NCLEX Practice Qs

The nurse is caring for a 2-year-old child with cancer. The parents have been told that the child will need an allogeneic bone marrow transplant and want to know what this means. What is the best response by the nurse? "A donor is determined after testing for similar human leukocyte antigens." "The donor bone marrow can be accepted from anyone who volunteers." "The donor for this type of transplant must have the same DNA as your child." "This type of transplant uses the child's own stem cells for the procedure."

"A donor is determined after testing for similar human leukocyte antigens."

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying: "Do not worry. Your new hip is very strong." "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation." "Use of a cushioned toilet seat helps to prevent dislocation."

"Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? "Family members should continue to talk to the client." "Oral intake of fluids should be limited for 1 week only." "Clean the tracheostomy tube with alcohol and water." "Limit the amount of protein in the diet."

"Family members should continue to talk to the client."

A nurse is assessing a woman who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, the nurse should ask the client which question? "Has your hair been falling out in clumps?" "Have you been sleeping at night?" "Do you have your usual energy level?" "Have you had nausea or vomiting?"

"Have you had nausea or vomiting?"

An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling" him. Which response would be most appropriate? "Hold him when he is fussy or crying." "Try to hold him infrequently to avoid overstimulation." "You can hold him periodically throughout the day." "Hold him as much as you want to hold him."

"Hold him as much as you want to hold him."

A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client? "Are you on any blood pressure medications?" "Are you on any type of special diet at home?" "How frequently do you urinate each day?" "How often do you have a bowel movement?"

"How frequently do you urinate each day?"

Which statement made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history? "How has the stroke affected your ability to perform your daily activities?" "What have your daily blood pressure and pulse rate readings been?" "Have you been taking your blood pressure medication exactly as prescribed?" "Tell me about your family's history with heart disease."

"How has the stroke affected your ability to perform your daily activities?"

A client is readmitted with an exacerbation of celiac disease 2 weeks after discharge. Which statement by the client indicates the need for a dietary consult? "I don't understand this; I took the medication the doctor ordered and followed the diet." "I didn't eat anything I shouldn't have; I just ate roast beef on rye bread." "I don't understand why this happened again; I didn't travel out of the country." "I don't like oatmeal, so it doesn't matter that I can't have it."

"I didn't eat anything I shouldn't have; I just ate roast beef on rye bread."

A nurse is assessing the client's ability to perform ear care. Which statement by the client requires further education by the nurse? "I use cotton-tipped applicators daily to remove cerumen." "I use a washcloth to clean the auricles and cerumen when needed." "I clean my ear mold on my hearing aid daily before use." "I never use bobby pins or other sharp objects when cleaning cerumen."

"I use cotton-tipped applicators daily to remove cerumen."

A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement? "Signs of any type of infection must be reported immediately." "At the earliest signs of a crisis, I need to seek treatment." "I will need more frequent appointments during the remainder of the pregnancy." "I will need to take an iron supplement even if my laboratory values are normal."

"I will need to take an iron supplement even if my laboratory values are normal."

The client diagnosed with agoraphobia refuses to walk down the hall to the group room. Which response by the nurse is most appropriate? "I will walk with you." "I know you can do it." "Try holding onto the wall as you walk." "You can miss group this one time."

"I will walk with you."

After teaching nursing students about substance abuse and its effects on individuals and families, the instructor determines that additional teaching is necessary when the students state which of the following? "Substance abuse involves use of alcohol and illegal, prescribed, or over-the-counter drugs." "People experiencing substance abuse problems often have difficulty using adaptive behaviors." "Individuals frequently engage in substance use and abuse to enhance their decision-making ability." "Substance abuse is widespread, occurring in all types of settings."

"Individuals frequently engage in substance use and abuse to enhance their decision-making ability."

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best? "Have you talked this over with your family?" "You know that we will do everything needed to keep you comfortable even though you have the DNR in place." "Do you want to rescind the DNR, or just change it?" "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."

"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."

The client who has been taking venlafaxine 25 mg PO three times a day for the past 2 days states, "This medicine is not doing me any good. I am still so depressed." Which response by the nurse is most appropriate? "It is too soon to tell if your medication will help you." "Perhaps we will need to increase your dose." "Let us wait a few days and see how you feel." "It takes about 2 to 4 weeks to receive the full effects."

"It takes about 2 to 4 weeks to receive the full effects."

The nurse is assessing a 4-year-old child who demonstrates unintelligible speech. The parents are concerned and ask about the cause of the speech problem. What is the most appropriate response by the nurse? "Many speech problems are the result of a hearing deficit." "Your child needs to be exposed to more talking by adults." "Your child may have a fear of talking that needs to be identified." "Speech problems are often caused by inadequate nutrition."

"Many speech problems are the result of a hearing deficit."

A child newly diagnosed with rheumatic fever is to receive penicillin therapy. Which statement by the parents should lead the nurse to judge that the parents understand the teaching about penicillin as part of the treatment plan? "We should give our child the medication after eating." "We need to also give these pills to our other children to prevent them from getting rheumatic fever." "Our child should take the medication until the primary health care provider discontinues it." "How long will it take for the penicillin to help relieve the joint discomfort?"

"Our child should take the medication until the primary health care provider discontinues it."

A child who is 18 months of age is brought to the emergency department by her babysitter. The babysitter states, "She fell from the sofa an hour ago and has not been herself since." On questioning, the babysitter appears to be unsure of time and other facts about the incident. Which question below would be most effective in obtaining more information about the child's injuries? "Have you taken a course in safe babysitting?" "Why did you leave the child alone on the couch?" "Tell me what was happening before she fell." "Where are her parents? Do they know this happened?"

"Tell me what was happening before she fell."

As a representative of the treatment team, a nurse is reviewing results of diagnostic studies with the family of an adolescent with anorexia nervosa. What explanation should the nurse give the family about the client's abnormal blood urea nitrogen (BUN) value? "The BUN is elevated because your daughter is dehydrated." "The BUN is elevated because your daughter has hypoglycemia." "The BUN is decreased because your daughter is hypertensive." "The BUN is decreased because your daughter has developed hypothyroidism."

"The BUN is elevated because your daughter is dehydrated."

The nurse determines that a female client understands how to perform breast self-examination when the client states: "I should use my whole hand to feel for lumps and only at the nipple." "The best time to perform the exam is 1 week after my period." "I should palpate the breast in a random manner with my thumb." "Dimples around the nipple are normal and increase with age."

"The best time to perform the exam is 1 week after my period."

After teaching the parents of a child with febrile seizures about methods to lower temperature other than using medication, which statement indicates successful teaching? "We will add extra blankets when he reports being cold." "We will make the bath water cold enough to make him shiver." "We will use a solution of half alcohol and half water when sponging him." "We will wrap him in a blanket if he starts shivering."

"We will wrap him in a blanket if he starts shivering."

A man found wandering in a local park is unable to state who or where he is or where he lives. He is brought to the emergency department, where his identification is eventually discovered. The client's wife states that he was diagnosed with Alzheimer's disease 3 years earlier and has experienced increasing memory loss. She tells a nurse she is worried about how she'll continue to care for him. Which response by the nurse is most helpful? "Do you have any children or friends who could give you a break from his care every now and then?" "Because of the nature of your husband's disease, you should start looking into nursing homes for him." "You may benefit from a support group called Mates of Alzheimer's Disease Clients." "What aspect of caring for your husband is causing you the greatest concern?"

"What aspect of caring for your husband is causing you the greatest concern?"

A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I have changed my mind and now do not want the feeding tube." What would be the most appropriate response by the nurse? "After you have given consent in writing, you cannot change your mind." "Changing your mind now would be really inconvenient for the surgeon." "You have a right to withdraw consent, so let's discuss your decision." "You must have the feeding tube inserted before the chemotherapy."

"You have a right to withdraw consent, so let's discuss your decision."

A hospitalized adolescent diagnosed with anorexia nervosa refuses to comply with her daily before-breakfast weigh-in. She states that she just drank a glass of water, which she feels will unfairly increase her weight. What is the nurse's best response to the client? "You must weigh in every day at this time. Please step on the scale." "Do not drink or eat for two hours, and then I will weigh you." "If you do not get on the scale, I will be forced to call your health care provider." "You are here to gain weight, so that will work in your favor."

"You must weigh in every day at this time. Please step on the scale."

Myelominingocele

*midline defect where the meninges and the spinal cord protrude through overlying defect *most in the lumbosacral region *Majority of patients also have hydrocephalus and Arnold-Chiari malformation *most common nonlethal malformation

calcium gluconate (IV)

--- electrolyte supplement hypocalcemia

Digoxin toxicity

-Cholinergic—nausea, vomiting, diarrhea, blurry yellow vision (think van Gogh), arrhythmias, AV block. -Can lead to hyperkalemia, which indicates poor prognosis. (???)

