NCLEX-PN 3000 Questions
Correct Answer: 4 RATIONALES: The purpose of rehabilitative treatment in alcoholism is to help the client identify the relationship between his problems and his alcohol consumption. Rehabilitative treatment promotes abstinence, not limiting or controlling consumption. It isn't intended to help the client identify a new group of friends or understand the effects of alcohol on his body.
A 40-year-old client is admitted to the hospital for alcohol abuse for the third time in the past 9 months. The health care team recommends rehabilitative treatment for this client. Why was this treatment recommended? 1. It's the only option for controlling alcohol consumption. 2. It helps the client identify a new group of friends. 3. It helps the client understand the effects of alcohol on his body. 4. It helps the client identify the relationship between his problems and alcohol consumption.
Correct Answer: 1,2,3,4 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.
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
Correct Answer: 4 RATIONALES: If 6 hours or less have passed since the onset of symptoms related to MI, thrombolytic therapy is indicated. (The client's chest pain began 4 hours before diagnosis.) The preferred choice is tPA. The client doesn't exhibit symptoms that indicate the use of lidocaine. Stress testing shouldn't be performed during the acute phase of an MI, but it may be ordered before discharge. Serial cardiac biomarkers, not serial liver enzymes, would be ordered for this client.
A 43-year-old man was transferring a load of firewood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which immediate order by the physician? 1. Lidocaine administration 2. Cardiac stress test 3. Serial liver enzyme testing 4. Tissue plasminogen activator (tPA)
Correct Answer: 1 RATIONALES: Clients with Alzheimer's-type dementia tend to fluctuate in their capabilities. Encouraging self-care to the extent possible helps increase the client's orientation and promotes a trusting relationship with the nurse. Making the client assume responsibility for physical care is unreasonable. Assigning a staff member to take over the client's physical care restricts the client's independence. Accepting the client's desire to go without bathing promotes poor hygiene.
A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would bestprevent further regression in the client's personal hygiene? 1. Encouraging the client to perform as much self-care as possible 2. Making the client assume responsibility for physical care 3. Assigning a staff member to take over the client's physical care 4. Accepting the client's desire to go without bathing
Correct Answer: 4 RATIONALES: The rhythm method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period. This method helps identify safe and unsafe periods for sexual intercourse. A natural family planning method, the rhythm method doesn't involve use of chemical barriers, hormones, or mechanical barriers.
A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves: 1. chemical barriers that act as spermicidal agents. 2. hormones that prevent ovulation. 3. mechanical barriers that prevent sperm from reaching the cervix. 4. determination of the fertile period to identify safe times for sexual intercourse.
Correct Answer: 3 RATIONALES: Reflecting is correct because the nurse is referring feelings back to the client to explore. When restating, the nurse simply repeats what the client said. Reframing is offering a new way to look at a situation. The nurse's response is specific; it isn't offering a general lead.
A client asks the nurse, "Do you think I should leave my husband?" The nurse responds, "You aren't sure if you should leave your husband?" The nurse is using which therapeutic technique? 1. Restating 2. Reframing 3. Reflecting 4. Offering a general lead
Correct Answer: 4 RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis. Other signs of meningeal irritation include nuchal rigidity and Kernig's sign. Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF pressure.
A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate? 1. Increased intracranial pressure (ICP) 2. Cerebral edema 3. Low cerebrospinal fluid (CSF) pressure 4. Meningeal irritation
Correct Answer: 2 RATIONALES: The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. The antipsychotic effects of the drug may take several weeks to appear. Droperidol increases the risk ofextrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately.
A client has a history of chronic undifferentiated schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? 1. Asking the physician for droperidol (Inapsine) to control any extrapyramidal symptoms that occur 2. Sitting up for a few minutes before standing to minimize orthostatic hypotension 3. Notifying the physician if her thoughts don't normalize within 1 week 4. Expecting symptoms of tardive dyskinesia to occur and to be transient
Correct Answer: 2 RATIONALES: During the data collection step of the nursing process, the nurse obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating the nursing diagnoses. During the planning step, the nurse designs methods to help resolve client problems and meet client needs. During evaluation, the nurse determines the effectiveness of nursing interventions in achieving client goals. During implementation, the nurse takes actions to meet the client's needs.
A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing? 1. Planning 2. Data collection 3. Evaluation 4. Implementation
Correct Answer: 1 RATIONALES: A client with delusions of grandeur has a false belief that he is highly important or famous. A delusion of persecution is a false belief that one is being persecuted. A delusion of reference is a false belief that one is connected to events unrelated to oneself or a belief that one is responsible for the evil in the world.
A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that he is: 1. highly important or famous. 2. being persecuted. 3. connected to events unrelated to himself. 4. responsible for the evil in the world.
