NCLEX Adult Health

1.)The nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? A. Calling the health care provider who gave the telephone prescription to clarify the prescription B. Calling the nursing supervisor for assistance in determining the route of administration C. Administering the medication intravenously, because this route is generally used for clients with CHF D. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department

1.)Answer A Rationale: Telephone prescriptions involve a health care provider's dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription clearly and precisely to the physician. The nurse then writes the prescription on the physician's prescription sheet. Under no circumstances should the nurse try to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. The nurse must call the health care provider who gave the telephone prescription and clarify the prescription.

10. The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first? A. Prepare the medication B. Verify the dosage of meperidine C. Assess the client's pain score before administration. D. Clarify the medication prescription with the health care provider.

10. Answer D Rationale: After fracture treatment, the client often has pain for a prolonged time during the healing process. The health care provider commonly prescribes opioid and non-opioid analgesics, anti-inflammatory drugs, and muscle relaxants. The nurse should immediately recognize that meperidine is contraindicated for the older client because it has toxic metabolites that can cause seizures and other complications. The first step the nurse should take is to clarify the prescription with the health care provider. The other steps should not be done.

11. A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? A. Bleeding B. Renal colic C. Infection at the site D. Increased temperature

11. Answer D Rationale: Bleeding should be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs of infection would not appear immediately after a biopsy. There is no information in the question to indicate the presence of renal colic.

12.A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? A. Placing the tube in warm water B. Hyperextending the head while inserting the tube C. Removing the tube if any resistance to insertion is met D. Asking the client to swallow as the tube is being advanced

12. Answer D Rationale: To facilitate insertion, the nurse asks the client to lower the head slightly, swallow, and take sips of water (if allowed). The head is not hyperextended, because this would open the airway and could result in placement of the nasogastric tube in the trachea. The tube should be iced to make it stiff for easier insertion. If resistance is met, the tube may be withdrawn slightly, then readvanced.

16. A client with myocardial infarction is being monitored closely for signs of cardiogenic shock. For which signs of this type of shock is the nurse alert? Select all that apply. A. Polyuria B. Bradypnea C. Tachycardia D. Restlessness E. Hypotension F. Increased central venous pressure (CVP)

16. Answer C,D,E,F Rationale: Manifestations of cardiogenic shock include tachycardia; hypotension; urine output of less than 30 mL/hr; cold, clammy skin; poor peripheral pulses; agitation; restlessness or confusion; pulmonary congestion; tachypnea; chest pain; and increased CVP.

2.A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first: A. Check the client's apical pulse B. Check the placement of the tube C. Check when the last feeding was given D. Check when the last medications were given

2.) Answer B Rationale: To help prevent aspiration, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Checking when a feeding or medication was last given and checking the client's apical pulse are not directly related to the subject of the question.

20.The nurse is preparing a list of home care instructions for a client with chronic obstructive pulmonary disease (COPD). Which instructions should the nurse include on the list? Select all that apply. A. Avoid immunizations. B. Sleep on the right side. C. Alternate periods of rest with activity. D. Avoid exposure to people with infections. E.Perform pursed-lip and diaphragmatic breathing exercises. F. Increase the oxygen flow rate if breathing becomes difficult.

20. Answer C,D,E A client with COPD experiences hypoxemia and chronic hypercarbia and requires a lower level of oxygen, usually 1 to 2 L/min by way of nasal cannula. A low arterial oxygen level is the client's primary drive for breathing, and the client should not be instructed to increase the oxygen flow rate if breathing difficulty occurs. Rather, the client should contact the health care provider. The client must conserve energy by pacing activities and alternating periods of rest with activity. The client should sleep with the head of the bed elevated. This position and one in which the client leans forward will ease the client's breathing. The client is at increased risk for infections and should avoid exposure to people with infections and should get such immunizations as the pneumonia and influenza vaccines. Breathing techniques help alleviate dyspneic episodes and prolong the exhalation phase of breathing.