Diaphragmatic Hernia Tx

1) immediate intubation (may require extracorporeal membrane oxygenation), 2) followed by surgical correction. abnormal displacement of organs through the muscle separating the chest and abdomen

A physician orders the following preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glycopyrrolate, 0.3 mg. The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer? 2 ml 3.8 ml 2.5 ml 5 ml

2.5 ml

A child with osteomyelitis is to receive nafcillin I.V. every 6 hours. Before administering the drug, the nurse calculates the appropriate dosage. The recommended dosage is 50 to 100 mg/kg daily; the child weighs 22 lb (10 kg). Which dosage is acceptable? 500 mg every 6 hours 100 mg every 6 hours 50 mg every 6 hours 250 mg every 6 hours

250 mg every 6 hours

Before surgery, a neonate is to receive an IM injection of an antibiotic. Which gauge and size of needle should the nurse select? 23G, 2" (5 cm) needle 25G, 5/8" (1.6 cm) needle 19G, 1 1/2" (3.8 cm) needle 20G, 1" (2.5 cm) needle

25G, 5/8" (1.6 cm) needle

A client has been placed in an isolation room, and family members have stated that access to the client seems restricted. Which of the following actions would be appropriate for the nurse to take to address this situation? Select all that apply. Acknowledgement of the family's concerns A thorough explanation of the isolation procedures A communication plan for the family and client Discontinued isolation procedures at the family's request Free access to the client for immediate family

A communication plan for the family and client A thorough explanation of the isolation procedures Acknowledgement of the family's concerns

Trousseau's sign

A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.

Which colloid is expensive but rapidly expands plasma volume? Lactated Ringer solution Dextran Albumin Hypertonic saline

Albumin

Magnesium hydroxide (Milk of Magnesia)

Antacid. Neutralize gastric acid and inactivate pepsin. Side effects: diarrhea, renal impairment, and hypermagnesemia.

Promethazine (Phenergan)

Antiemetic. Side effects: drowsiness, anticholinergic effects, EPSs, potentiates effects when given with narcotics. Nursing interventions: monitor VS, safety precautions, IM (large muscle)

Colchicine (Colcrys)

Antigout. Inhibits processes to prevent leukocytes from invading joints. Used for acute gouty arthritis. Precautions/interactions: use caution in clients who have renal, cardiac, or GI dysfunction. Should not be combine with theophylline (Theo-Dur). Side effects: GI distress, hepatitis.

Valproic Acid (Depakote)

Antiseizure med. Precautions/interactions: contraindicated in liver disease, pregnancy. Side effects: hepatotoxicity, teratogenic effects, pancreatitis.

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test? Red blood cell count Arterial blood gas (ABG) analysis Total hemoglobin Sputum culture

Arterial blood gas (ABG) analysis

The client is laughing and telling jokes to a group of clients. Suddenly, the client is crying and talking about a death in the family. A moment later, the client is laughing and joking again. The nurse should: Call the health care provider (HCP) for a prescription for lorazepam as needed. Place the client in seclusion and call the HCP for a prescription for the seclusion. Ignore the client's behavior in order not to give the client too much attention. Ask the client to come to a quiet area to talk to the nurse individually.

Ask the client to come to a quiet area to talk to the nurse individually.

A client is undergoing treatment for prostate cancer. He has chemotherapy sessions regularly. However, of late he is showing symptoms of food allergy and loss of appetite. He has lost considerable weight as a result. Which is an appropriate nursing task in this situation? Administer serotonin blockers. Ask the client to keep a diet diary. Include fruits in the client's diet. Ensure greater fluid intake.

Ask the client to keep a diet diary.

A patient who adheres to the dietary laws of Judaism is in traction and confined to bed. The patient needs assistance with the evening meal of chicken, rice, beans, a roll, and a carton of milk. Which nursing approach is most representative of promoting wellness? Ask a family member to assist the patient with the tray and the overbed table, then straighten the area in an attempt to provide a pleasant atmosphere for eating. Ask whether the patient would like to make any substitutions in the foods and fluids received. Remove items from the overbed table to make room for the dinner tray. Push the overbed table toward the bed so that it will be within the patient's reach when the dinner tray arrives.

Ask whether the patient would like to make any substitutions in the foods and fluids received.

A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision? Autonomy Veracity Nonmaleficence Fidelity

Autonomy

The nurse is administering a medication to a client for the treatment of his constipation. The client states that he prefers not to take the medication today. The nurse respects the client's right and informs him if he needs it later, just let the nurse know. What professional value is the nurse displaying? Beneficence Autonomy Fidelity Nonmaleficence

Autonomy (constipation Tx)

A nurse is beginning a health history with a client and states, "Which part of your health history would you like to start with?" This type of communication technique is called Using silence Suggesting Broad opening Listening

Broad opening

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? Adventitious Bronchovesicular Bronchial Vesicular

Bronchial

albuterol

Bronchodilator

Methylphenidate (Ritalin)

CNS stimulant

A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which assessments or actions by the nurse would be most appropriate? Check the patency and amount of drainage from the NG tube. Irrigate the NG tube with water and give an analgesic as ordered. Administer an analgesic and antiemetic as ordered. Explain that nausea is common because the NG tube irritates the gag reflex.

Check the patency and amount of drainage from the NG tube.

Incidence of fungal infections has increased with the rising number of people who are immunocompromised. What groups are considered to have a compromised immune system? (Select all that apply.) Clients taking immunosuppressant drugs Middle-class citizens The elderly Clients with acquired immune deficiency syndrome (AIDS) and AIDS-related complex (ARC) Clients who have undergone transplantation surgery or cancer treatment

Clients with acquired immune deficiency syndrome (AIDS) and AIDS-related complex (ARC) Clients taking immunosuppressant drugs Clients who have undergone transplantation surgery or cancer treatment The elderly

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? Imbalanced nutrition: Less than body requirements Risk for infection Decreased cardiac output Impaired physical mobility

Decreased cardiac output

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents? Deficient knowledge related to inability to cope. Deficient knowledge related to lack of exposure to apnea monitor. Risk for aspiration related to nil orally status. Deficient knowledge related to ventilatory support.

Deficient knowledge related to lack of exposure to apnea monitor.

A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which intervention by the nurse would be therapeutic for this child? Limit the child's opportunities to verbalize anger and frustration. Define behaviors that are acceptable and behaviors that are not permitted. Increase the child's sensory stimulation. Restrict the child's participation in physical activities.

Define behaviors that are acceptable and behaviors that are not permitted.

A nurse is caring for a 34-month-old who is hospitalized for a lengthy illness. Which behaviors would the nurse identify as examples of expected developmental regression for the child's age group? Select all that apply. Altered gait. One to two word expressions. Loss of fine motor skills. Encopresis. Enuresis.

Enuresis. Encopresis. One to two word expressions.

Which term is defined as a formal systematic study of moral beliefs? Morality Veracity Ethics Fidelity

Ethics

Which of the following nursing interventions will a nurse perform to transfer heat and improve circulation in a dying client? Administer warm intravenous fluids. Gently massage the arms and legs. Administer intramuscular injections. Change the position frequently.

Gently massage the arms and legs.

An Asian family brings their special needs school-ager in for a routine visit. What use of adjuvant therapies would it be particularly wise for the nurse to explore? Herbal remedies Massage Pet therapy Music therapy

Herbal remedies

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? Low-fat 1,800-calorie ADA High-protein Full-liquid

High-protein

word salad

Incoherent mixture of words, phrases, and sentences

Students are reviewing information about substance abuse and its effects on individuals and families. The students demonstrate understanding of this topic when they identify which of the following? Substance abuse applies primarily to the use of illegal drugs. Substance abuse is most frequently seen in outpatient settings. Individuals use substances to enhance their decision-making ability. Individuals with substance abuse often have difficulty using adaptive behaviors.

Individuals with substance abuse often have difficulty using adaptive behaviors.

A nurse is working with a client who is undergoing genetic testing. The nurse would least likely be responsible for which of the following? Educating the client about the testing procedures Advocating for confidentiality of the results Obtaining the client's family history Informing the client about the testing results

Informing the client about the testing results

A nurse working in a long-term care facility institutes interventions to prevent falls in the older adult population. Which intervention would be an appropriate alternative to the use of restraints for ensuring client safety and preventing falls? Involve family members in the client's care. Allow the client to use the bathroom independently. Keep the client sedated with tranquilizers. Maintain a high bed position so the client will not attempt to get out unassisted.

Involve family members in the client's care.

