged breast tissue in both male and female neonates in their first few days of life due to maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.

One day after undergoing a traditional cholecystectomy, a client is scheduled to stand at the bedside and walk. What should a nurse teach the client to do before standing and walking for the first time after surgery? 1. Place the bed in the flat position before getting out of bed. 2. Flex her legs when moving to a sitting position. 3. Maintain a slightly flexed-at-the-waist position when walking. 4. Relax her buttock muscles when rising to a standing position.

2. Flex her legs when moving to a sitting position. RATIONALES: Flexing the legs when moving to a sitting position reduces the tension on the abdomen and the pain associated with moving. The bed should be placed in the sitting position, rather than flat. The client should be encouraged to stand erect when walking, not flexed at the waist. The buttock muscles should be tightened so that the act of moving uses the leg and buttock muscles rather than the abdominal muscles.

A neonate's pulse rate drops below 60 beats/minute. How should the nurse intervene? Rank in chronological order. Use all the options. 1. Place the neonate on a firm, flat surface. 2. Gently shake the neonate shoulders. 3. Call for help. 4. Use the head-tilt-chin-lift method. 5. Assess breathing, and then give 2 slow breaths. 6. Give chest compressions.

2. Gently shake the neonate shoulders. 3. Call for help. 1. Place the neonate on a firm, flat surface. 4. Use the head-tilt-chin-lift method. 5. Assess breathing, and then give 2 slow breaths. 6. Give chest compressions. RATIONALES: This neonate is experiencing bradycardia. The nurse should gently shake the neonate's shoulders; call for help; place the neonate on a firm, flat surface; open the neonate's airway using the head-tilt-chin-lift method; assess breathing and administer 2 slow breaths; and give chest compressions.

What medication would probably be ordered for the acutely aggressive schizophrenic client? 1. Chlorpromazine (Thorazine) 2. Haloperidol (Haldol) 3. Lithium carbonate (Lithonate) 4. Amitriptyline (Elavil)

2. Haloperidol (Haldol) RATIONALES: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Lithium carbonate is useful in bipolar disorder, and amitriptyline is used for depression.

Which of the following actions displayed by a grieving husband over his dying wife would cause the nurse to suggest counseling? 1. He takes out wedding pictures and memorabilia to show to the staff. 2. He refuses to acknowledge his wife's family and blames them for her current health problems. 3. He has already planned his wife's funeral. 4. He is planning to give away his wife's treasured items to family members.

2. He refuses to acknowledge his wife's family and blames them for her current health problems. RATIONALES: Abnormal grief may manifest itself as exaggerated or excessive expressions of normal grief reactions, such as anger, sadness, or depression. It's therapeutic to review a person's life with loved ones. Funeral planning can be therapeutic because it allows the individual to do one last thing for his loved one. It's therapeutic to share treasured items with staff and other family members.

A 15-month-old admitted with meningitis develops a rectally obtained fever of 105° F (40.5° C). The registered nurse inserts an I.V. catheter and antibiotics are administered. Which step should be taken next by the licensed practical nurse caring for the toddler? 1. Bathing the toddler in alcohol to lower the temperature 2. Obtaining an order for an antipyretic and administering it immediately 3. Sponging the toddler with tepid water 4. Initiating seizure precautions

2. Obtaining an order for an antipyretic and administering it immediately RATIONALES: The priority is to try to lower the toddler's temperature by first obtaining an order for an antipyretic and administering it. After the antipyretic is administered, the nurse should bathe the toddler with tepid water, not alcohol, and initiate seizure precautions because seizures sometimes accompany high fever and meningitis.

Which client is at highest risk for suicide? 1. One who appears depressed, frequently thinks of dying, and gives away all personal possessions 2. One who plans a violent death and has the means readily available 3. One who tells others that he or she might do something if life doesn't get better soon 4. One who talks about wanting to die

2. One who plans a violent death and has the means readily available RATIONALES: The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage). A client who gives away possessions, thinks about death, or talks about wanting to die or attempting suicide is considered a lower risk for suicide. This behavior typically serves to alert others that the client is contemplating suicide and wishes to be helped.