Correct Answer: 3 RATIONALES: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant? 1. Decreased level of consciousness (LOC) 2. Elevated blood pressure 3. Increased urine output 4. Decreased heart rate
Correct Answer: 3 RATIONALES: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client's blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don't change significantly after nitroglycerin administration.
A client is receiving nitroglycerin ointment (Nitrol) to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin? 1. Heart rate 2. Respiratory rate 3. Blood pressure 4. Temperature
Correct Answer: 1 RATIONALES: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) reach its maximum effectiveness. Therefore, if the cannulation is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. Applying EMLA at 6:30 a.m. is too early. The other time options are too late for the local anesthetic to be effective.
A client is scheduled for an excretory urography at 10 a.m. An order states to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at: 1. 7:30 a.m. 2. 6:30 a.m. 3. 9 a.m. 4. 9:30 a.m.
Correct Answer: 1 RATIONALES: The client's statement reveals a Deficient knowledge related to food restrictions associated with general anesthesia.The other options may be applicable but aren't related to the client's statement.
A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurse should formulate which nursing diagnosis? 1. Deficient knowledge related to food restrictions associated with anesthesia 2. Fear related to surgery 3. Risk for impaired skin integrity related to upcoming surgery 4. Ineffective coping related to the stress of surgery
Correct Answer: 3 RATIONALES: For an epidural block, the nurse should anticipate that the anesthesiologist will inject a local anesthetic agent into the epidural space, located between the dura mater and the ligamentum flavum in the lumbar region of the spinal column. When administering a spinal block, the anesthesiologist injects the anesthetic agent into the subarachnoid space. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites.
A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the: 1. subarachnoid space. 2. area between the subarachnoid space and the dura mater. 3. area between the dura mater and the ligamentum flavum. 4. ligamentum flavum.
Correct Answer: 2 RATIONALES: When initiating a 24-hour urine specimen, have the client void, and then start timing. The collection should start on an empty bladder. The exact time the test starts isn't important, but it's commonly started in the morning.
A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collectiontime should: 1. start with the first voiding. 2. start after a known voiding that empties the bladder. 3. always be with first morning urine. 4. always be the last evening's void as the last sample.
Correct Answer: 3 RATIONALES: The nurse should respond by asking the client what he's already been told about his ability to walk again. After assessing the client's knowledge, she can better respond to the client's questioning. Option 1 provides the client with false hope, and option 2 may place the client on the defensive. Option 4 is an inappropriate response.
A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate? 1. "If you keep a positive attitude, you can do anything." 2. "What makes you think you won't be able to walk again?" 3. "What has your physician told you about your ability to walk again?" 4. "Most likely you won't be able to, but we never know for sure."
Correct Answer: 1 RATIONALES: Folding towels and pillowcases is a simple activity that redirects the client's attention. Also, because this activity is familiar, the client is likely to perform it successfully. Cards, charades, and aerobic exercise are too complicated for a confused client.
A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: 1. fold towels and pillowcases. 2. play cards with another client. 3. participate in a game of charades. 4. perform an aerobic exercise.
Correct Answer: 2 RATIONALES: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal — not hypotonic — saline solution.
A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion? 1. Insulin 2. Hydrocortisone 3. Potassium 4. Hypotonic saline
Correct Answer: 4 RATIONALES: Health care professionals must ensure a health care ethic that respects the role of the client in the decision-making process. According to the Patient's Bill of Rights, the client has the right to make decisions about his care at any time. The nurse should be a client advocate and be supportive of the decision he made.
A client with chronic obstructive pulmonary disease, who has been receiving mechanical ventilation for the past 5 days, expresses to a nurse his desire to have treatment withdrawn. Which statement about the client's legal rights is true in this situation? 1. The nurse's assessment of the client and communication with the family guides the decision-making process. 2. The nurse is an advocate for the client and should encourage the client to accept his current treatment regimen. 3. The health care team must follow the treatment plan that was already established with client and family input. 4. The client has the right to refuse treatment at any time.
Correct Answer: 4 RATIONALES: The nurse should assess the client's cardiac rhythm using electrocardiography because an elevated serum potassium level may lead to a life-threatening cardiac arrhythmia. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? 1. Blood pressure 2. Respirations 3. Temperature 4. Cardiac rhythm
Correct Answer: 2 RATIONALES: The protozoal enteric infection caused by Cryptosporidium results in profuse watery diarrhea. Because diarrhea will lead to dehydration, the nurse should focus on fluid replacement. Pain management is also a concern in the care of a client with AIDS. However, with Cryptosporidium, the main concern is hydration. Antiretroviral therapy is most useful when a client with human immunodeficiency virus (HIV) doesn't have opportunistic infections. With the wasting associated with AIDS, high-calorie nutrition is important but with Cryptosporidium-related diarrhea, hydration takes precedence.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infectioncaused by the protozoa. In planning the client's care, the nurse should focus on his need for: 1. pain management. 2. fluid replacement. 3. antiretroviral therapy. 4. high-calorie nutrition.