A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate? Make sure all medications are kept in containers with childproof safety caps. Teach rules of the road for bicycle safety. Never leave a toddler unattended on a bed. Always make the toddler wear a seat belt when riding in a car.

Make sure all medications are kept in containers with childproof safety caps.

The nurse discovers that a young client has been given a dose of morphine four times the ordered dose. Which of the following is the immediate priority action for the nurse to take? Ensure that the error is corrected on the medication record. Obtain an order for naloxone and administer it promptly. Notify the parents of the medication error. Bring emergency resuscitation equipment to the child's room.

Obtain an order for naloxone and administer it promptly.

Which phase of pain transmission occurs when the one is made aware of pain? Perception Transduction Transmission Modulation

Perception

A client in an acute care facility is assigned a case manager to oversee and coordinate care. What important function does a case manager have? Make home visits to see that the client is taken care of after discharge. Provide care to the client who is terminally ill and has less than 6 months to live. Provide early, thorough discharge planning. Make sure the client is administered medications.

Provide early, thorough discharge planning.

Which valve lies between the right ventricle and the pulmonary artery? Pulmonic valve Tricuspid valve Mitral valve Chordae tendineae

Pulmonic valve

A 17-year-old unmarried primigravida at 10 weeks' gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do? Refer the client to a social worker for enrollment in a food assistance program. Ask the client if she has a job and the amount of income earned. Determine whether the client qualifies for local assistance programs. Instruct the client in methods for low-cost, highly nutritious meal preparation.

Refer the client to a social worker for enrollment in a food assistance program.

Metoclopramide Hydrochloride

Reglan Antiemetic

A nurse is assigned to care for a non-English-speaking client. Which of the following is the most appropriate action by the nurse to provide effective nursing care? Request a trained interpreter. Communicate with gestures and symbols. Take help from a bilingual family member. Request help from a nurse colleague.

Request a trained interpreter.

The nurse is caring for a child with acute glomerulonephritis and is meeting with the family to discuss discharge instructions. Which of the following are important teaching points for the nurse to review with the child's family? Select all that apply. Increase protein in the diet. Restrict the intake of sodium. Report any signs of infection. Administer potassium supplements. Monitor fluid intake and output.

Restrict the intake of sodium. Monitor fluid intake and output. Report any signs of infection.

Venlafaxine (Effexor)

SNRI antidepressant

Parents ask the nurse for advice about handling their 2-year-old's negativism. What is the best recommendation? Ignore this behavior because it is a stage the child is going through. Punish the child for misbehaving or violating set, strict limits. Set realistic limits for the child, and then be sure to stick to them. Encourage the grandmother to visit frequently to relieve them.

Set realistic limits for the child, and then be sure to stick to them.

A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distension. What is the priority action by the nurse? Lower the head of the bed. Repeat the vital signs in 1 hour. Administer oxygen and encourage the client to breathe deeply. Slow the intravenous rate and notify the physician.

Slow the intravenous rate and notify the physician.

automaticity

The ability of the heart to generate and conduct electrical impulses on its own.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control? The client expresses positive feelings about himself. The client verbalizes a manageable level of discomfort. The client exhibits signs of adequate GI perfusion with normal bowel sounds. The client maintains skin integrity.

The client exhibits signs of adequate GI perfusion with normal bowel sounds.

The nurse is assessing a client who has recently been given the first dose of a new anti-infective. What finding should lead the nurse to suspect that the client is experiencing a hypersensitivity reaction? The client is experiencing vertigo. The client's blood pressure is 141/88 mm Hg. The client recently had an episode of diarrhea. The client has a facial and trunk rash.

The client has a facial and trunk rash.

A female Asian client is admitted to the emergency department with a fractured femur. What cultural factor might affect client care? A male provider may not be allowed. The client may overreact to any procedure. The illness may be perceived as a sign of punishment. The client may not report pain.

The client may not report pain.

Which information should the nurse include in the teaching plan of a female client with bilateral adrenalectomy? The client will need to take steroids whenever her life involves physical or emotional stress. The client must decrease the dose of steroid medication carefully to prevent crisis. The client will require steroids only until her body can manufacture sufficient quantities. The client will need steroid replacement for the rest of her life.

The client will need steroid replacement for the rest of her life.

Which of the following is a reliable source for quantifying pain? The extent of the client's injury The client's vital signs The nature of the client's injury or condition The client's description of the pain

The client's description of the pain

The nurse is caring for the following infant after surgery. Which short term goal is the priority? The infant will bond with parents by holding and cuddling during each visit. The infant will maintain 5 to 7 moderately wet diapers daily. The infant will continue breastfeeding 3 to 5 times daily. The infant will remain infection free in the postoperative period.

The infant will remain infection free in the postoperative period.

homonymous hemianopsia

The loss of the right or left half of the field of vision in both eyes.

Perseveration

The tendency to persevere in, or stick to, one thought or action for a long time.

Professional regulations and laws that govern nursing practice are in place for what reason? To limit the number of nurses in practice To ensure that practicing nurses have strong interpersonal skills To protect the safety of the public To ensure that enough new nurses are always available

To protect the safety of the public

harlequin sign

a deep red color develops over one side of the body while the other remains pale. (caused by vasomotor disturbance, lasts from 1-20mins, clinically insignificant)

purine

a nitrogenous base that has a double-ring structure; one of the two general categories of nitrogenous bases found in DNA and RNA; either adenine or guanine

The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor? the need for a chest radiograph a need for close monitoring for the mother a normal pattern in infants of this age the need for an apnea monitor

a normal pattern in infants of this age

Avolition

a symptom of schizophrenia marked by apathy and an inability to start or complete a course of action

For a client with hyperthyroidism, treatment is most likely to include: a synthetic thyroid hormone. thyroid extract. a thyroid hormone antagonist. emollient lotions.

a thyroid hormone antagonist.

The client's blood sugar is 210 mg/dL (11.7 mmol/L) this morning, the nurse verifies a dose of 8 units of Regular insulin from the sliding scale. Which sites are acceptable for the nurse to administer the insulin? Select all that apply abdomen buttocks upper outer thighs deltoid upper outer arms

abdomen upper outer arms upper outer thighs

ascites

abnormal accumulation of fluid in the abdomen

Agenerase

amprenavir HIV protease inhibitor

A nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to prevent: gastric ulcers. diarrhea. abdominal distention. aspiration.

aspiration.

clozapine

atypical antipsychotic

scotoma

blind spot in vision

thrombosis

blood clot

tamponade

compression of a part by pressure or a collection of fluid

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend: consuming a low-carbohydrate, high-protein diet and avoiding fasting. increasing intake of vitamins B and D and taking iron supplements. increasing saturated fat intake and fasting in the afternoon. eating a candy bar if light-headedness occurs.

consuming a low-carbohydrate, high-protein diet and avoiding fasting.

When developing a teaching plan for the mother of an infant about introducing solid foods into the diet, which measure should the nurse expect to include in the plan to help prevent obesity? introducing the infant to the taste of vegetables by mixing them with formula or breast milk decreasing the amount of formula or breast milk intake as solid food intake increases using a large-bowled spoon for feeding solid foods during the first several months mixing cereal and fruit in a bottle when offering solid food for the first few times

decreasing the amount of formula or breast milk intake as solid food intake increases

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as elective. urgent. required. emergency.

emergency.

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to: establish a rapport to foster trust. place the client in full leather restraints. ensure safety by initiating suicide precautions. try to communicate with the client in writing.

ensure safety by initiating suicide precautions.

Extravasation

escape of blood from the blood vessel into the tissue

A client has had a cerebrovascular accident (CVA) which has affected the left side of the client's brain. The nurse should assess the client for: agnosia. expressive aphasia. apraxia. dyslexia.

expressive aphasia.

When caring for a client receiving haloperidol, the nurse should assess for which problem? hypersalivation extrapyramidal symptoms orthostasis oversedation

extrapyramidal symptoms

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods? high-calcium foods carbohydrates fats high-sodium foods

fats (GERD)

A client takes prednisone, as ordered, for rheumatoid arthritis. During follow-up visits, the nurse should assess the client for common adverse reactions to this drug, such as: abdominal cramps and diarrhea. tetany and tremors. anorexia and weight loss. fluid retention and weight gain.

fluid retention and weight gain.

When developing the plan of care for a toddler who has taken an acetaminophen overdose, which intervention should the nurse expect to include as part of the initial treatment? frequent blood level determinations tracheostomy gastric lavage electrocardiogram

gastric lavage

A positive tuberculin skin test indicates that a client: will develop full-blown tuberculosis. has an active case of tuberculosis. has produced an immune response. is actively immune to tuberculosis.

has produced an immune response.