A client is receiving captopril (Capoten) for heart failure. Which finding indicates that the medication isn't producing the desired treatment outcome and requires the nurse to notify the physician? 1. Skin rash 2. Peripheral edema 3. Dry cough 4. Orthostatic hypotension

2. Peripheral edema RATIONALES: Peripheral edema is a sign of fluid volume overload and worsening heart failure. A skin rash, dry cough, and orthostatic hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

An 10-year-old boy is brought to a rural clinic listless and pale. The parents state that the child had a "bad sore throat" 2 weeks ago and that they had him gargle with salt water. The parents report that they saw improvement but now the child has flulike symptoms. The child is diagnosed with rheumatic fever. Which of the following signs and symptoms are associated with rheumatic fever? Select all that apply: 1. Nausea and vomiting 2. Polyarthritis 3. Chorea 4. High-grade fever 5. Carditis 6. Rash

2. Polyarthritis 3. Chorea 5. Carditis 6. Rash RATIONALES: Characteristic manifestations of rheumatic fever include polyarthritis, chorea, carditis, and a red rash. The child doesn't usually experience nausea and vomiting. He may have a minor low-grade fever in the afternoon.

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? 1. "Take your temperature every 4 hours." 2. "Increase your fluid intake to 2 to 3 L per day." 3. "Apply an antibacterial dressing to the incision daily." 4. "Be aware that your urine will be cherry red for 5 to 7 days."

2. RATIONALES: Increasing fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary system. Measuring temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision. Hematuria may occur for a few hours after lithotripsy but then should disappear.

The nurse is checking a client's I.V. infusion rate at the beginning of her shift. The nursing Kardex states that the infusion should run at 125 ml/hour. To verify the I.V. drip rate, the nurse must know the drip factor, which is: 1. the number of milliliters in one drop. 2. the number of drops in one milliliter. 3. the number of drops per minute to be infused. 4. the number of drops per hour to be infused.

2. RATIONALES: The drip factor is the number of drops in one milliliter, not the number of milliliters in one drop. The drip rate refers to the number of drops infused per minute. The flow rate is the number of milliliters, not the number of drops, infused per hour.

During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis? 1. Hold the neonate loosely and gently. 2. Support the neonate's head and back with the forearm. 3. Use one hand to support the neonate's head. 4. Strap the neonate into the bath basin.

2. Support the neonate's head and back with the forearm. RATIONALES: To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with her forearm. A loose hold may increase the risk of dropping the neonate. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should: 1. insert an oral airway. 2. withhold food and fluids. 3. position the client on his side. 4. insert a nasogastric (NG) tube.

2. withhold food and fluids. RATIONALES: Following a transesophageal echocardiogram in which the client's throat has been anesthetized, food and fluid should be withheld until the gag reflex returns. There is no indication for oral airway placement. The client should be in the upright position, and inserting an NG tube is unnecessary.

A physician orders phenytoin (Dilantin) 150 mg by mouth twice per day for a child. The dosage strength of the oral suspension on hand is 30 mg/5 ml. How many milliliters of suspension should the nurse administer with each dose?

25 RATIONALES: To calculate the dose, set up the following proportion: 150 mg/X = 30 mg/5 ml X = 25 ml. The nurse should administer 25 ml of suspension with each dose.

During a teaching session, the nurse demonstrates how to change a tracheostomy dressing. Then, the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? 1. The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. 2. The client cleans around the incision site, using gauze squares moistened with normal saline. 3. The client cleans around the incision site, using gauze squares moistened with tap water. 4. The client applies cotton-filled gauze squares as the sterile dressing after cleaning.

2. The client cleans around the incision site, using gauze squares moistened with normal saline. RATIONALES: To change a tracheostomy dressing effectively, the client should clean around the incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline — not full-strength hydrogen peroxide. The client shouldn't use tap water because it may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares.