28. Which findings are specific characteristics of right-sided heart failure? Select all that apply. A.Cough B.Distended neck veins C.Crackles on auscultation D.Pitting dependent edema E.Abdominal pain and bloating

28.Answer B,D,E. Signs of right-sided heart failure are evident in the systemic circulation: pitting dependent edema of the feet, legs, sacrum, back, buttocks; ascites, caused by portal hypertension; tenderness of the right upper quadrant, organomegaly; distended neck veins; pulsus alternans (regular alteration of weak and strong beats in the pulse); anorexia, nausea, abdominal pain, bloating; fatigue; weight gain; and nocturnal diuresis. Signs of left-sided failure, which are evident in the pulmonary system, include cough and crackles on auscultation.

3.The client with heart failure is preparing to be discharged from the hospital. Which interventions should the nurse include in the client's discharge teaching plan? Select all that apply. A. Teach the client coping strategies B. Develop a regular exercise program C. Educate the client about dietary restrictions D. Give the client a minimal role in the self-management program E. Provide the client with a list of current medications and dosing times

3.) Answer A,B,C Rationale: Any client discharged from the hospital should be encouraged to become involved in as much self-care as possible and the client's condition allows. Coping strategies are helpful for most clients to manage any stress that may arise. An exercise program is also important to maintain strength and circulation. Dietary restrictions may be necessary for the client with heart failure and may include fluid restrictions and sodium restrictions. Clients need to clearly understand how to administer prescribed medications and a written list of instructions is extremely helpful to ensure safety and compliance.

30. The nurse provides discharge instructions to a client who has undergone mechanical valve replacement. Which statement by the client indicates an understanding of the instructions? A."I'll have to take a blood thinner for the rest of my life." B."If I hear a clicking sound I need to call the surgeon immediately." C."I need to avoid lifting anything heavier than 30 lb (13.6kg) for at least 6 weeks." D."I shouldn't worry if I see redness at the incision site or clear drainage, because it's normal."

30.Answer A. After mechanical valve replacement, the client must continue anticoagulant therapy to prevent the development of clots. A soft clicking sound may be heard, but this is a normal finding. The client must avoid lifting anything heavier than 10 lb, not 30 lb (13.6kg). Redness and serous drainage are signs of infection, not normal findings.

4.The nurse is providing care to a client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply. A. Cyanosis of the skin in the affected extremity B. Skin temperature cool to touch in the affected extremity C. Client complaints of problems moving the affected extremity D. Complaints of sudden and severe pain in the affected extremity E. Bounding pulse in the affected extremity below the level of the occlusion

4.) Answer A,B,C,D Rationale: Although chronic peripheral arterial disease (PAD) progresses slowly, the onset of acute arterial occlusions may be sudden and dramatic. Acute arterial occlusion is serious and occurs when blood flow in a leg artery stops suddenly. If blood flow to the toe, foot, or leg is completely blocked, the tissue begins to die and can lead to gangrene. Intervention is needed immediately to restore blood flow. Manifestations of acute arterial occlusion are due to a lack of blood flow and include cyanosis, cool skin temperature, severe pain, problems moving the affected extremity, and a lack of a pulse. There would be no pulse as a result of the occlusion and blocked artery.

40. A nurse provides home care instructions to a client who has been hospitalized for acute diverticular disease. Which instruction should the nurse give the client to prevent the occurrence of an acute episode? A.Avoid lifting, straining, or coughing. B.Restrict fluid intake to 1000 mL daily. C.Avoid foods that contain whole grains. D.Restrict consumption of fruits and vegetables.

40.Answer C. Acute diverticular disease is managed by means of the prevention of constipation through the use of a high-fiber diet containing fruits, vegetables, and whole grains. The client is instructed to increase fluid intake to 2500 to 3000 mL daily unless this is contraindicated. The client should also consume a small amount of bran daily, as prescribed, to increase stool mass and softness. The client should refrain from lifting, straining, coughing, or bending as a means of avoiding increased intraabdominal pressure.

41.Which individual is at greatest risk for developing hypertension? A.45 year-old African American attorney B.60 year-old Asian American shop owner C. 40 year-old Caucasian nurse D.55 year-old Hispanic teacher

41. AnswerA The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.

5.)A client is being discharged home after a routine hip replacement surgery. The nurse is instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply. A. "Limiting fiber is necessary to avoid diarrhea." B. "I should empty my bladder when I feel the urge." C. "Avoiding pain medication will prevent constipation." D. "I should drink plenty of liquids like iced tea or coffee." E. "I should continue with my physical therapy and walking."