Correct Answer: 3 RATIONALES: A clear liquid diet consists of foods that are clear liquids at room temperature or body temperature, such as ice pops, regular or decaffeinated coffee and tea, gelatin desserts, carbonated beverages, and clear juices. Milk, pasteurized eggs, egg substitutes, and oatmeal are part of a full liquid diet.
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client: 1. milk and ice pops. 2. decaffeinated coffee and scrambled eggs. 3. tea and gelatin dessert. 4. apple juice and oatmeal.
Correct Answer: 1 RATIONALES: In a client with PIH, uteroplacental perfusion may be inadequate and gas exchange may be poor. Regional anesthesia increases the risk of hypotension resulting from sympathetic blockade, possibly causing fetal and maternal hypoxia. Hypertension, seizures, and renal toxicity aren't associated with regional anesthesia.
A client with moderate pregnancy-induced hypertension (PIH) is a poor candidate for regional anesthesia during labor and delivery. If she were to receive this form of anesthesia, she might experience: 1. hypotension. 2. hypertension. 3. seizures. 4. renal toxicity.
Correct Answer: 4 RATIONALES: Listening, responding quickly, and providing support promote therapeutic communication. Offering to talk about the client's feelings validates those feelings and allows the client to express them. Options 1 and 2 ignore the client's feelings. Option 3 identifies the client's feelings but doesn't follow through by exploring them.
A client with newly diagnosed breast cancer asks the nurse, "Why me? I've always been a good person. What have I done to deserve this?" Which response by the nurse would be most therapeutic? 1. "Don't worry. You'll probably live longer than I will." 2. "I'm sure a cure will be found soon." 3. "You seem upset. Let's talk about something happy." 4. "Would you like to talk about this?"
Correct Answer: 2 RATIONALES: Magnesium sulfate is given to prevent and control seizures in clients with PIH. Beta-adrenergic blockers (such as propranolol, labetalol, and atenolol) and centrally acting blockers (such as methyldopa) are used to lower blood pressure. Magnesium sulfate has no effect on labor or dopamine receptors.
A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 4 g in 50% solution I.V. over 20 minutes. What is the purpose of administering magnesium sulfate to this client? 1. To lower blood pressure 2. To prevent seizures 3. To inhibit labor 4. To block dopamine receptors
Correct Answer: 1 RATIONALES: The client's memory of a traumatic childhood incident and her current symptoms (nightmares, flashbacks, and related fears) suggest that she has PTSD with delayed onset. The client doesn't occasionally lose track of her movements and actions, as in multiple personality disorder. Her anxiety isn't primary but results from severe emotional trauma. Although she experiences flashbacks, these aren't psychotic episodes, as in schizophrenia.
A client, age 20, is being treated for depression. During a conversation with the nurse, she states that her father raped her when she was 7 years old. She says she has nightmares about the experience and sometimes relives it. She also reveals that she fears older men. The client may be exhibiting signs of: 1. posttraumatic stress disorder (PTSD), delayed onset. 2. multiple personality disorder. 3. anxiety disorder. 4. schizophrenia.
Correct Answer: 2 RATIONALES: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client? 1. A private room down the hall from the nurses' station 2. An isolation room close to the nurses' station 3. A semiprivate room with a 32-year-old client who has viral meningitis 4. A two-bed room with a client who previously had bacterial meningitis
Correct Answer: 3 RATIONALES: Insulin requirements are increased by growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.
A diabetic client develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect may these findings have on his need for insulin? 1. They will have no effect. 2. They will decrease the need for insulin. 3. They will increase the need for insulin. 4. They will cause wide fluctuations in the need for insulin.
Correct Answer: 4 RATIONALES: This statement demonstrates a realistic understanding of the client's disorder and effective family coping with the challenges it presents. Options 1 and 2 indicate that the family is having difficulty adjusting. Option 3 suggests that the family is in denial or has an unrealistic view of the prognosis for a client with Alzheimer's disease.
A geriatric client with Alzheimer's disease has been living with his grown child's family for the last 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement? 1. "It's difficult dealing with Dad. It's a thankless job." 2. "We had no idea this would be so difficult. It's our cross to bear." 3. "Dad really seems to be making progress. We're hoping he'll be able to move back into his house soon." 4. "Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break."
Correct Answer: 1,2,3,4,6 RATIONALES: The nurse needs to know when the last dose was administered. Some clients request pain medication earlier than is ordered by the physician. Pain, the fifth vital sign, should be assessed using a pain scale and documented in the nursing notes whenever a pain medication is given. Pain is usually reassessed about 30 minutes after the medication is given. Physicians commonly order several different types of pain medication based on the client's condition. The nurse should know which medication and which route was used to administer prior dosages. Evaluating the effectiveness of medications is also an important nursing function when managing the client's pain. Therefore, she should ask the client if the prior dose was helpful. The nurse should also note whether the client experienced any adverse effects of the medication. Most medications are ordered based on the client's admission weight, not current weight and height. A client's weight may fluctuate when he's in the hospital, so it's unlikely that the nurse will have the most current weight available. Also, taking steps to obtain the client's current weight postpones the pain treatment and can potentially worsen pain.