The grandmother of a preschool-age child calls the clinic to report that the child has had a fever, has been fussy, and now has a rash that started on the neck and has spread to the rest of the child's body. The child was exposed to chickenpox about 3 weeks ago. Which of the following would be the most important advice to give the grandmother? 1. Bring the child in immediately so the diagnosis can be confirmed. 2. Treat the child's symptoms and use diphenhydramine (Benadryl) for itching. 3. Be sure the child stays quiet, and limit the amount of television viewing. 4. After the fever is gone, the child can return to day care.

2. Treat the child's symptoms and use diphenhydramine (Benadryl) for itching. RATIONALES: The most likely explanation for the child's illness is chickenpox. The nurse should review the treatment for chickenpox, which includes acetaminophen for fever and fussiness, and oatmeal baths and diphenhydramine for itching. Unless the child is severely ill or has complications, the child doesn't need to be seen in the clinic. Limiting a preschooler's television viewing is appropriate but isn't the most important advice. Typically, children will limit their own activities as needed. The child may still be contagious after the fever subsides. He shouldn't return to day care until after the lesions crust over.

The nurse is collecting data on a client with hyperthyroidism. What findings should the nurse expect? 1. Weight gain, constipation, and lethargy 2. Weight loss, nervousness, and tachycardia 3. Exophthalmos, diarrhea, and cold intolerance 4. Diaphoresis, fever, and decreased sweating

2. Weight loss, nervousness, and tachycardia RATIONALES: Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs of hypothyroidism.

The physician teaches a client about the need to increase her intake of calcium. At a follow-up appointment, the nurse asks the client which foods she has been consuming to increase her calcium intake. Which answer suggests that teaching about calcium-rich foods was effective? 1. Broccoli and nuts 2. Yogurt and kale 3. Bread and shrimp 4. Beans and potatoes

2. Yogurt and kale RATIONALES: Yogurt and kale are good sources of calcium, so the client reporting increased intake of these foods indicates that teaching was effective. Broccoli and beans are also good sources of calcium, but nuts, bread, potatoes, and shrimp aren't.

The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it: 1. dilates cerebral blood vessels. 2. constricts cerebral blood vessels. 3. decreases peripheral vascular resistance. 4. decreases the stimulation of baroreceptors.

2. constricts cerebral blood vessels. RATIONALES: Ergotamine relieves migraine headaches by constricting cerebral arterial vessels. The drug's ability to prevent norepinephrine reuptake may add to this effect. The net result is decreased pulsatile blood flow through the cerebral vessels and symptom relief. Ergotamine doesn't decrease either peripheral vascular resistance or stimulation of baroreceptors.

An emergency department nurse suspects neglect in a 3-year-old boy admitted for failure to thrive. Signs of neglect in the child would include: 1. slapping, kicking, and punching others. 2. poor hygiene and weight loss. 3. loud crying and screaming. 4. pulling hair and hitting.

2. poor hygiene and weight loss. RATIONALES: Neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Slapping, kicking, pulling hair, hitting, and punching are forms of physical abuse. Loud crying and screaming aren't abnormal findings in a 3-year-old boy.

A client is in the first stage of Alzheimer's disease. The nurse should plan to focus this client's care on: 1. offering nourishing finger foods to help maintain the client's nutritional status. 2. providing emotional support and individual counseling. 3. monitoring the client to prevent minor illnesses from turning into major problems. 4. suggesting new activities for the client and family to do together.

2. providing emotional support and individual counseling. RATIONALES: Clients in the first stage of Alzheimer's disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling. The other options are appropriate during the second stage of Alzheimer's disease, when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems. During this second stage, offering nourishing finger foods helps clients feed themselves and maintain adequate nutrition.

To calculate drug dosages for a 4-year-old child, the physician might use a formula that involves the child's: 1. weight in pounds and ounces. 2. weight in kilograms. 3. height in inches. 4. height in centimeters.

2. weight in kilograms. RATIONALES: To calculate drug dosages for a child, the physician might use a formula that involves the child's weight in kilograms. A second recommended method involves the child's body surface area; however this method uses a nomogram containing height and weight to calculate drug dosages. Other methods of dosage calculation aren't recommended.