When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, what should the nurse tell the parents to use to deliver the blows? palm of the hand fingertips entire hand heel of the hand

heel of the hand

For the first 72 hours after thyroidectomy surgery, a nurse should assess a client for Chvostek's sign and Trousseau's sign because they indicate: hypokalemia. hypercalcemia. hypocalcemia. hyperkalemia.

hypocalcemia.

A client has received an overdose of sympathomimetic agents. The nurse should assess the client for which late signs of an overdose? Select all that apply. bradycardia hypotension hypertension profound pyrexia seizures

hypotension seizures profound pyrexia

A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for: tremors. diaphoresis. hypotension. headache.

hypotension.

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? cardiogenic neurogenic anaphylactic hypovolemic

hypovolemic

Chorioretinitis

inflammation of the choroid and retina

Epiglottiditis

inflammation of the epiglottis

stomatitis

inflammation of the mouth

nystagmus

involuntary, jerking movements of the eyes

The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she: prefers to play with her sister. prefers to play team games. likes to play only with other girls. likes to play alone.

likes to play only with other girls.

auscultating pulmonic area

listen w/ diaphragm at left 2nd interspace near sternum

Furosemide (Lasix)

loop diuretic

The parent tells the nurse that an 8-year-old child is continually telling jokes and riddles to the point of driving the other family members crazy. The nurse should explain this behavior is a sign of: mastery of language ambiguities. inadequate parental attention. inappropriate peer influence. excessive television watching

mastery of language ambiguities.

The nurse is caring for a client with an injury to the thalamus. The nurse should plan to: keep patches on the client's eyes to prevent corneal abrasion. give higher doses of pain medication. avoid turning the client. monitor the temperature of the bathwater.

monitor the temperature of the bathwater.

pyloric stenosis

narrowing of the opening of the stomach to the duodenum

urethral stricture

narrowing or constriction of the urethra

An 18-year-old pregnant college student presented at the prenatal clinic for an initial visit at 14 weeks' gestation. The client's history revealed that when she was 12, she and her mother survived a plane crash that killed her father and sister. Since that time, she has taken fluoxetine 20 mg orally daily for posttraumatic stress disorder (PTSD) and depression. Her medication was recently increased to 40 mg daily because of reports of increased stress and suicide ideation. Which side effect of fluoxetine would the nurse judge to be the greatest risk for the client and her developing fetus at this stage in her pregnancy? decreased libido insomnia headache nausea/anorexia

nausea/anorexia

gentamicin toxicity

nephrotoxicity, ototoxicity, neuromuscular blockade

Gentamicin IV has been prescribed to treat a client's infection. The nurse should monitor the client for: ascites. cardiac arrhythmias. confusion. ototoxicity.

ototoxicity.

The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness? devotion overprotection insecurity mistrust

overprotection

anterior fontanel

part of fetal skull that closes at 12-18 months Anterior side of the skull Where the sagittal suture and coronal suture meet

biliary

pertaining to bile or the biliary tract

Spironolactone (Aldactone)

potassium sparing diuretic aldosterone antagonist

Which type of nursing diagnosis identifies an existing condition that the client is experiencing? syndrome risk problem-focused health promotion

problem-focused

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: provide access for wound irrigation. minimize development of scar tissue. decrease postoperative discomfort. promote drainage of wound exudates.

promote drainage of wound exudates.

The nurse has begun the intravenous infusion of the first dose of a client's prescribed antibiotic. A few minutes later, the client is diaphoretic, gasping for breath and has a heart rate of 145 beats per minute. After calling for help, what is the nurse's priority action? monitoring the client's vital signs at least every five minutes providing reassurance to the client administering intravenous antihistamines as prescribed protecting and maintaining the patency of the client's airway

protecting and maintaining the patency of the client's airway

hiatal hernia

protrusion of a part of the stomach upward through the opening in the diaphragm

The parents of a preschooler ask the nurse how to handle the child's temper tantrums. Which technique should the nurse include in the teaching plan? Select all that apply. ignoring the child trying to reason with the child putting the child in "time-out" spanking the child putting the child to bed

putting the child in "time-out" ignoring the child

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for ingestion of bismuth. pilonidal cyst. occult blood. recent foods ingested.

recent foods ingested.

erythema

redness of the skin

The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is: efficient pulmonary circulation. stimulation of the medullary respiratory center. relief from spasms of the diaphragm. relaxation of smooth muscles in the bronchioles.

relaxation of smooth muscles in the bronchioles.

pulmonic valve

right semilunar valve separating the right ventricle and pulmonary artery

oophorectomy

surgical removal of an ovary

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? engaging in physical activity keeping track of feelings in a journal playing a card game with other clients talking with the nurse

talking with the nurse

Which finding is an expected outcome for an elderly client following treatment for bacterial pneumonia? chest pain that is minimized by splinting the rib cage a respiratory rate of 25 to 30 breaths/min the ability to perform activities of daily living without dyspnea a maximum loss of 5 to 10 lb (2 to 5 kg) of body weight

the ability to perform activities of daily living without dyspnea

eructation

the act of belching or raising gas orally from the stomach

Selye's General Adaptation Syndrome

three-stage process which describes the body's reaction to stress: 1) alarm reaction, 2) resistance, 3) exhaustion

Alteplase (tPA)

thrombolytic agent

Type O

universal blood donor

The client with an above-the-knee amputation is to be fitted with a functioning prosthesis. The nurse has been teaching the client how to care for the residual limb. Which behavior would demonstrate that the client has an understanding of proper residual limb care? The client: removes the prosthesis whenever he sits down. washes and dries the residual limb daily. inspects the residual limb weekly with a mirror. applies powder to the residual limb.

washes and dries the residual limb daily.

Beclomethasone

QVAR

Diltiazem (Cardizem)

calcium channel blocker

leukocytosis

increase in the number of white blood cells

An athletic teenager who is diagnosed with infectious mononucleosis is told to avoid contact sports for 3 to 4 weeks. The teenager protests to the nurse and demands to know why sports must be avoided for so long. What is the best response by the nurse? "Your spleen is enlarged from your illness and could easily rupture with an injury." "Vigorous activity can further weaken your immune system." "Your illness causes fatigue and it's best for you to rest while recovering." "This helps prevent transmission of the infection to your teammates."

"Your spleen is enlarged from your illness and could easily rupture with an injury."

Gentamicin (Garamycin)

Aminoglycoside. Binds to 30s subunit. Gram +/- effective, better gram -. First line bacterial ocular tx. SE: SPK and delayed re-epithelialization.

A child with hemophilia is brought to the clinic with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, what should the nurse do? Administer aspirin for discomfort. Obtain a type and cross-match for platelets. Elevate the right knee. Immobilize the knee in a dependent position.

Elevate the right knee.

Which type of nursing diagnosis has a goal to increase well-being and enhance specific health behaviors? Risk Problem-focused Syndrome Health promotion

Health promotion

A group of students are reviewing information about disorders of the bladder and urethra. The students demonstrate understanding of the material when they identify which of the following as a voiding dysfunction? Urinary retention Cystitis Urethral stricture Bladder stones

Urinary retention

Aspirin

acetylsalicylic acid

The nurse should instruct the client to avoid which drug while taking metoclopramide hydrochloride? antacids anticoagulants antihypertensives alcohol

alcohol

Prednisone (Deltasone)

anti-inflammatory corticosteroid

When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? burning pain in the left calf coldness of the left foot and ankle numbness and tingling in the left leg aching pain in the left calf

coldness of the left foot and ankle

esophageal atresia

congenital absence of part of the esophagus. Food cannot pass from the baby's mouth to the stomach

An adolescent with insulin-dependent diabetes is being taught the importance of rotating the sites of insulin injections. The nurse should judge that the teaching was successful when the adolescent identifies which complication that can result of using the same site? destruction of the tissue and too-rapid insulin uptake development of resistance to insulin and need for increased amounts destruction of nerves and painful neuritis destruction of the fat tissue and poor absorption

destruction of the fat tissue and poor absorption

Oxygen and carbon dioxide move between the alveoli and the blood by: hyperosmolar pressure. negative pressure. osmosis. diffusion.

diffusion. (O2 and CO2)

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: wearing an appliance pouch only at bedtime. increasing fluid intake to prevent dehydration. consuming a low-protein, high-fiber diet. taking only enteric-coated medications.

increasing fluid intake to prevent dehydration.

pleurisy (pleuritis)

inflammation of the pleural membrane characterized by a stabbing pain that is intensified by coughing or deep breathing

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first? obtain the child's vital signs. ask the parent about medication allergies. inquire about the health of siblings at home. institute droplet precautions.

institute droplet precautions.