5.) Answer A,C,D Rationale: Constipation is common after surgery due to pain medication, decreased movement, and anesthesia. Fiber intake should be encouraged as it promotes the prevention of stool retention. Although pain medication can cause constipation, it should not be avoided in the post-operative period. Drinking plenty of fluids is encouraged for both bowel and bladder maintenance, but the client should choose non-caffeinated options. Physical therapy, walking, and exercise will help prevent constipation. Emptying the bladder when the urge is present can help prevent urinary tract infections.

53. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A.Eating 3 balanced meals a day B.Adding complex carbohydrates C.Avoiding very heavy meals D.Limiting sodium to 7 gms per day

54. Answer A. Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease

56. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A.Decrease in level of consciousness B.Loss of bladder control C.Altered sensation to stimuli D.Emotional ability

56. Answer A. A further decrease in the level of consciousness would be indicative of a further progression of the CVA.

8. The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? History and Physical Laboratory Findings Medications Expiratory rales on auscultation Blood pressure 145/94 mmHg Lisinopril 20mg orally daily Peripheral Vascular Disease (PVD) Serum Potassium 3.5 mEq/L (3.5 mmol/L) Atorvastatin 10mg orally at bedtime A. Expiratory rales B. Atorvastatin prescription C. Peripheral vascular disease D. Potassium level of 3.5 mEq/L (3.5 mmol/L)

8. Answer D Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should anticipate that the potassium level would drop with the administration of furosemide. Therefore, the nurse should verify continuing the prescription if this potassium level was noted. Expiratory rales are an expected finding with fluid overload and furosemide would be an appropriate treatment. Atorvastatin and peripheral vascular disease are not impacted by the administration of furosemide.

13. A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

13. Answer A Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. In conditions such as diarrhea, these fluids may be lost from the body before they can be reabsorbed. The decreased bicarbonate level produces the actual base deficit of metabolic acidosis.

14. A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

14.Answer D Rationale: Wound dehiscence is the disruption of a surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in a low Fowler's position or supine with the knees bent and instructs the client to lie quietly. These actions will minimize protrusion of the underlying tissues. The nurse then covers the wound with a sterile dressing moistened with sterile saline. The health care provider is notified, and the nurse documents the occurrence and the nursing actions that were implemented in response.

15. A client is receiving digoxin for the treatment of heart failure. For which signs of digoxin toxicity does the nurse monitor the client? Select all that apply. A. Tinnitus B. Bradycardia C. Hypotension D. Muscle twitching E. Visual disturbances

15.Answer B,E Rationale: The signs and symptoms of toxicity include abdominal pain, nausea and vomiting, diarrhea, headaches, visual disturbances (e.g., blurred, yellow, or green vision; halos around lights), confusion, bradycardia, and other dysrhythmias. The other options are unrelated to digoxin therapy

17.A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion (ROM) of the cervical spine? A. Headache B. Neck trauma C. Sinus infection D. Muscle spasms

17. Answer B Rationale: A nurse performing a musculoskeletal assessment would not test ROM in a client who has sustained neck trauma, which may have resulted in a cervical fracture. If a cervical fracture is present, further movement of the neck could result in spinal cord injury. ROM testing does not need to be avoided if the client is experiencing a headache, sinus infection, or muscle spasms.

18. A health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? A. Supine B. Upright C. Left side-lying D. Right side-lying

18. Answer B Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. The client ideally empties the bladder, and then sits upright in a chair with the feet flat on the floor. The other positions are incorrect for this procedure.

19. A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information? A. Lack of control B. Lack of physical mobility C. Lack of adequate diversional activity D. Lack of energy to bathe and feed self

19. Answer C Rationale: A characteristic of lack of adequate diversional activity is the expression of boredom by the client. The question does not identify client difficulties with coordination, range of motion, or muscle strength, which would lack of physical mobility. Nor does the question address client's lack of energy to perform activities of daily living (bathing/hygiene self-care deficit) or lack of control.