Which of the following laboratory values supports a diagnosis of pyelonephritis? 1. Myoglobinuria 2. Ketonuria 3. Pyuria 4. Low white blood cell (WBC) count

3. Pyuria RATIONALES: Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low. Ketonuria indicates a diabetic state.

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? 1. "I will have to take the medication for up to a year." 2. "This disease may come back later if I am under stress." 3. "I will stay in isolation for at least 6 weeks." 4. "I will always have a positive test for tuberculosis."

3. "I will stay in isolation for at least 6 weeks." RATIONALES: The client needs to be in isolation for 2 weeks, not 6, while receiving antitubercular drug therapy. After 2 weeks of antitubercular therapy, the client is no longer considered contagious. The client needs to receive the drugs for 9 months to a year. He will be positive when tested, and if he's sick or under some stress he could have a relapse of the disease.

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: 1. return to preovulatory basal body temperature. 2. basal body temperature increase of 0.1° F to 0.2° F (0.06° C to 0.11° C) on the second or third day of the cycle. 3. 3 days of elevated basal body temperature and clear, thin cervical mucus. 4. breast tenderness and mittelschmerz.

3. 3 days of elevated basal body temperature and clear, thin cervical mucus. RATIONALES: Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7° F to 0.8° F (.39° C to .44° C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't significant. Breast tenderness and mittelschmerz aren't reliable indicators of ovulation.

Every morning a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain? 1. 70 units of isophane insulin suspension (NPH) insulin and 30 units of regular insulin 2. 70 units of regular insulin and 30 units of NPH insulin 3. 70% NPH insulin and 30% regular insulin 4. 70% regular insulin and 30% NPH insulin

3. 70% NPH insulin and 30% regular insulin RATIONALES: Humulin 70/30 insulin is a combination of 70% NPH insulin and 30% regular insulin.

The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds? 1. A rub occurs during expiration only and produces a light, popping, musical noise. 2. A rub occurs during inspiration only and may be heard anywhere. 3. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound. 4. A rub occurs during inspiration only and clears with coughing.

3. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound. RATIONALES: A pleural friction rub, heard in the lateral portion of the lungs during both inspiration and expiration, produces a squeaking or grating sound. Other abnormal sounds may clear with coughing, but pleural friction rubs don't.

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information? 1. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests. 2. Advanced medical intervention can cure most autoimmune disorders. 3. Autoimmune disorders include connective tissue (collagen) disorders. 4. Autoimmune disorders are distinctive, aiding differential diagnosis.

3. Autoimmune disorders include connective tissue (collagen) disorders. RATIONALES: Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.

A nurse places a client in full leather restraints. How often must the nurse check the client's circulation? 1. Once per hour 2. Once per shift 3. Every 15 minutes 4. Every 2 hours

3. Every 15 minutes RATIONALES: Circulatory as well as skin and nerve damage can occur quickly. Therefore, circulation should be assessed at least every 15 minutes. Checking every hour, 2 hours, or 8 hours isn't often enough and could result in permanent damage to the client's extremities.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? 1. Fear 2. Urinary retention 3. Excess fluid volume 4. Toileting self-care deficit

3. Excess fluid volume RATIONALES: A client with renal failure can't eliminate sufficient fluid, increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance.

A nurse is working with a 23-year-old client with a history of alcohol abuse. The nurse uses the CAGE Screening Tool while performing her assessment. She begins explaining the significance of each letter contained in the acronym. The nurse should explain that the letter "A" represents which assessment question? 1. Are you a member of Alcoholics Anonymous? 2. Do you have an addiction disorder? 3. Have people annoyed you by criticizing your drinking? 4. Is alcohol your drug of choice?

3. Have people annoyed you by criticizing your drinking? RATIONALES: The CAGE screening tool is used during screening for alcohol addiction. The acronym CAGE stands for Cut down, Annoyed by criticism, Guilty about drinking, and Eye-opener drinks.