When preparing to administer a tap water enema, in which position should the nurse place the client? semi-Fowler's supine right lateral left Sims'

left Sims'

A client has a history of macular degeneration. While in the hospital, the priority nursing goal will be to: promote a safe, effective care environment. provide education regarding community services for clients with adult macular degeneration (AMD). improve vision. provide health care related to monitoring his eye condition.

promote a safe, effective care environment.

Holmes and Rahe

stress and coping; used "social readjustment scale" to measure stress

A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction? "Client verbalizes an understanding of the need to seek emergency help if his heart rate increases markedly while at rest." "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." "Client performs relaxation exercises three times per day to reduce stress." "Client walks 4 miles (6.4 kilometers) in 1 hour every day."

"Client walks 4 miles (6.4 kilometers) in 1 hour every day."

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? "I'll use an electric razor to shave." "I'll eat four servings of fresh, dark green vegetables every day." "I'll report unexplained or severe bruising to my doctor right away." "I'll watch my gums for bleeding when I brush my teeth."

"I'll eat four servings of fresh, dark green vegetables every day."

A 15-year-old girl is sent to the school nurse with reports of dizziness and nausea. While assessing the girl, who denies any health problems, the nurse smells alcohol on her breath. Which response by the nurse is most appropriate? "Tell me everything that you have had to eat and drink yesterday and today." "I know that high school is stressful, but drinking alcohol is not the best way to handle it." "Do not tell me that you have been drinking alcohol before you came to school this morning!" "What is the real reason that you are feeling sick this morning?"

"Tell me everything that you have had to eat and drink yesterday and today."

A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client: "The radiation is necessary to treat your tumor." "The radioactivity will gradually decrease, and you will be discharged when the radioactive material reaches its half-life." "The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." "Careful shielding prevents the area above your waist from radioactivity."

"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain."

A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is dark pink and moist. What is the best response to the child's parents about the appearance of the stoma? "The stoma looks healthy; continue your present care." "The stoma is irritated; change the appliance more frequently." "The stoma is too moist; we must try to prevent skin breakdown." "The stoma looks infected; you need an antibiotic cream."

"The stoma looks healthy; continue your present care."

A child with iron deficiency anemia is ordered ferrous sulfate, an oral iron supplement. When teaching the child and parent how to administer this preparation, the mother asks why she needs to mix the supplement with citrus juice. Which response by the nurse is best? "Having food and juice in the stomach helps with iron absorption." "The vitamin C in the citrus juice helps with iron absorption." "There isn't a specific reason for it." "The citrus juice counteracts the unpleasant taste of the iron."

"The vitamin C in the citrus juice helps with iron absorption."

An older adult has asthma and asks the nurse about taking the pneumonia vaccine. The nurse should tell the client: "You will need the vaccine only if you have frequent asthma attacks." "You do not need the vaccine unless you are exposed to pneumonia." "You should not have the vaccine because it is contraindicated in asthma." "You should receive the vaccine."

"You should receive the vaccine."

A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, "It is that school nurse again. She has done nothing but try to make trouble for our family since my son started school. And now you are in on it." The nurse should respond by saying: "The school nurse is concerned about your son and is only doing her job." "You sound pretty angry with the school nurse. Tell me what has happened." "Let me tell you why your son was referred, and then you can tell me about your concerns." "You do not need to feel singled out. We see a number of children who go to your son's school."

"You sound pretty angry with the school nurse. Tell me what has happened."

Fluoxetine (Prozac)

Antidepressant, SSRI

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses? Behavioral deviations result from an incongruence between verbal and nonverbal communication. The first 6 years of a person's life determine personality. Behavior that is reinforced will be perpetuated. All behavior has meaning.

All behavior has meaning.

Which measure would be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery? Apply ice compresses. Blow the nose gently. Apply warm, moist compresses. Lie in a prone position.

Apply ice compresses.

The client with obsessive-compulsive disorder eats slowly and is always the last to finish lunch, which makes it difficult for the group to start at 1300. Which approach would be the best plan of action for this problem? Inform the client that he will have to eat faster so that the group can begin on time. Change the time of the group to accommodate the client. Begin the group without the client so that he will have ample time for his lunch. Arrange for the client to start eating earlier than the others.

Arrange for the client to start eating earlier than the others.

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client? Tell family members to try to stay away from the client. Disinfect all clothing and eating utensils. Ask family members to wash their hands frequently. Spray the house to eliminate infected insects.

Ask family members to wash their hands frequently.

A 6-year-old child is being discharged from the emergency department after being diagnosed with varicella (chickenpox). The nurse knows the parents need more medication teaching when they state they will give the child which over-the-counter medication? Ibuprofen Naproxen Acetaminophen Aspirin

Aspirin

A parent brings a 3-month-old infant to the clinic, reporting that the infant has a cold, is having trouble breathing, and "just does not seem to be acting right." Which action should the nurse take first? Weigh the infant. Assess the infant's oxygen saturation. Obtain more information from the father. Check the infant's heart rate.

Assess the infant's oxygen saturation.

Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter? Serotonin Acetylcholine Dopamine Glutamate

Dopamine

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants? Encourage parents to be present during the treatment. Tell the infant that it will be over within a minute. Ask a child specialist to be present during treatment. Provide the infant with soft toys or a feeding bottle.

Encourage parents to be present during the treatment.

When providing care to a patient with anxiety, which intervention would be the highest priority? Exploring appropriate coping strategies Improving the patient's sleeping patterns Ensuring adequate nutritional intake Administering prescribed anti-anxiety medications

Exploring appropriate coping strategies

A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? I.V. catheter insertion Instilling eye drops Colostomy irrigation Nasogastric tube irrigation

I.V. catheter insertion

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? IV II I III

II

Which element is involved in the planning phase of the nursing process? Carry out the nursing orders Complete health history Identify measurable outcomes Identify collaborative problems

Identify measurable outcomes

The unlicensed assistive personnel (UAP) tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse? Put up all four side rails on the bed. Administer the client's sedative as ordered. Contact the physician for a restraint order. Initiate use of a bed alarm.

Initiate use of a bed alarm.

Which behavior typical of children with autism spectrum disorder (ASD) requires you to maintain special care to keep them safe? A fascination with bright colors Loss of hearing for high frequencies A craving for salt Insensitivity to pain

Insensitivity to pain

An inmate from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation? Perform morning care while the client is handcuffed. Ask another nurse to accompany the nurse into the room. Insist that the officers stay in the room at all times. Ask one of the officers to remove the handcuffs.

Insist that the officers stay in the room at all times.

A client is scheduled for a creatinine clearance test. What should the nurse do? Instruct the client about the need to collect urine for 24 hours. Prepare to insert an indwelling urethral catheter. Instruct the client to force fluids to 3,000 mL/day. Provide the client with a sterile urine collection container.

Instruct the client about the need to collect urine for 24 hours.

At an initial prenatal visit the client tells the nurse that her last menstrual period started on April 14th. Using Naegele's rule, the nurse determines the woman's estimated due date is when? February 14 February 21 January 21 January 28

January 21

Which areas of discharge planning are important to ensuring client safety? Select all that apply. Social status Special diet instructions Payment of care Medication education Food-drug interactions

Medication education Food-drug interactions Special diet instructions

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? Measure blood urea nitrogen and serum creatinine levels. Monitor the appearance, size, and number of stools. Monitor vital signs every 4 hours. Measure intake and output.

Monitor the appearance, size, and number of stools.

Meperidine (Demerol)

Opioid Analgesic

A new surgical patient has been prescribed an opioid analgesic intravenously for pain control. The nurse should be aware of which most serious adverse effect of this medication? Nausea and vomiting Pruritus Respiratory depression Constipation

Respiratory depression

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Leave the restraints on and talk with her, explaining that she must calm down. Sedate her with sleeping pills and leave the restraints on. Talk with the client's family about taking her home because she is out of control. Take the restraints off, stay with her, and talk gently to her.

Take the restraints off, stay with her, and talk gently to her.

A client with ulcerative colitis is scheduled for a bowel resection. The client is receiving parenteral nutrition prior to surgery. Which of the following is the best explanation for the nurse to give the client about the need for parenteral nutrition? The client has lost 15% of body weight and has prolonged diarrhea. The client cannot absorb nutrients through the colon. It will help restore fluid and electrolyte imbalances. It will help the client have surgery as soon as possible.

The client has lost 15% of body weight and has prolonged diarrhea.

A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply. The client uses the bedpan. The client has a "do not resuscitate" prescription. The client needs oxygen at 2 L/minute. The client has four grandchildren. The client has been in normal sinus rhythm for 6 hours.

The client needs oxygen at 2 L/minute. The client has a "do not resuscitate" prescription. The client uses the bedpan. The client has been in normal sinus rhythm for 6 hours.