21.The clinic nurse assess a client's risk for a pulmonary embolism. Which clients are at risk for pulmonary embolism? Select all that apply. A.A pregnant client B.A client who is underweight C. A client under the age of 30 years D. A client who is in traction and immobilized E. A client who has undergone abdominal surgery

21. Answer A,D,E Pulmonary embolism occurs when a thrombus that forms in a deep vein is detached and travels to the right side of the heart, then lodges in a branch of the pulmonary artery. Clients at risk for deep vein thrombosis (i.e., prolonged immobilization, surgery, obesity, pregnancy, heart failure, advanced age, or history of thromboembolism) are at greatest risk for pulmonary embolism.

22. A Mantoux skin test is administered to a child infected with human immunodeficiency virus (HIV). Forty-eight hours after the test is administered, the nurse checks the skin test site and notes an area of induration 5 mm in diameter. How does the nurse interpret this finding? A.Positive result B.Negative result C.Inconclusive result D.Inaccurate result requiring a repeat test

22.Answer A An area of induration of 5 mm or greater represents a positive reaction in a child with an immunosuppressive condition or HIV infection. Therefore the other options are incorrect.

23. A client who is hospitalized with active tuberculosis (TB) asks the nurse how long it will take before the disease is no longer communicable. What should the nurse tell the client? A.The disease is communicable until the cough subsides. B.The disease is no longer communicable once medication has been started. C.The disease is usually no longer communicable after medication has been taken for 2 to 3 weeks. D.The disease is communicable for the duration of medication therapy, which is usually 9 months.

23.Answer C The client with TB is instructed to follow the medication regimen exactly as prescribed, and the nurse must stress the importance of compliance. Telling the client that the disease is not communicable after the cough subsides, that it is not communicable once the medication has been started, or that it is communicable for the duration of the medication therapy is incorrect. The client must be told that the disease is usually no longer communicable after the medication has been taken for 2 to 3 consecutive weeks and clinical improvement is seen; however, the client must take the prescribed medication for 6 months or longer, as prescribed.

24. The nurse collects data from a client who has experienced an episode of chest pain. The client tells the nurse that the chest pain started shortly after he started raking leaves but went away after he rested and took a nitroglyerin tablet. Which type of angina should the nurse recognize in the client's description? A.Stable B.Variant C.Unstable D.Intractable

24.Answer A Stable angina, also called exertional angina, occurs during activities that involve exertion or emotional stress and is relieved by rest or nitroglycerin. It usually has a stable pattern of onset, duration, severity, and relieving factors. Variant angina, also called Prinzmetal or vasospastic angina, results from coronary artery spasm. It may occur when the client is at rest and may be associated with ST-segment elevation on electrocardiography. Unstable angina is also called preinfarction angina. It occurs with an unpredictable degree of exertion or emotion and increases in frequency, duration, and severity over time; it may not be relieved by nitroglycerin. Intractable angina is a chronic, incapacitating type of angina that is unresponsive to interventions.

25. Which measures should the nurse implement in the immediate management of the care of a client experiencing angina? Select all that apply. A.Administering oxygen B.Assessing the client's pain C.Administering nitroglycerin D.Placing the client in a side-lying supine position E.Helping the client identify anxiety-precipitating events or experiences

25.Answer A,B,C. The immediate management of care includes assessing the pain and instituting pain relief measures; administering nitroglycerin to dilate the coronary arteries, reduce oxygen requirements of the myocardium, and relieve chest pain; Administer oxygen by nasal cannula as prescribed; maintain bedrest in a semi-Fowler's position; monitor vital signs; obtain a 12-lead electrocardiogram; institute continuous cardiac monitoring; initiate an intravenous (IV) line. The nurse would always stay with the client. Following the acute episode and once the client is stabilized, the nurse would help the client identify angina-precipitating events; provide client instructions on management of the disorder, diet, and medications; and instruct the client to seek medical attention if pain persists after treatment.

26. Which risk factors for a mycoardial infarction are modifiable? Select all that apply. A.The client smokes four or five cigarettes a day. B.The client reports a sedentary lifestyle. C.The client is 5 feet 1 inch (155 cm) tall and weighs 232 lb (105 kg). D.The client's blood pressure consistently ranges between 148/88 and 170/96 mm Hg E.The client reports that her mother has a history of severely increased cholesterol levels that cannot be controlled with diet or medication.