A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply: 1. Administration time of the last dose 2. Client's pain level on a scale of 1 to 10 3. Type of medication the client has been taking 4. Client's reaction to the previous dose 5. Client's most current height and weight 6. Effectiveness of prior dose of medication
Correct Answer: 3 RATIONALES: This is an example of a negative attitude and passive-aggressive behavior in response to demands for adequate performance. People with this disorder won't confront or discuss issues with others but will go to great lengths to "get even." Obsessive-compulsive disorder involves rituals or rules that interfere with normal functioning. A person with a narcissistic personality has an exaggerated sense of self-worth. A person with a dependent personality is submissive and frequently apologizes and backs down when confronted.
A man at a pizza parlor verbally confronts the waiter for lack of attentiveness. Later, in the back room, the waiter spits on the man's pizza. This is an example of a behavior typical of which disorder? 1. Obsessive-compulsive 2. Narcissistic 3. Passive-aggressive 4. Dependent
Correct Answer: 4 RATIONALES: The law mandates that health care agencies ask all clients if they have an advance directive. Therefore, the LPN must address this question regardless of whether the client initiates a conversation about it. Nurses must always act in the best interest of their clients, maintain confidentiality, and support the Patient's Bill of Rights.
A newly hired licensed practical nurse (LPN) is helping the charge nurse admit a client. The charge nurse asks the LPN if she understands the facility's rules of ethical conduct. Which statement by the LPN indicates the need for further teaching? 1. "I make sure that I do everything in my client's best interest." 2. "I maintain client confidentiality at all times." 3. "I always support the Patient's Bill of Rights." 4. "I don't discuss advance directives unless the client initiates the conversation."
Correct Answer: 3 RATIONALES: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene? 1. Explain that she can't give medical advice. 2. Inform the neighbor that she might require surgery. 3. Advise the neighbor to seek medical attention. 4. Tell the neighbor that she'll be fine because she was able to get through the night.
Correct Answer: 3 RATIONALES: Frequent breast-feeding empties the breasts and increases circulation, helping to remove fluid that may lead to engorgement. If the infant isn't ill or physically impaired and can breast-feed, the client shouldn't use an electric breast pump because this deprives the infant of optimal sucking and skin-to-skin contact with the mother. Applying warm, moist compresses stimulates the let-down reflex and causes the breasts to fill, which may lead to engorgement. A brassiere supports the breasts but doesn't prevent engorgement.
A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to: 1. use an electric breast pump. 2. apply warm, moist compresses to the breasts. 3. breast-feed every 1½ to 3 hours. 4. wear a brassiere 24 hours per day.
Correct Answer: 3 RATIONALES: The nurse shouldn't give a positive appraisal of the child's prognosis because doing so gives the parents false hope. The nurse must be honest about the child's prognosis and provide them accurate information about treatment options, which include palliative care, comfort care, and pain management. The physician — not the nurse — should discuss such treatment options as chemotherapy or bone marrow transplantation, if indicated.
A school-age child with terminal leukemia is admitted to the pediatric unit. The nurse must discuss advance directives with the child's parents. The nurse should include which information? 1. Positive appraisal of the child's prognosis 2. Chemotherapy options 3. Comfort care options 4. Bone marrow transplantation information
Correct Answer: 4 RATIONALES: Not crying when moved most strongly suggests child abuse. A victim of child abuse typically doesn't complain of pain, even with obvious injuries, for fear of further displeasing the abuser. Trying to sit up on the stretcher is a typical client response. Trying to move away from the nurse indicates fear of strangers, which is normal in a toddler. Difficulty answering the nurse's questions is expected in a toddler because of poorly developed cognitive skills.
A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior most stronglysuggests that the child's injuries stem from abuse? 1. Trying to sit up on the stretcher 2. Trying to move away from the nurse 3. Not answering the nurse's questions 4. Not crying when moved
Correct Answer: 3 RATIONALES: During a seizure, the nurse's first priority is to protect the child from injury. To prevent injury caused by uncontrolled movements, the nurse must remove objects from the child's surroundings and pad objects that can't be removed. Restraining the child or placing an object in the child's mouth during a seizure may cause injury. Once the seizure stops, the nurse should check for breathing and, if indicated, initiate rescue breathing.
A toddler is having a tonic-clonic seizure. What should the nurse do first? 1. Restrain the child. 2. Place a tongue blade in the child's mouth. 3. Remove objects from the child's surroundings. 4. Check the child's breathing.