After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? The normal saline irrigant is infusing at a rate of 50 drops/minute. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned. The client reports bladder spasms and the urge to void. The urine in the drainage bag appears red to pink.

The client reports bladder spasms and the urge to void.

A client reports to the primary health care facility for routine physical examination after cardiac rehabilitation that followed myocardial infarction. Keeping in mind that the client speaks English as a second language, how should the nurse conduct the interview? The nurse should sit at a long distance from the client. The nurse should ask closed-ended questions. The nurse should ask the client to express himself emotionally. The nurse should avoid using complex medical terminology.

The nurse should avoid using complex medical terminology.

The nurse has observed that a client's food intake has diminished in recent days. What intervention should the nurse perform in order to stimulate the client's appetite? Offer nutritional supplements and explain the potential benefits of each. Try to ensure that the client's food is attractive and sufficiently warm. Offer larger meals and encourage the client to eat as much as is comfortable. Reduce the frequency of meals in order to allow the client to develop an appetite.

Try to ensure that the client's food is attractive and sufficiently warm.

A charge nurse is making assignments for a group of children on a pediatric unit. The nurse should avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus (RSV) and: a 1-year-old with a heart defect. a 9-year-old 8 hours post-appendectomy. an 18-month-old with RSV. a 6-year-old with sickle cell crisis.

a 1-year-old with a heart defect.

When assessing an infant with an undescended testis, the nurse should be alert for which symptom? poor weight gain abnormal lower extremity reflexes a history of frequent emesis a bulging in the inguinal area

a bulging in the inguinal area

While reading a client's chart, the nurse notices that the client is documented to have paresthesia. The nurse plans care for a client with absence of muscle tone. involuntary twitch of muscle fibers. abnormal sensations. absence of muscle movement suggesting nerve damage.

abnormal sensations.

matter-of-fact

accepting of conditions; not fanciful or emotional

The proper use of the principles of body mechanics: acts as a safeguard against legal action by the client. primarily protects the client from injury. acts to prevent injury to the client and/or nurse. Primarily protects the nurse from injury.

acts to prevent injury to the client and/or nurse.

Naegele's Rule

add 7 days to LMP, subtract 3 months, add 1 year

A client who had a cesarean birth 1 day ago asks for pain medication when the nurse enters the room to perform her shift assessment. The client states that her pain level is an 8 on a 0-to-10-point scale. The priority of care should be for the nurse to: administer any ordered pain medication. have the client get up to wash so she can make the bed. tell the client the pain will subside if she relaxes. start the postpartum assessment.

administer any ordered pain medication.

Immediately after receiving an injection of bupivacaine, the client becomes restless and nervous and reports a feeling of impending doom. The nurse should: ask the client explain these feelings. assess the client's vital signs. reassure the client that it is normal to feel restless before a procedure. administer epinephrine.

assess the client's vital signs.

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? cheese omelet and bacon cheeseburger and french fries gelatin salad and tea chicken and orange slices

chicken and orange slices

polycythemia vera

condition characterized by too many erythrocytes; blood becomes too thick to flow easily through blood vessels

The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is: a cervical cap. spermicides. a diaphragm. condoms.

condoms. (best barrier)

A primigravid client at 38 weeks' gestation is admitted to the labor suite in active labor. The client's physical assessment reveals a chlamydial infection. The nurse explains that if the infection is left untreated, the neonate may develop which problem? conjunctivitis harlequin sign brain damage heart disease

conjunctivitis

A 24-year-old client admitted to the hospital is suspected of having an ectopic pregnancy. On admission, which factor would be most important to assess? sexual practices use of a diaphragm type of oral contraceptives date of last menstrual period

date of last menstrual period

A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which should the nurse include as the action of spermicides when teaching the client? destruction of spermatozoa before they enter the cervix prevention of spermatozoa from entering the uterus a change in vaginal pH from acidic to alkaline slowing of the movement of the migrating spermatozoa

destruction of spermatozoa before they enter the cervix

When developing a therapeutic relationship with the client who has withdrawn from alcohol, the nurse should first set goals with the client that involve: listing reasons for alcohol abuse. discussing family role responsibilities. delving into painful childhood experiences. developing effective coping skills.

developing effective coping skills.

A client who has ulcerative colitis says to the nurse, "I cannot take this anymore; I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I do not know how to deal with this." Based on these comments, the nurse should determine the client is experiencing: a sense of isolation. disturbed thought. extreme fatigue. difficulty coping.

difficulty coping.

When obtaining a nursing history from parents who are suspected of abusing their child, which characteristic about the parents should the nurse particularly assess? difficulty with controlling aggression ability to relate the child's developmental achievements self-blame for the injury to the child attentiveness to the child's needs

difficulty with controlling aggression

A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). The nurse should: withhold the next dose of antihypertensive medication. encourage the client to increase fluid intake. encourage the client to eat at least half of a banana per day. restrict the client's sodium intake.

encourage the client to increase fluid intake.

A client is having a level 2 ultrasound. A nurse knows that physicians order this procedure: to satisfy the client's curiosity. to provide images of the fetus for family and friends. to assess the correct date of gestation. for diagnostic purposes when fetal development is in question.

for diagnostic purposes when fetal development is in question.

A nurse is caring for a toddler who has just been immunized. When teaching the child's parents about potential adverse effects, the nurse should instruct the parents to immediately report: generalized urticaria. pain at the injection site. local swelling at the injection site. mild temperature elevation.

generalized urticaria.

The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. The most appropriate goal for this client is to: learn new self-care skills. adapt to new levels of energy. gradually increase activity tolerance. increase mobility.

gradually increase activity tolerance.

The nurse is inspecting the client's abdomen (see the accompanying image). The nurse should document that the client's abdomen: is flat and symmetrical. shows striae. has an aortic pulsation. reveals a hernia.

is flat and symmetrical.

The nurse notes grapefruit juice on the breakfast tray of a client taking repaglinide. The nurse should: contact the manager of the Food and Nutrition Department. request that the dietitian discuss the drug-food interaction of repaglinide and grapefruit juice. substitute a half grapefruit in place of grapefruit juice. remove the grapefruit juice from the client's tray and bring another juice of the client's preference.

remove the grapefruit juice from the client's tray and bring another juice of the client's preference.

A woman is taking oral contraceptives. The nurse teaches the client to report which complication? mild headache breakthrough bleeding weight gain of 3 lb (1.4 kg) severe calf pain

severe calf pain

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? urine output greater than 35 mL/hour an increase in body weight fluid intake less than urinary output blood pressure of 90/60 mm Hg

urine output greater than 35 mL/hour

Atropine Sulfate

use as first line defense in sinus bradycardia 0.5mg every 3-5 minutes as needed MAX is 3mg ( think alive gets 0.5) do not use if hypothermia

Allopurinol (Zyloprim)

xanthine oxidase inhibitor anti-gout

A nurse should expect to administer which medication to a client with gout? Colchicine Aspirin Furosemide Calcium gluconate

Colchicine

A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior? Perseveration Word salad Avolition Tangential

Avolition

A client who has been arrested eight times in the past year for driving under the influence is admitted for alcohol treatment by judicial mandate. Which statement is most suggestive of alcohol dependence? "I've been known to have a beer or two at a ballgame." "I'm a family man, and my family doesn't drink." "I drink just a little on rare social occasions." "I never drink alone, so I don't have a problem."

"I never drink alone, so I don't have a problem."

The healthcare provider prescribes venlafaxinefor the client. The nurse explains the purpose of the medication to the client. The client asks the nurse, "If I start taking the pills, will I have to take them the rest of my life?" Which would be the nurse's most accurate and therapeutic reply? "I would hope not!" "The medication prescribed is safe and routine." "Now, do not think that way." "After your symptoms decrease, the need for medication will be reevaluated."

"After your symptoms decrease, the need for medication will be reevaluated."

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." "There's no other option but to assume the knee-chest position." "I'll report your concerns to the physician." "Lying on your left side will be fine during the procedure."

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask? "How long have you heard the voices?" "Why are the voices starting again?" "When do you hear the voices?" "Are you going to hurt yourself?"

"Are you going to hurt yourself?"

The nurse is teaching the Crede maneuver to a client who has difficulty urinating. Which nursing teaching is appropriate? "Attempt to void as soon as you awake from sleep." "Run water from your faucet while you are attempting to urinate." "Visualize an ocean or a river as you sit on the toilet." "Bend forward and apply pressure over your bladder."

"Bend forward and apply pressure over your bladder."