Which intervention by a nurse might help prevent pressure ulcers? 1. Placing a cushion under the client's buttocks 2. Placing a donut cushion under the client's buttocks when he is sitting in a chair 3. Placing an alternating-current mattress on the client's bed 4. Turning and repositioning the client every 4 hours

3. Placing an alternating-current mattress on the client's bed RATIONALES: Placing an alternating-current mattress on the client's bed helps relieve pressure over bony prominences, thereby reducing the risk of pressure ulcers. Placing cushions of any kind under the client's buttocks compromises circulation and increases the client's risk for pressure ulcers. The client should be turned and repositioned every 2 hours, not every 4 hours.

When administering gentamicin to a preschooler, which of the following monitoring schedules is best for determining the drug's effectiveness? 1. A serum trough level every morning 2. A serum peak level after the second dose 3. A serum trough and peak level with the third dose 4. Serial serum trough levels after three doses (24 hours)

3. RATIONALES: Aminoglycosides such as gentamicin have a narrow range between therapeutic and toxic serum levels. A serum peak and trough level (taken half an hour before the dose and half an hour after the dose has been administered) around the third dose (the third dose provides enough medication build up in the blood stream to be measured) is the most accurate way to determine the correct serum values. A trough level every morning, a serum peak level after the second dose, and serial serum trough levels won't provide sufficient data about the effectiveness of the antibiotic.

The nurse is using drawing, puppetry, and other forms of play therapy while treating a terminally ill, school-age child. The primary purpose of these techniques is to help the child: 1. internalize his feelings about death and dying. 2. accept responsibility for his situation. 3. express feelings that he can't articulate. 4. have a good time while he's in the hospital.

3. RATIONALES: Children may not have the verbal and cognitive skills to express what they feel and may benefit from alternative modes of expression. The child needs to find a way to express internalized feelings. The child must know that he isn't to blame for this situation. In the process of doing play therapy, the child can also have fun, but that isn't the main goal of therapy.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation? 1. Chickenpox 2. Impetigo 3. Measles 4. Cholera

3. RATIONALES: Measles warrants respiratory isolation, which aims to prevent disease transmission primarily over short distances through the air (droplet transmission). Other infections necessitating respiratory isolation include epiglottitis or pneumonia caused by Haemophilus influenzae, erythema infectiosum, meningitis caused by H. influenzae or meningococci, meningococcal pneumonia, meningococcemia, mumps, and pertussis. Chickenpox calls for strict isolation; impetigo, contact isolation; and cholera, enteric isolation.

The nurse is providing care for a client who underwent heart surgery. The best example of a measurable outcome goal is for the client to: 1. change his own dressing. 2. walk in the hallway. 3. walk from his room to the end of the hall and back before discharge. 4. eat a special diet.

3. RATIONALES: Walking from his room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.

Which information should a nurse include when consulting with a home health care agency about the nursing care and physical therapy needs of a client who will be discharged after undergoing total hip replacement surgery? 1. The client has two daughters who reside in different states. 2. The client lives in a two-bedroom apartment. 3. The client lives alone and will be restricted from driving for at least 6 weeks. 4. The client frequently calls emergency medical services when he is ill.

3. The client lives alone and will be restricted from driving for at least 6 weeks. RATIONALES: It's important for the home health care agency to know that the client lives alone and has no transportation so that they can adequately provide for his home health care needs. Informing the agency that the client's daughters reside in different states doesn't clarify whether the client lives alone. Explaining that the client lives in a two-bedroom apartment doesn't establish whether the apartment accommodates his limited mobility. Informing the agency about the client's frequent calls to emergency medical services is inappropriate and judgmental.

A client has been receiving chlorpromazine (Thorazine), an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? 1. Restlessness, difficulty sitting still, and pacing 2. Involuntary rolling of the eyes 3. Tremors, shuffling gait, and masklike face 4. Extremity and neck spasms, facial grimacing, and jerky movements

3. Tremors, shuffling gait, and masklike face RATIONALES: Pseudoparkinsonism, characterized by tremors, shuffling gait, masklike face, drooling, rigidity, and "pill rolling," may appear 1 to 5 days after starting an antipsychotic. Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis is recognized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered an emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing.