Correct Answer: 2 RATIONALES: During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release. A single daily dose of insulin wouldn't control this client's blood glucose level as effectively. Limiting dietary fat intake wouldn't help the body use glucose at the cellular level. An adolescent with type 1 diabetes mellitus doesn't produce insulin and therefore can't receive an oral antidiabetic agent instead of insulin.
An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client? 1. Administering insulin once per day 2. Administering multiple doses of insulin 3. Limiting dietary fat intake 4. Substituting an oral antidiabetic agent for insulin
Correct Answer: 2 RATIONALES: To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, andangina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemiaby ingesting: 1. 2 to 5 g of a simple carbohydrate. 2. 10 to 15 g of a simple carbohydrate. 3. 18 to 20 g of a simple carbohydrate. 4. 25 to 30 g of a simple carbohydrate.
Correct Answer: 4 RATIONALES: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.
As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy? 1. Decreased appetite 2. Inadequate fluid intake 3. Prolonged gastric emptying 4. Reduced intestinal motility
Correct Answer: 2 RATIONALES: The purpose of an incident report is threefold: to identify ways to prevent incident recurrences, to identify patterns of care problems, and to identify facts surrounding each incident. Incident reports aren't used to hold people accountable for their actions, to punish those involved in the incident, or to punish the nurse-manager responsible for the unit.
As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is a goal of the report? 1. To reprimand the involved staff members for their actions 2. To identify the learning needs of staff to prevent incident recurrences 3. To reprimand the nurse-manager responsible for the unit 4. To hold people accountable for their actions
Correct Answer: 2 RATIONALES: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.8 mEq/L is an acceptable value. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significantproblem during this procedure? 1. Blood glucose level of 200 mg/dl 2. White blood cell (WBC) count of 20,000/mm3 3. Potassium level of 3.8 mEq/L 4. Hematocrit (HCT) of 35%
Correct Answer: 3 RATIONALES: The temporal lobe contains the auditory association area. If the area is damaged in the dominant hemisphere, the client hears words but doesn't know their meaning. Damage to the parietal lobe affects the client's ability to identify special relationships with the environment. When damaged, the occipital lobe affects visual associations. The client can visualize objects but can't identify them. The frontal lobe acts as a storage area for memory.
Damage to which area of the brain results in receptive aphasia? 1. Parietal lobe 2. Occipital lobe 3. Temporal lobe 4. Frontal lobe
Correct Answer: 4 RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion.
During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by: 1. slowing the glomerular filtration rate. 2. increasing sodium resorption. 3. decreasing potassium excretion. 4. stimulating or hindering micturition.
Correct Answer: 3 RATIONALES: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.
Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is: 1. erythema. 2. leukocytosis. 3. pressurelike pain. 4. swelling.
Correct Answer: 4 RATIONALES: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
For a client with Graves' disease, which nursing intervention promotes comfort? 1. Restricting intake of oral fluids 2. Placing extra blankets on the client's bed 3. Limiting intake of high-carbohydrate foods 4. Maintaining room temperature in the low-normal range
Correct Answer: 1 RATIONALES: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.
In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by: 1. hypothyroidism. 2. hyperglycemia. 3. hypertension. 4. antiseizure medication.
Correct Answer: 1 RATIONALES: The client is exhibiting signs of preeclampsia. In addition to hypertension and hyperreflexia, most preeclamptic clients have edema. Headache and blurred vision are indications of the effects of the hypertension. Abdominal pain, urinary frequency, diaphoresis, nystagmus, dizziness, lethargy, chest pain, and shortness of breath are inconsistent with a diagnosis of preeclampsia.
Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which complaints? 1. Headache, blurred vision, and facial and extremity swelling 2. Abdominal pain, urinary frequency, and pedal edema 3. Diaphoresis, nystagmus, and dizziness 4. Lethargy, chest pain, and shortness of breath
Correct Answer: 2 RATIONALES: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.
One aspect of implementation related to drug therapy is: 1. developing a content outline. 2. documenting drugs given. 3. establishing outcome criteria. 4. setting realistic client goals.
Correct Answer: 3 RATIONALES: This response shows that the nurse finds the client's behavior unacceptable, yet still regards the client as worthy of help. The other options give the false impression that the client is in control of the behavior; the client hasn't been in treatment long enough to control the behavior.
One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic? 1. "You're behaving in an unacceptable manner, and you need to control yourself." 2. "If you continue to talk like that, no one will want to be around you." 3. "You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy." 4. "You're scaring everyone in the group. Leave the room immediately."
Correct Answer: 1 RATIONALES: This child is in Erikson's developmental stage of initiative versus guilt. Guilt develops when the child is made to feel bad about his behavior. Ignoring the negative behavior shows the child that he'll gain nothing through negative behavior such as temper tantrums. Promising the child a new toy or giving in to his demands will reinforce his negative behavior by rewarding his tantrums. Mimicking the child will make him feel guilty.