A 9-month-old infant whose parents have emigrated from Mexico presents in the clinic with severe dehydration from vomiting. The infant was seen in the clinic just 3 days ago for a well-child visit, but now the family seems very distrustful of the health care team. The nurse should ask the parents: "Has immigration been causing you problems?" "Are you afraid your baby will be taken from you?" "Have you been speaking with a healer?" "Did anything concern you about your last visit?"

"Did anything concern you about your last visit?"

While reviewing a client's chart, the nurse notes the client has been experiencing enuresis. To assess whether this remains an ongoing problem for the client, the nurse asks which question? "Is it painful when you urinate?" "Does it burn when you urinate?" "Do you have a strong desire to void?" "Do you urinate while sleeping?"

"Do you urinate while sleeping?"

The nurse admits a 10-year-old who has just eaten lobster and has hives over much of the body. In collecting data regarding this child, which question should the nurse ask the caregiver first? "Is your child allergic to peanuts or other foods?" "Does anyone in your family have any food allergies?" "Has the child ever eaten shellfish before now?" "Have you ever given your child antihistamines?"

"Has the child ever eaten shellfish before now?"

Which statement would lead the nurse to determine that a client lacks understanding of her acute cardiac illness and the ability to make changes in her lifestyle? "I talked with my husband yesterday about working on a new budget together." "No more working 10 hours a day for me unless it is an emergency." "I already have my airline ticket, so I will not miss my meeting tomorrow." "These relaxation tapes sound okay; I will see if they help me."

"I already have my airline ticket, so I will not miss my meeting tomorrow."

Which statement by an adolescent receiving gentamicin should the nurse interpret as indicating drug toxicity? "I am feeling dizzy." "I have not moved my bowels in 3 days." "I have no appetite." "I urinate a lot now."

"I am feeling dizzy."

A client with posttraumatic stress disorder states, "You do not know what I have been through. What can you do?" The nurse should respond: "Perhaps you will feel better if you can become interested in a hobby once again." "I need to refer you to a survivors' group where you will feel more comfortable." "I would like to help you if you will let me." "I have not been through what you have, but I will be better able to understand if you tell me more about it."

"I have not been through what you have, but I will be better able to understand if you tell me more about it."

One of the clients in group with a dual diagnosis of chronic schizophrenia and alcohol abuse states, "I am not going to take medicine every day." Which response by the nurse would be most appropriate? "Would anyone in group like to discuss this?" "Let us discuss this tomorrow if we have time." "I hear you say that you do not like taking medication daily." "Your health care provider wants you to take your medication everyday."

"I hear you say that you do not like taking medication daily."

A client with diabetes is explaining to the nurse how he cares for the feet at home. Which statement indicates the client needs further instruction on how to care for the feet properly? "I inspect my feet once a week for cuts and redness." "I should not go barefoot, even in my home." "I am not allowed to use a heating pad on my feet." "It is important to dry my feet carefully after my bath."

"I inspect my feet once a week for cuts and redness."

The client with mania is irritable and insulting to an unlicensed assistive personnel (UAP). The UAP states, "I cannot believe Mark is so rude. Should he not be overly happy?" Which response by the nurse should help the UAP understand the client's behavior? "I will go and speak to him about his behavior and make sure he understands that he needs to control what he is saying." "We must reprimand Mark for doing that because there is no reason for him to behave like that." "It is our responsibility to listen to him even though we might not like what he's saying." "I know it is difficult, but Mark is a client whose irritable mood is a symptom of his mania."

"I know it is difficult, but Mark is a client whose irritable mood is a symptom of his mania."

The client tells the nurse that she stopped taking olanzapine 2 weeks ago because she is better and wants "to make it on my own without this darned medicine." What would be the nurse's most therapeutic response? "You are a smart girl. You know what will happen if you do not take your medication. Why do you want to stop?" "I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?" "You have told me about other times like this when you stopped taking your medication and you got sick again. You should know better by now." "Maybe you are ready for a short holiday from the olanzapine. I will talk it over with the healthcare provider. But you need to keep taking it until I talk with your health care provider"

"I know you get tired of taking the medication, especially when you are doing well. Is there any special reason you decided to stop right now?"

After a period of unsuccessful treatment with amitriptyline, a woman diagnosed with depression is switched to tranylcypromine. Which statement by the client indicates the client understands the side effects of tranylcypromine? "I must refrain from strenuous exercise." "I should decrease my intake of foods containing sugar." "I must refrain from eating aged cheese or yeast products." "I need to increase my intake of sodium."

"I must refrain from eating aged cheese or yeast products."

A client comes to the mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? "I need to keep my appointment here at the clinic this week for a blood test." "I can take over-the-counter sleeping medication if I have trouble sleeping." "I need to call my health care provider in 2 weeks for a checkup." "I can drink alcohol with this medication."

"I need to keep my appointment here at the clinic this week for a blood test."

Which statement indicates that the client needs further teaching about taking medication to control cancer pain? "It is okay to take my pain medication even if I am not having any pain." "I should take my medication around-the-clock to control my pain." "I should skip doses periodically so I do not get hooked on my drugs." "I should contact the oncology nurse if my pain is not effectively controlled."

"I should skip doses periodically so I do not get hooked on my drugs."

The nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. Which statement would indicate that the client has understood the instructions? "I wish I did not have to give up swimming." "I will avoid lying down after a meal." "If I wear a girdle, I will have more support for my stomach." "I can still enjoy my potato chips and cola at bedtime."

"I will avoid lying down after a meal."

After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching? "I will drink adequate fluids separate from my meals or snacks." "I will eat dry crackers or toast before arising in the morning." "I will snack on a small amount of carbohydrates throughout the day." "I will eat two large meals daily with frequent protein snacks."

"I will eat two large meals daily with frequent protein snacks."

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which statement made by the nurse is appropriate? "Let me speak with your husband. He might be okay with it." "We have a psychiatrist available for sexual dysfunction therapy." "Give him time. He will get over it." "I would like to refer you to a support group so that you can speak with others with similar problems."

"I would like to refer you to a support group so that you can speak with others with similar problems."

A client is participating in a cardiac research study in which his physician is directly involved. Which statement by the client indicates a need for additional teaching about his rights as a research study participant? "I may withdraw from the study at anytime, but if I do, I won't receive the compensation I was promised." "My confidentiality won't be compromised by this study." "I understand that there may be risks associated with this study." "I'll have to find a new physician if I don't complete this study."

"I'll have to find a new physician if I don't complete this study."

A 15-year-old female who is 26 weeks pregnant has been admitted to the labor and delivery unit with a complaint of abdominal pain. Her parents want to speak with a nurse about to her condition. How should the nurse respond? "She is experiencing Braxton Hicks contractions and is too young to understand the difference between these contractions and labor pains." "I'll need a signed consent from your daughter to give you medical information." "She will be OK. It's just a stomachache." "The physician can give you more information without consent."

"I'll need a signed consent from your daughter to give you medical information."

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

"I'll play card games with my friends."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Take in a small amount of air very quickly and then exhale as quickly as possible." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A client with diabetes is explaining to the nurse how to care for the feet at home. Which statement indicates that the client understands proper foot care? "When I injure my toe, I will plan to put iodine on it." "It is important to dry my feet carefully after my bath." "It is okay to go barefoot in the house." "I should inspect my feet at least once a week."

"It is important to dry my feet carefully after my bath."

A client who tells the nurse that she would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful? "When my temperature remains elevated for 7 days, ovulation has occurred." "Because this method is not very effective, I should use other forms of contraception too." "It is important to take my temperature at about the same time every morning before arising." "Taking my temperature in the evening just after dinner or before I go to bed is best."

"It is important to take my temperature at about the same time every morning before arising."

A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? "It will hasten the death of the patient." "It will enable the patient to remain home if that is what is desired." "It will use artificial means of life support if the patient requests it." "It will prolong life in a dignified manner."

"It will enable the patient to remain home if that is what is desired."

A client taking clozapine states, "I do not like feeling so sedated during the day. I can hardly keep my eyes open." Which response by the nurse would be most appropriate? "Going to bed earlier at night might help." "Sleep as long as you need to and nap fairly often." "Let us talk to your health care provider about taking most of the drug at bedtime." "Try waking up an hour earlier to see if that helps."

"Let us talk to your health care provider about taking most of the drug at bedtime."

After being hospitalized for status asthmaticus, a child, age 5, is discharged with prednisone and other oral medications. Two weeks later, when the child comes to the clinic for a checkup, the nurse instructs the mother to gradually decrease the dosage of prednisone, which will be discontinued. The mother asks why prednisone must be discontinued. How should the nurse respond? "Steroids increase the appetite, leading to obesity with prolonged use." "The child may develop a hypersensitivity to steroids with continued use." "Long-term steroid therapy may interfere with a child's growth." "Prolonged steroid use may cause depression."

"Long-term steroid therapy may interfere with a child's growth."