26.Answer A,B,C,D. An MI occurs when myocardial tissue is abruptly and severely deprived of oxygen. Ischemia results and may lead to necrosis of myocardial tissue if blood flow is not restored. An MI can be caused by atherosclerosis and CAD. Hereditary factors are nonmodifiable. Modifiable risk factors are those that can be changed—for instance, smoking, hypertension, obesity, physical inactivity, impaired glucose intolerance, and stress.

27. A client who is experiencing chest pain is brought to the emergency department by a family member. Assessing the client, the nurse obtains a description of the client's chest pain. Which information from the client causes the nurse to determine that the client's pain is most likely angina? A.The pain is unrelieved by rest. B.The pain is unrelieved by nitroglycerin. C.The pain was precipitated by a stressful event. D.The pain is accompanied by nausea, vomiting, diaphoresis, and dyspnea.

27 Answer.C. Angina is characterized by substernal chest discomfort, often radiating to the left arm. It is usually precipitated by exertion or stress and is relieved by nitroglycerin or rest. Pain caused by an MI presents as substernal chest pressure and may radiate to the jaw, back, and left arm. It occurs without cause, primarily in the morning, and is unrelieved by rest or nitroglycerin; pain is relieved by opioids only. It is accompanied by nausea and vomiting, diaphoresis, dyspnea, dysrhythmias, fear and anxiety, pallor, cyanosis, and coolness of the extremities.

29. A nurse provides home care instructions to a client with bacterial infective endocarditis. Which statement by the client indicates a need for further teaching? A."I need to let my dentist know that I had this infection." B."I need to take antibiotics before I have any invasive procedures." C."I need to be sure to floss my teeth and use an electric toothbrush." D."I should check my temperature every day and call the health care provider if I have a fever."

29.Answer C. Endocarditis is an inflammation of the inner lining of the heart and valves. Ports of entry for the infecting organism include the oral cavity (especially if the client has undergone a dental procedure in the previous 3 to 6 months), cutaneous invasion, infections, and invasive procedures and surgeries. The nurse encourages the client to perform good oral hygiene, including the use a soft toothbrush for twice-daily brushing twice a day, and rinse the mouth with water afterward. The client is instructed not to use irrigation devices or floss the teeth, because bacteremia may result.

32. Which interventions should the nurse include in the plan of care for a client with hypothyroidism? Select all that apply. A.Providing a cool environment for the client B.Instructing the client to consume a high-fat diet C.Instructing the client about thyroid-replacement therapy D.Encouraging the client to consume fluids and high-fiber foods E.Instructing the client to contact the health care provider if chest pain occurs F.Informing the client that radioactive iodine preparations may be prescribed to treat the disorder

32. Answer C,D,E. The signs/symptoms of hypothyroidism are the result of decreased metabolism caused by low levels of thyroid hormones. Interventions are aimed at replacing the hormones and addressing the signs and symptoms of decreased metabolism. The nurse encourages the client to consume a balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to help prevent constipation. The client is often intolerant of cold and requires a warm environment. The client should be instructed to notify the health care provider if chest pain occurs, because this could be an indication of overreplacement of thyroid hormone. Radioactive iodine preparations may be used to destroy thyroid cells in the treatment of hyperthyroidism.

33. A nurse is monitoring a client with hyperparathyroidism for signs of hypocalcemia and prepares to test the client for the Trousseau sign. Which item should the nurse obtain to perform this test? A.Cotton B.Tongue blade C.Reflex hammer D.Blood pressure cuff

33. Answer D. The presence of the Trousseau sign is an indication of hypocalcemia. To test for the Trousseau sign, the nurse places a blood pressure cuff around the client's upper arm, inflates the cuff to a pressure greater than the client's systolic pressure, and keeps the cuff inflated for 1 to 4 minutes. In a positive result, the client's hands and fingers go into spasm in palmar flexion under these hypoxic conditions. Cotton, a tongue blade, and a reflex hammer are not needed to perform this test.