The mother of a 3-year-old child is complaining that her son still throws temper tantrums when he doesn't get his way. How should the nurse advise the mother to respond? 1. Tell the mother to ignore the child because eventually he will stop having temper tantrums. 2. Tell the mother to promise him a new toy if he stops the tantrum. 3. Tell the mother to give in to his demands; he is only 3-years-old. 4. Tell the mother to mimic him so that he can see what his behavior looks like.
Correct Answer: 3 RATIONALES: Anger is the stage of grief in which a person expresses anger about the diagnosis or situation. Acceptance occurs when the person comes to terms with the diagnosis. This situation isn't an example of a psychotic episode; it's a normal stage of the grieving process. Denial is the stage of grief when a person refuses to believe the truth.
The mother of a 3-year-old has been told that her child has a brain tumor. She initially begins to cry and accuses the physicians oflying. Which of the following stages is the mother most likely experiencing? 1. Acceptance 2. Psychotic episode 3. Anger 4. Denial
Correct Answer: 2 RATIONALES: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4° F (38° C) also are common at 24 hours postpartum.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation? 1. Chills 2. Scant lochia rubra 3. Thirst and fatigue 4. Temperature of 100.2° F (37.9° C)
Correct Answer: 4 RATIONALES: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal data collection findings.
The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? 1. Serum potassium level of 4.9 mEq/L 2. Serum sodium level of 135 mEq/L 3. Temperature of 99.2° F (37.3° C) 4. Urine output of 20 ml/hour
Correct Answer: 2 RATIONALES: The nurse should advise the mother to avoid giving her child large, round chunks of meat such as hot dog. The mother can safely give the toddler small pieces of banana; cooked vegetables, such as lima beans and corn; and frozen desserts such as ice cream.
The nurse is advising a mother about foods to avoid to prevent choking in her toddler. Which foods should she include in her instruction? 1. Small pieces of banana 2. Large, round chunks of meat such as hot dog 3. Cooked vegetables such as lima beans and corn 4. Frozen desserts such as ice cream
Correct Answer: 3 RATIONALES: Degenerative changes can lead to decreased reflexes, which is a normal result of aging. Cloudy vision, incontinence, and tremors may be signs and symptoms of underlying pathology and shouldn't be considered normal results of aging.
The nurse is assessing an elderly client. When performing the assessment, the nurse should consider that one normal age-related change is: 1. cloudy vision. 2. incontinence. 3. diminished reflexes. 4. tremors.
Correct Answer: 3,4,5 RATIONALES: Because food delays absorption, the nurse should instruct the client to take the supplement between meals to increase absorption. The client should take the supplement with juice (preferably orange juice) or water, but not with milk or antacids. The nurse should also tell the client not to crush or chew extended-release forms of the drug.
The nurse is caring for a 16-year-old pregnant client who is taking an iron supplement. Which instruction should the nurse include when teaching the adolescent about ferrous sulfate? Select all that apply: 1. Take the supplement with food. 2. Report black stools to the physician immediately. 3. Avoid taking the supplement with milk. 4. Avoid taking the supplement with antacids. 5. Avoid chewing the extended-release form of the drug.
Correct Answer: 1 RATIONALES: Providing a safe environment is the most important aspect of caring for a client with delirium. Although all other options are logical and appropriate, meeting the client's safety needs takes priority.
The nurse is caring for a client with delirium. Which of the following is most important for the nurse to provide the client? 1. A safe environment 2. An opportunity to release frustration 3. Prescribed medications 4. Medications as needed, judiciously
Correct Answer: 2 RATIONALES: Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. Applying maximum bandages should be avoided because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.
The nurse is caring for a client with skin grafts covering third-degree burns on the arms and legs. During dressing changes, the nurse should be sure to: 1. apply maximum bandages to allow for absorption of drainage. 2. wrap elastic bandages distally to proximally on dependent areas. 3. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. 4. put on sterile gloves only when removing bandages.
Correct Answer: 1,2,6 RATIONALES: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his room; masks must be discarded before leaving the client's room. Hand washing is required after direct contact with the client or contaminated articles. Strict isolation isn't required if the client adheres to special respiratory precautions. The client, not the people in contact with him, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.
The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply: 1. Wear gloves when handling tissues containing sputum. 2. Wear a face mask at all times. 3. Keep the client in strict isolation. 4. When the client leaves the room for tests, have all people in contact with him wear a mask. 5. Keep the client's door open to allow fresh air into room and prevent social isolation. 6. Wash hands after direct contact with the client or contaminated articles.
Correct Answer: 1 RATIONALES: According to the Denver Developmental Screening Test, most infants should be able to sit unsupported by age 7 months. A 15-month-old child should be able to say two words. By 17 months, the toddler should be able to feed himself with a spoon. A 10-month-old infant should be able to play patty-cake.