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." The purpose is to evaluate the client's ability to think: 1. rationally. 2. concretely. 3. abstractly. 4. tangentially.

3. abstractly. RATIONALES: Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual functioning than concrete thinking, in which the client explains the proverb by its literal meaning. Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential thinking is scattered, not goal-directed, and hard to follow. Clients with such conditions as organic brain disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They interpret such statements as "Don't cry over spilled milk" in a literal sense such as "Even if you spill your milk, you shouldn't cry about it."

The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: 1. avoid shopping for large amounts of food. 2. control eating impulses. 3. identify anxiety-causing situations. 4. eat only three meals per day.

3. identify anxiety-causing situations. RATIONALES: Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety. Controlling shopping for large amounts of food isn't a goal early in treatment. Managing eating impulses and replacing them with adaptive coping mechanisms can be integrated into the plan of care after initially addressing stress and underlying issues. Eating three meals per day isn't a realistic goal early in treatment.

A child who recovered from bacterial meningitis is scheduled to have his hearing checked before discharge. The mother asks why this test is necessary. Which response by the nurse is best? 1. "The test is necessary to make sure your child is developing appropriately." 2. "The test will identify attention deficit problems related to your child's illness." 3. "The test is necessary to make sure the steroid therapy your child had in the hospital didn't affect his hearing." 4. "Despite treatment, some children with bacterial meningitis suffer neurologic damage, especially to the nerve responsible for hearing."

4. "Despite treatment, some children with bacterial meningitis suffer neurologic damage, especially to the nerve responsible for hearing." RATIONALES: The most common neurologic complications of meningitis are hearing loss, mental retardation, seizures, visual impairment, and behavioral problems. Steroid therapy isn't associated with hearing loss. Hearing tests aren't used to identify developmental or attention deficit problems.

The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the client is using the spirometer properly. During each waking hour, the client should perform a minimum of how many sustained, voluntary inflation maneuvers? 1. 1 to 2 2. 3 to 4 3. 5 to 7 4. 8 to 10

4. 8 to 10 RATIONALES: The client should perform at least 8 to 10 sustained, voluntary maximal inflation maneuvers with the incentive spirometer during each waking hour. Performing fewer than 8 maneuvers would reduce the respiratory benefits of this therapy.

A school-age client is complaining of pain. After asking the client to rate his pain using an age-appropriate pain scale, the nurse determines that the client's pain is minor. What is the drug of choice for treating mild pain in children? 1. Morphine 2. Fentanyl 3. Ibuprofen 4. Acetaminophen

4. Acetaminophen RATIONALES: Acetaminophen, when used as directed, is safe even for neonates and has the benefit of helping to reduce fever in addition to relieving mild pain. Morphine, fentanyl, and ibuprofen aren't drugs of choice for treating mild pain in children. Morphine and fentanyl are reserved for severe pain.

Small air bubbles adhering to the interior surface of the syringe might have which effect with parenteral administration? 1. Altered onset of action 2. Altered duration 3. Altered drug absorption 4. Altered drug dose

4. Altered drug dose RATIONALES: Although not harmful to the client when injected, small air bubbles can change the dose of medication actually administered; therefore, the nurse should remove the air bubbles. The drug's onset of action, duration, and absorption won't be affected. Air bubbles may actually be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.

A client comes to the emergency department with chest pain, dyspnea, and an irregular heartbeat. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is appropriate at this time? 1. Deficient knowledge related to interventions used to treat acute illness 2. Impaired physical mobility related to complete bed rest 3. Social isolation related to restricted visiting hours in the ICU 4. Anxiety related to the threat of death

4. Anxiety related to the threat of death RATIONALES: Anxiety related to the threat of death is an appropriate nursing diagnosis because anxiety can adversely affect the heart rate and rhythm by stimulating the autonomic nervous system. Also, because the client required resuscitation, the threat of death is a real and immediate concern. Unless anxiety is dealt with first, the client's emotional state will impede learning. Client teaching should be limited to clear, concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so a knowledge deficit would continue despite teaching attempts. Impaired physical mobility and Social isolation are necessitated by the client's critical condition; therefore, they are considered therapeutic, not problems warranting nursing diagnoses.