39. A nurse provides home care instructions to a client with acute hepatitis. Which statement by the client indicates a need for further teaching? A."I need to eat frequent small meals." B."I need to eat foods high in carbohydrates and low in fat." C."I need to maintain my normal physical activity and daily routine." D."I need to avoid close physical contact with other people until my test results are negative."

39 Answer C. A client with hepatitis needs considerable rest during the acute phase of illness to promote healing of the liver. The permissible level of physical activity is based on the client's degree of fatigue and the severity of disease. Rest periods should be arranged throughout the day. The client should eat small frequent meals that are high in carbohydrate and low in fat. Close personal contact (e.g., kissing, sexual activity) should be discouraged until testing for hepatitis B surface antigen (HBsAg) returns a negative result.

31. A nurse is reviewing the laboratory results of a client with Addison's disease. Which finding should the nurse expect to note? A.Calcium level of 8.6 mg/dL (2.15 mmol/L) B. Sodium level of 145 mEq/L (145 mmol/L) C. Potassium level of 5.5 mEq/L (5.5 mmol/L) D. Blood glucose level of 110 mg/dL (6.1 mmol/L)

31. Answer C Laboratory testing in Addison's disease reveals hypoglycemia, hyperkalemia, hyponatremia, and hypercalcemia. The normal blood glucose level ranges from 70 to 110 mg/dL. The normal potassium level ranges from 3.5 to 5.0 mEq/L. The normal sodium level ranges from 135 to 145 mEq/L. The normal calcium level ranges from 8.6 to 10 mg/dL.

34. A nurse provides instructions to a client with type 1 diabetes mellitus about home care measures to treat hypoglycemia. The nurse determines that the client understands the instructions if which statement is made? A.I will eat six saltine crackers B.I will call the health care provider C.I will report to the emergency department D.I will take an additional dose of regular insulin

34. Answer A. Hypoglycemia is the term used to describe a blood glucose level below 70 mg/dL. If hypoglycemia is suspected, the client should obtain a glucose reading immediately. The client must consume a substance that contains 10 to 15 g of carbohydrates — for instance, commercially prepared glucose tablets, six to 10 Life Savers or other hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of honey or syrup, a half-cup of fruit juice, 8 oz of low-fat milk, six saltines, or three graham crackers. Administering regular insulin will lower the blood glucose. It is not necessary to notify the health care provider or to report to the emergency department for a single episode of hypoglycemia. The client should, however, contact the health care provider if hypoglycemia were to persist or hypoglycemic episodes were frequent.

35. The school nurse receives a telephone call from a physical education teacher, who says that a student with diabetes mellitus is feeling shaky and weak. Which action should the nurse tell the teacher to take immediately? A.Laying the student on the floor B.Staying with the student until the nurse arrives C.Giving the student a glass of orange juice or non-diet soda D.Calling for an ambulance to bring the student to the emergency department

35. Answer C. Exercise can cause the blood glucose level to drop. Shakiness and weakness are signs of a hypoglycemic reaction in a diabetic client. A hypoglycemic reaction is treated promptly with a substance that contains 10 to 15 g of carbohydrates — for instance, commercially prepared glucose tablets, six to 10 Life Savers or other hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of honey or syrup, a half-cup of fruit juice or regular (non-diet) soft drink, 8 oz of low-fat milk, six saltines, or three graham crackers. If the symptoms are not relieved in 15 minutes, the treatment is repeated. Laying the student on the floor, staying with the student until the nurse arrives, and calling for an ambulance would each delay necessary interventions. There is no need to call an ambulance at this time.

36. The nurse provides instructions to a client with type 1 diabetes mellitus with regard to foot care. The nurse determines there is a need for further teaching if the client makes which statement? A.I will inspect my feet daily B.I will walk barefoot only at home C.I will wash my feet with warm water and a mild soap D.I will check my shoes for foreign objects before putting them on

36. Answer B In clients with diabetes mellitus, minor foot problems may progress to major problems, in some cases severe enough to necessitate amputation. Many foot problems can be prevented with proper foot care. The client is instructed not to walk barefoot, even at home. Inspecting the feet daily, using warm water and a mild soap to wash the feet, and checking shoes for foreign objects before putting them on are all appropriate foot care measures for the diabetic client. The client should also avoid thermal injuries from hot water, heating pads, and baths; prevent moisture from accumulating between the toes; wear socks to keep the feet warm and change them daily; and trim toenails straight across and smooth nails with an emery board.