The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age? 1. Sitting without support 2. Saying two words 3. Feeding himself with a spoon 4. Playing patty-cake
Correct Answer: 4 RATIONALES: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter? 1. Family history of pressure ulcers 2. Presence of existing pressure ulcers 3. Potential areas of pressure ulcer development 4. Overall risk of developing pressure ulcers
Correct Answer: 3,4,6 RATIONALES: Failure of the toes to curl downward when the baby's soles are stroked and lack of response to a loud sound can be evidence that neurological damage from asphyxia has occurred. The normal responses would be that the toes curl downward with stroking and that the arms and legs extend in response to a loud noise. Weak, ineffective sucking is another sign of neurologic damage; a neonate should root and suck when the side of his cheek is stroked. A neonate should also grasp a person's finger when it's placed in the palm of his hand, do stepping movements when held upright with the soles touching a surface, and turn toward an object when his cheek is touched by it.
The nurse is performing a neurologic assessment on a 1-day-old neonate. Which of the following findings would indicate possible asphyxia in utero? Select all that apply: 1. The neonate grasps the nurse's finger when she puts it in the palm of his hand. 2. The neonate does stepping movements when held upright with his sole touching a surface. 3. The neonate's toes don't curl downward when his soles are stroked. 4. The neonate doesn't respond when the nurse claps her hands above him. 5. The neonate turns toward an object when the nurse touches his cheek with it. 6. The neonate displays weak, ineffective sucking.
Correct Answer: 4 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.
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
Correct Answer: 2 RATIONALES: The small intestine absorbs products of digestion, completes food digestion, and secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach stores, mixes, and liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. Although the large intestine completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption.
The nurse is teaching a client about malabsorption syndrome and its treatment. The client asks which part of the GI tract absorbs food. The nurse tells the client that products of digestion are absorbed mainly in the: 1. stomach. 2. small intestine. 3. large intestine. 4. rectum.
Correct Answer: 3 RATIONALES: The spread of childhood infections, including impetigo, can be reduced when children are taught proper hand-washing technique. Because impetigo is spread through direct contact, covering the mouth and nose when sneezing won't prevent its spread. Currently, there is no vaccine to prevent a child from contracting impetigo. Isolating the child with impetigo is unnecessary.
The nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to: 1. teach children to cover mouths and noses when they sneeze. 2. have their children immunized against impetigo. 3. teach children the importance of proper hand washing. 4. isolate the child with impetigo from other members of the family.
Correct Answer: 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 awet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues.
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.
Correct Answer: 3 RATIONALES: The nurse-manager should inform the nurse that she wishes to speak with her. Then, in a private location, she should discuss the inappropriateness of the nurse's comment and an action plan to improve her care. If the client is experiencing pain the nurse should act as a client advocate and notify the physician of the client's pain. However, because the client isn't requesting pain medication, there's no need to request pain medication from the physician.
The nurse-manager overhears a nurse tell a client, "If I were you, I'd ask the doctor for something for pain; you shouldn't have to suffer during labor." How should the nurse-manager respond to the nurse's comment? 1. Don't respond because the nurse's statement is correct. 2. Confront the nurse in the client's room and remind her that it's inappropriate to administer pain medications to clients in labor. 3. Inform the nurse that she'd like to speak with her, then discuss the inappropriateness of her comment in a private location. 4. Notify the physician of the client's pain and request that he prescribe pain medication for the client.
Correct Answer: 3 RATIONALES: Research shows a correlation between the use of aspirin during chickenpox and the development of Reye's syndrome (a disorder characterized by brain and liver toxicity). Therefore, the nurse should instruct the parents to avoid administering aspirin or other products that contain salicylates and to consult the physician or pharmacist before administering any medication to a child with chickenpox. No research has found a link between aspirin use, chickenpox, and the development of Guillain-Barré syndrome, rheumatic fever, or scarlet fever.
The parent of a preschooler with chickenpox asks the nurse about measures to make the child comfortable. The nurse instructs the parent to avoid administering aspirin or any other product that contains salicylates. When given to children with chickenpox, aspirin has been linked to which disorder? 1. Guillain-Barré syndrome 2. Rheumatic fever 3. Reye's syndrome 4. Scarlet fever
Correct Answer: 1.3 RATIONALES: To perform the dosage calculation, first convert the infant's weight from pounds to kilograms by setting up the following proportion: 2.2 lb/1 kg = 14 lb/X X = 6.4 kg. Then perform the following calculation to determine the total dose prescribed: 2 mg/kg = X/6.4 kg X = 12.8 mg. Then set up the following proportion to determine the volume of medication to administer: 10 mg/ml = 12.8 mg/X X = 1.3 ml.
The physician prescribes furosemide (Lasix), 2 mg/kg P.O., as a one-time dose for an infant with fluid overload. The infant's documented weight is 14 lb. The oral solution contains 10 mg/ml. How many milliliters of solution should the nurse administer?
Correct Answer: 3 RATIONALES: For an infant, the nurse should use a needle with the smallest appropriate gauge for the medication to be given. For an I.M. injection of meperidine, a 25G to 22G needle is appropriate.