A client is recovering from an acute myocardial infarction (MI). During the first week of recovery, the nurse should stay alert for which abnormal heart sound? 1. Opening snap 2. Graham Steell's murmur 3. Ejection click 4. Pericardial friction rub

4. Pericardial friction rub RATIONALES: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week after an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell's murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.

The nurse is assisting in developing a teaching plan for a child with acute poststreptococcal glomerulonephritis. What is the most important point to address in this plan? 1. Infection control 2. Nutritional planning 3. Prevention of streptococcal pharyngitis 4. Blood pressure monitoring

4. RATIONALES: Because poststreptococcal glomerulonephritis may cause severe, life-threatening hypertension, the nurse must teach the parents how to monitor the child's blood pressure. Infection control, nutritional planning, and prevention of streptococcal pharyngitis are important but are secondary to blood pressure monitoring.

The physician prescribes digoxin (Lanoxin) elixir for a toddler with heart failure. Immediately before administering this drug, the nurse must check the toddler's: 1. serum sodium level. 2. urine output. 3. weight. 4. apical pulse.

4. apical pulse. RATIONALES: Because digoxin may reduce the heart rate and heart failure may cause a pulse deficit, the nurse should measure the toddler's apical pulse before administering the drug to prevent further slowing of the heart rate. The serum sodium level doesn't affect digoxin's action. For a child with heart failure, the nurse should check urine output and measure weight regularly, but not necessarily just before digoxin administration.

A school-age child is admitted to the facility with a diagnosis of acute lymphoblastic leukemia (ALL). The nurse recognizes a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the child's risk of infection? 1. Implementing reverse isolation 2. Maintaining standard precautions 3. Requiring staff and visitors to wear masks 4. Practicing thorough hand washing

4. RATIONALES: Both ALL and its treatment cause immunosuppression. Thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep anyone with a known or suspected infection out of the client's room.

Which statement regarding heart sounds is correct? 1. S1 and S2 sound equally loud over the entire cardiac area. 2. S1 and S2 sound fainter at the apex. 3. S1 and S2 sound fainter at the base. 4. S1 is loudest at the apex, and S2 is loudest at the base.

4. RATIONALES: The S1 sound — the "lub" sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.

For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should the nurse include in the data collection? 1. "Does the pain worsen in the morning upon rising?" 2. "Does the pain increase with activity and lessen with rest?" 3. "Is the pain relieved by position changes?" 4. "Is the pain worse when your toes are pointed toward your knee?"

4. RATIONALES: The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will elicit discomfort. The time of the day doesn't influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position will increase venous stasis and the pain associated with DVT.

The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? 1. Friction 2. Impaired circulation 3. Localized pressure 4. Shearing forces

4. Shearing forces RATIONALES: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use.

A client is to receive several oral medications. Which nursing instruction or action is appropriate in this situation? 1. Telling the client to take all the medications at once 2. Advising the client to take each medication with 8 oz of water 3. Leaving the medications at the bedside for the client to take when desired 4. Stating the name and action or use of each medication before administering it

4. Stating the name and action or use of each medication before administering it RATIONALES: When administering several oral medications, the nurse should state the name of each medication and its action or use before administering it. The client may take the medications all at once or one at a time with any amount or type of fluid. Leaving medications at the bedside may lead to errors such as the client not taking them. The nurse should always observe the client taking medication to ensure that it has been taken.

A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client behavior identifies a safe level of alcohol intake for this client? 1. The client consumes no more than 2 oz of alcohol daily. 2. The client consumes no more than 4 oz of alcohol daily. 3. The client consumes 2 to 6 oz of alcohol daily, depending on body weight. 4. The client consumes no alcohol.