37. The nurse provides information to the client about measures to treat gastrointestional esophageal reflux disease (GERD). Which statement by the client indicates the need for further teaching? A."I should stop drinking caffeinated coffee." B."I should lie down for at least an hour after I eat." C."I should prop up the head of my bed." D."I shouldn't eat or drink anything for 2 hours before bedtime."

37. Answer B The client with GERD should avoid foods and positioning that decrease lower esophageal sphincter pressure or cause esophageal irritation. The client should consume a low-fat, high-fiber diet in small, frequent meals; minimize the amount of liquids drunk at mealtimes; and avoid reclining for 1 hour after eating; The client should also avoid caffeine, tobacco, and carbonated beverages; avoid eating and drinking 2 hours before bedtime; avoid wearing tight clothes; and elevate the head of the bed on 6- to 8-inch blocks. Medications such as antacids, histamine H2-receptor antagonists and proton pump inhibitors which neutralize or decrease gastric acid secretions and prokinetic medications, which accelerate gastric emptying, may be prescribed; anticholinergics are avoided because they delay stomach emptying.

38. A nurse is conducting the admission interview of a client with cholecystitis who is scheduled for laparoscopic cholecystectomy. Which finding does the nurse expect the client to report? A.Heartburn B.Hiccups C.Right upper quadrant abdominal pain that is relieved when the client eats high-protein food D.Right upper quadrant abdominal pain that radiates to the back and right shoulder after the client eats fatty food

38. Answer D. Clinical manifestations of cholecystitis include nausea and vomiting; chills, fever, and diaphoresis; and pain in the right upper quadrant, radiating to the back and right shoulder, 2 to 4 hours after the client eats fatty food. Pain is also noted on palpation of the abdomen, and the Murphy sign (pain on inspiration when the examiner's fingers pass below the hepatic margin) is present on physical examination. Heartburn and hiccups are not associated with cholecystitis but may occur with gastritis.

42. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A.Gastric lavage PRN B.Acetylcysteine (mucomyst) for age per pharmacy C.Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D.Activated charcoal per pharmacy

42. Answer A Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next drug to give would be activated charcoal, then mucomyst and lastly the IV fluids.

43. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A. angina at rest B. thrombus formation C. dizziness D .falling blood pressure

43. Answer B Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A falling BP occurs along with hemorrhage of the insertion site which is associated with the first 12 hours after the procedure.

44. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A.Maintain fluid and electrolyte balance B.Control nausea C.Manage pain D.Prevent urinary tract infection

44. Answer C The immediate goal of therapy is to alleviate the client's pain.

45. What would the nurse expect to see while assessing the growth of children during their school age years? A.Decreasing amounts of body fat and muscle mass B.Little change in body appearance from year to year C.Progressive height increase of 4 inches each year D.Yearly weight gain of about 5.5 pounds per year

45. Answer D School age children gain about 5.5 pounds each year and increase about 2 inches in height.

46. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states "My blood pressure is usually much lower." The nurse should tell the client to A.go get a blood pressure check within the next 48 to 72 hours B.check blood pressure again in 2 months C.see the health care provider immediately D.visit the health care provider within 1 week for a BP check

46. Answer A The blood pressure reading is moderately high with the need to have it rechecked in a few days. The client states it is 'usually much lower.' Thus a concern exists for complications such as stroke. However immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.

47. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A.A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B.A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C.An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens-Johnson syndrome that morning D.An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago

47. Answer A The best candidate for discharge is one who has had a chronic condition and is most familiar with their care. This client in option A is most likely stable and could continue medication therapy at home.

48. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A.Should be taken in the morning B.May decrease the client's energy level C.Must be stored in a dark container D.Will decrease the client's heart rate

48. Answer A Thyroid supplement should be taken in the morning to minimize the side effects of insomnia

49. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A.Prepare the child for x-ray of upper airways B.Examine the child's throat C.Collect a sputum specimen D.Notify the healthcare provider of the child's status

50. Answer D. These findings suggest a medical emergency and may be due to epiglottises. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

50. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? evaluation? A.Polyphagia B.Dehydration C.Bed wetting D.Weight loss

51. Answer C In children, fatigue and bed wetting are the chief complaints that prompt parents to take their child for evaluation. Bed wetting in a school age child is readily detected by the parents.

51. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A.Trichomoniasis B.Chlamydia C.Staphylococcus D.Streptococcus

52. Answer B. Chlamydial infections are one of the most frequent causes of salpingitis or pelvic inflammatory disease.

52. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B.A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" C.An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 10 D.An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room

53.Answer C Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opoid toxicity with the pinpoint pupils and has the least risk of complications to occur in the near future.

54. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A.The client complains of discomfort at the IV insertion site B.The client states "I just can't get relief from my pain." C.The level of drug is 100 ml at 8 AM and is 80 ml at noon D.The level of the drug is 100 ml at 8 AM and is 50 ml at noon

55. Answer B. The minimal dose of 10 ml per hour which would be 40 ml given in a 4 hour period. Only 60 ml should be left at noon. The pump is not functioning when more than expected medicine is left in the container.

57. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A.Place a call to the client's health care provider for instructions B.Send him to the emergency room for evaluation C.Reassure the client's wife that the symptoms are transient D.Instruct the client's wife to call the doctor if his symptoms become worse

57.Answer B. This client requires immediate evaluation. A delay in treatment could result in further deterioration and harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.

58.The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A."You need to regain your strength before attempting such exertion." B."When you can climb 2 flights of stairs without problems, it is generally safe." C."Have a glass of wine to relax you, then you can try to have sex." D."If you can maintain an active walking program, you will have less risk."

58. Answer There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.

6. The nurse is creating a plan of care for a client that will undergo a total joint replacement. What should the nurse include in the client's plan of care? Select all that apply. A. Teach interventions to reduce client anxiety B. Educate the client on what to expect after surgery C. Complete a physical assessment before the surgery D. Include the client's family in discussions about the surgery E. Allow time for the surgeon to address questions after the surgery

6.)Answer A,B,C,D Rationale: The client's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the client for the surgery and client safety. The nurse should include activities in the plan of care that will focus on preparing the client for surgery such as interventions that will reduce the client's level of anxiety and education on what to expect after surgery. The nurse should perform a physical assessment and alert the surgeon to any findings that would interfere with the surgery. When possible, the client's family should be included in discussions pertaining to the surgery. The nurse should allow time for the surgeon to meet with the client and family before (not after) the surgery to address any questions or concerns.

7.The nurse is educating a client on how to self-manage care at home, following an admission to the hospital for heart failure. Which statements by the client indicate that teaching has been effective? Select all that apply. A. "I will weight myself daily." B. "I will wear my oxygen at night as prescribed." C. "I will follow up with my health care provider (HCP) as scheduled." D. "I will report new signs and symptoms to my home care nurse when she visits." E. "I have my medications and dosages written down for easy review and administration."

7. Answer A,B,C,E Rationale: Health teaching is essential for promoting self-management. Many clients with heart failure are readmitted to hospitals because they do not maintain their prescribed treatment plan, including lifestyle changes. The client should state the importance of daily weights to monitor for increases indicating fluid retention, wearing oxygen at night to prevent hypoxia, keeping follow-up appointments for monitoring status, and having medications and dosages written down and available for review and administration. The client should not wait for the home care nurse to report new signs and symptoms, but should report them immediately to the HCP in charge of care. Waiting could lead to worsening heart failure and complications such as pulmonary edema.

9. Which manifestations are specifically noted in a client with right-sided heart failure.? Select all that apply. A. Ascites B. Hepatomegaly C. Breathlessness D. Dependent edema E. Neck vein distention

9. Answer A,B,D,E Rationale: Right ventricular failure is associated with increased systemic venous pressure and congestion. Therefore, manifestations are noted in the systemic circulation and can include ascites, hepatomegaly, dependent edema and neck vein distention. Breathlessness and other pulmonary manifestations are often a sign of left-sided heart failure