The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-month-old child who has just had abdominal surgery. When administering this drug, the nurse should use a needle of which size? 1. 18G 2. 20G 3. 23G 4. 27G
Correct Answer: 14 RATIONALES: To determine the total daily dosage, set up the following proportion: 25 kg/X = 1 kg/56 mg X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 ml/125 mg X = 14 ml.
The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many milliliters of solution should the nurse administer with each dose?
Correct Answer: 4 RATIONALES: The surgeon should collaborate with the enterostomal nurse who can address the client's concerns. The enterostomal nurse may schedule a visit from a client who has a colostomy to offer support to the client. The clinical educator can provide information about the colostomy when the client is ready to learn. The staff nurse and social worker don't need to be consulted in this situation.
The surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of acolostomy. Based on the client's response, the surgeon should collaborate with which health team member? 1. Social worker 2. Staff nurse 3. Clinical educator 4. Enterostomal nurse
Correct Answer: 4 RATIONALES: Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions.
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a commonallergen? 1. Bread 2. Carrots 3. Oranges 4. Strawberries
Correct Answer: 4 RATIONALES: The nurse legally must document the client's reaction to the drug in addition to the time the drug was administered and the dosage given. The nurse isn't legally responsible for documenting the peak concentration time of the drug, safe drug ranges, or the client's socioeconomic data.
Which detail of a client's drug therapy is the nurse legally responsible for documenting? 1. Peak concentration time of the drug 2. Safe ranges of the drug 3. Client's socioeconomic data 4. Client's reaction to the drug
Correct Answer: 3 RATIONALES: Both benzodiazepines (such as alprazolam) and barbiturates (such as phenobarbital) are addictive, controlled substances. None of the other drugs listed are addictive substances.
Which drugs may be abused because of tolerance and physiologic dependence? 1. Lithium (Lithobid) and divalproex (Depakote). 2. Verapamil (Calan) and chlorpromazine (Thorazine) 3. Alprazolam (Xanax) and phenobarbital (Luminal) 4. Clozapine (Clozaril) and amitriptyline (Elavil)
Correct Answer: 1 RATIONALES: Neonates who are hypothermic typically develop bradycardia. Hypoglycemia, not hyperglycemia, and metabolic acidosis, not metabolic alkalosis, are also seen in neonates with hypothermia. Neonates typically don't shiver.
Which finding in a neonate suggests hypothermia? 1. Bradycardia 2. Hyperglycemia 3. Metabolic alkalosis 4. Shivering
Correct Answer: 4 RATIONALES: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.
Which interventions are appropriate when caring for a client with acute thrombophlebitis? 1. Apply cool soaks and keep the client's leg lower than the level of the heart. 2. Increase the client's activity level and encourage leg exercises. 3. Apply cool soaks and administer nitroglycerin. 4. Apply warm soaks and elevate the client's legs higher than the level of the heart.
Correct Answer: 1 RATIONALES: Elevating the head of the bed at least 30 degrees during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on the right side. The nurse should give enteral feedings at room temperature to minimize GI distress. To limit microbial growth, the nurse should hang only the amount of formula that can be infused in 8 hours.
Which nursing action is essential when providing continuous enteral feeding? 1. Elevating the head of the bed at least 30 degrees 2. Positioning the client on the left side 3. Warming the formula before administering it 4. Hanging a full day's worth of formula at one time
Correct Answer: 1 RATIONALES: Low self-esteem and repressed rage as well as depression can predispose an individual to search for solace in addictive medications. Usually, medications are used to minimize or blot out pain, rather than inflict additional pain. Personality disorders don't predispose a client to medication abuse; however, personality disorders, especially the antisocial ones, may be intensified by abuse.
Which psychological or personality factor is likely to predispose an individual to medication abuse? 1. Low self-esteem and unresolved rage 2. Desire to inflict pain upon one's self 3. Dependent personality disorder 4. Antisocial personality disorder
Correct Answer: 4 RATIONALES: The goal of care for clients with dementia is to maintain the highest level of functioning. When restraints must be used, the least restrictive type of restraint possible should be used. A lap tray over a wheelchair severely limits the client's mobility and can cause injury if the client tries to get out of the wheelchair. A walker can be very helpful to clients with dementia as they commonly have unsteady gaits. Childproof locks are helpful in preventing accidental contact with harmful substances. An electronic monitoring system is an effective way of managing a client who wanders.
Which safety device is most restrictive for a client with dementia? 1. Walker 2. Childproof locks on cabinets and doors 3. Electronic monitoring system 4. Lap tray placed on a wheelchair
Correct Answer: 1 RATIONALES: A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? 1. diphenhydramine hydrochloride (Benadryl) 2. pseudoephedrine hydrochloride (Sudafed) 3. guaifenesin (Robitussin) 4. loperamide (Imodium)