4. The client consumes no alcohol. RATIONALES: A safe level of alcohol intake during pregnancy hasn't been established. Therefore, authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may predispose her to complications early in her pregnancy.

A client with metastatic cancer is experiencing neuropathic pain. Which alternative therapy is most beneficial in treating this type of pain? 1. Cryotherapy 2. Biofeedback 3. Herbal therapy 4. Transcutaneous electrical nerve stimulation (TENS)

4. Transcutaneous electrical nerve stimulation (TENS) RATIONALES: TENS alters the client's perception of pain by blocking painful stimuli traveling over nerve fibers. This treatment is believed to help treat cancer pain because it reduces muscle spasm, decreases edema, and raises the pain threshold. This therapy appears to be the most effective in treating neuropathic pain. Cryotherapy is used for acute injuries, such as an ankle sprain, because it reduces inflammation. Biofeedback has been found to reduce cancer pain through the client's learned conscious control of the body's responses to pain. However, this method of pain control isn't the most beneficial in treating neuropathic pain. Herbal therapy isn't the most effective alternative therapy for treating neuropathic pain.

The nurse assesses a client for evidence of postpartum hemorrhage during the third stage of labor. Early signs of this postpartum complication include: 1. an increased pulse rate, decreased respiratory rate, and increased blood pressure. 2. a decreased pulse rate, increased respiratory rate, and increased blood pressure. 3. a decreased pulse rate, decreased respiratory rate, and increased blood pressure. 4. an increased pulse rate, increased respiratory rate, and decreased blood pressure.

4. an increased pulse rate, increased respiratory rate, and decreased blood pressure. RATIONALES: An increased pulse rate followed by an increased respiratory rate and decreased blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock.

An appropriate way for the nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the room designated for smoking is to: 1. restrict the client's smoking to times when a staff member can supervise closely. 2. encourage other clients to speak with the client about keeping the floor clean. 3. ask if the client puts out cigarettes on the floor at home. 4. hand the client an ashtray and state that he must use it or he won't be allowed to smoke.

4. hand the client an ashtray and state that he must use it or he won't be allowed to smoke. RATIONALES: Setting limits is necessary to help clients behave in socially acceptable ways. By handing the client an ashtray and clearly stating that the client must use it or he won't be allowed to smoke, the nurse is setting limits on behavior. Because this client is newly admitted, the nurse may need to restate these limits in a manner that shows disapproval of the behavior but doesn't reject the client as a person. A matter-of-fact, nonpunitive tone of voice is important. The nurse must stress that noncompliance will have consequences — in this case, a prohibition against smoking. Encouraging other clients to deal with a new client isn't advisable. Asking if the client puts out cigarettes on the floor at home has no bearing on whether this behavior is acceptable in the hospital.

The nurse is caring for a client with manic depression. The plan of care for a client in a manic state would include: 1. offering high-calorie meals and strongly encouraging the client to finish all of his food. 2. insisting that the client remain active through the day so that he'll sleep at night. 3. allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits. 4. listening attentively with a neutral attitude and avoiding power struggles.

4. listening attentively with a neutral attitude and avoiding power struggles. RATIONALES: The nurse should listen to the client's requests, express willingness to seriously consider the request, and respond later. The nurse should encourage the client to take short daytime naps because he expends so much energy. The nurse shouldn't try to restrain the client when he feels the need to move around as long as his activity isn't harmful. High-calorie finger foods should be offered to supplement the client's diet if he can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice.

Continual assessment is an important component in cardiopulmonary resuscitation (CPR). Before initiating CPR, the nurse should always assess for: 1. evidence of breathlessness. 2. an open airway. 3. pulselessness. 4. responsiveness.

4. responsiveness. RATIONALES: The nurse should first determine responsiveness by shaking the client and asking, "Are you okay?" Next, the nurse should call for help, open the airway, determine breathlessness, perform rescue breathing, determine pulselessness, and provide circulation with chest compressions.