A 20-year-old woman will soon begin taking oral contraceptives for the first time. What advice should the nurse provide to this client? "It will take 10 to 12 weeks before the birth control pills will actually prevent pregnancy, so be vigilant with other contraceptives until then." "Some women get some pain in their chest or abdomen when they take oral contraceptives, but this will pass as your body gets used to them." "You need to carefully consider whether you might want to get pregnant later in your life." "Make sure to seek care quickly if you experience bad headaches, calf pain, or changes in vision."

"Make sure to seek care quickly if you experience bad headaches, calf pain, or changes in vision."

A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which client statement indicates effective teaching? "After this procedure, I must abstain from intercourse for at least 3 weeks." "Both of my ovaries will be removed during the tubal ligation procedure." "Reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%." "My fallopian tubes will be tied off through a small abdominal incision."

"My fallopian tubes will be tied off through a small abdominal incision."

A nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding? "My son can't eat wheat, rye, oats, or barley." "My son must avoid potatoes, rice, and cornstarch." "My son can safely eat frozen and packaged foods." "My son needs a gluten-rich diet."

"My son can't eat wheat, rye, oats, or barley."

The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I do not know what to do!" After teaching the parent about ways to manage this behavior, which statement indicates that the nurse's teaching was successful? "Next time she screams and throws her legs, I'll ignore the behavior." "I will allow her to have what she wants once in a while." "When she behaves like this, I will tell her that she is being a bad girl." "I'll explain why she cannot have what she wants."

"Next time she screams and throws her legs, I'll ignore the behavior."

The nurse is instructing a community education class on stress. The nurse asks the participants, "Is all stress bad for you?" Which answer by the participants is most accurate? "No, not all stress is bad, but all stress can make a person sick." "No, the right amount of stress can be motivating to accomplish goals." "Yes, all stress is bad but in varying degrees depending on the nature." "Yes, all stress has negative effects on the body systems."

"No, the right amount of stress can be motivating to accomplish goals."

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. The nurse should tell the mother? "Circulation to the baby's heart is improved with humidified oxygen." "Oxygen is drying to the mucous membranes unless it is humidified." "The humidity helps to prevent viral or bacterial pneumonia." "The humidity promotes expansion of the neonate's immature lungs."

"Oxygen is drying to the mucous membranes unless it is humidified."

Which statement by a parent indicates the best understanding of why raisins should be limited as a snack food in toddlers? "Raisins are hard to digest entirely." "Raisins are low in nutritional value." "Raisins can increase tooth decay." "Raisins are easy to choke on."

"Raisins can increase tooth decay."

The nurse in an outpatient clinic is conducting a follow-up assessment on a child who had a severe streptococcal infection 1 week ago. The client is doing better, and the nurse is providing teaching to the parents about continuing to monitor the client for possible complications of the infection. Which information is most important for the nurse to discuss with the parents? "Expect the child's weight to decrease over the next 2 weeks." "The infection may cause the child to have some burning with urination." "Fevers may continue to occur as the body recovers from the infection." "Return immediately if acute flank or mid-abdominal pain occurs."

"Return immediately if acute flank or mid-abdominal pain occurs."

A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the client's behavior? "Reviewing your losses is a way to help you work through your grief and loss." "It is a simple escape mechanism to go back and live again in happier times." "Be patient. It takes time to adjust to such a massive loss." "Talking about the past is a form of denial. We have to help you focus on today."

"Reviewing your losses is a way to help you work through your grief and loss."

Two days following a colon resection, an elderly client shows new onset of confusion. When contacting the health care provider (HCP), the nurse should make which recommendation? "Shall I collect and send a urine sample for culture and sensitivity?" "Do you want a CT scan to rule out stroke?" "May we have a prescription for restraining this client?" "Would you like a stat potassium level done?"

"Shall I collect and send a urine sample for culture and sensitivity?"

A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which statement made by the mother would be most important? "She gets constipated often." "She spits up occasionally." "Her rectal temperature is 99.4° F (37.4 °C)." "Sometimes she gets colds."

"She gets constipated often."

On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." "Bunions are caused by a metabolic condition called gout." "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth." "Bunions are congenital and can't be prevented."

"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow."

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? "Do you take any medications on a regular basis?" "What were you doing when the pain started?" "Do you have a history of GERD (gastroesophageal reflux disease)?" "Have you ever had pain like this before?"

"What were you doing when the pain started?"

The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"? "You're very concerned when you think about how this will change your life." "I don't understand. You have survived this heart attack. Why do you think life will never be the same?" "This heart attack really saddens you." "Hope has important healing powers. You need to be a little more hopeful of your recovery from this heart attack."

"You're very concerned when you think about how this will change your life."

A nurse is reviewing discharge instructions with the parents of an adolescent who sustained a head injury to the frontal lobe of the brain. When discussing possible consequences of the injury, which of the following is the most important information to give the parents? "Your child may develop sudden problems with vision." "Your child will gradually lose the ability to hear." "Your child may mention unusual numbness and tingling." "Your child may exhibit drastic personality changes."

"Your child may exhibit drastic personality changes."

A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation? "Your verbal threats to the client are legally considered assault." "I will have to report you for unprofessional behavior toward a client." "Could you clarify for me whether you were joking with the client?" "I think you need to review therapeutic communication techniques."

"Your verbal threats to the client are legally considered assault."

Loperamide (Imodium)

*class*: antidiarrheal *Indication* acute diarrhea, decrease drainage post ileostomy *Action*: inhibits peristalsis, reduces the volume of feces while increasing the bulk and viscosity *Nursing Considerations*: -may lead to constipation - insure proper use - assess bowel function - assess fluid and electrolyte levels

The nurse is to administer 1,200 mg of an antibiotic. The drug is prepared with 6 g of the drug in 2 mL of solution. The nurse should administer how many milliliters of the drug? Record your answer using one decimal place.

0.4

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? 0.9% NaCl 5% NaCl Lactated Ringer solution 0.45% NaCl

0.45% NaCl

The nurse has received a prescription to add 20 mEq of potassium chloride to a 1,000-mL bottle of IV fluid. The nurse has a 30-mL, multiple-dose vial of potassium chloride. The label reads 2 mEq/mL. How many milliliters should the nurse add to the IV fluid? Record your answer using a whole number.

10

When vasoactive medications are administered, the nurse must monitor vital signs at least how often? 45 minutes 30 minutes Hourly 15 minutes

15 minutes

A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer: I.V. bolus of dextrose 50%. I.M. or subcutaneous glucagon. 10 units of fast-acting insulin. 15 to 20 g of a fast-acting carbohydrate such as orange juice.

15 to 20 g of a fast-acting carbohydrate such as orange juice.

A client is receiving magnesium sulfate at 3 g/h intravenously. The bag of 1,000 mL normal saline contains 20 g of magnesium sulfate. How many mL/hour should the nurse set the IV pump rate in order to deliver 3 g/h? Record your answer using a whole number.

150

An infant who weighs 7.5 kg is to receive ampicillin 25 mg/kg intrvenously every 6 hours. How many milligrams would the nurse administer per dose? Record your answer using one decimal place.

187.5

After laparoscopic cholecystectomy, a 43-year-old client reports pain and nausea. The nurse is preparing meperidine hydrochloride 75 mg and promethazine hydrochloride 12.5 mg to be administered I.M. in the same syringe. If the label on the meperidine reads 50 mg/ml and the label on the promethazine reads 25 mg/ml, how many milliliters should the nurse have in the syringe after the correct doses are drawn up? Record your answer using a whole number.

2

The physician has ordered an IV of 3000 mL of 0.9% sodium chloride to be infused over the next 24 hours. The nurse uses IV tubing that has a drip factor of 10. Calculate the drops per minute needed to deliver the correct amount of IV fluid. Record your answer using a whole number.

21

After receiving an oral dose of codeine for an intractable cough, a client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond? 2.5 hours 4 hours 1 hour 30 minutes

30 minutes

The nurse receives a physician's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31

A physician orders cefoxitin, 1 g in 100 ml of 5% dextrose in water, to be administered I.V. A nurse determines that the recommended infusion time is 15 to 30 minutes. The available infusion set has a calibration of 10 drops/ml. To infuse cefoxitin over 30 minutes, which drip rate should the nurse use? 30 drops/minute 33 drops/minute 66 drops/minute 10 drops/minute

33 drops/minute

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? 20 gtt/min 30 gtt/min 40 gtt/min 50 gtt/min

50 gtt/min

The nurse is caring for four clients. For which client is a sitz bath most appropriate? 73-year old with pneumonia who can get up to bedside commode 51-year old with hemorrhoids 60-year old who is 1-day post-op from a knee replacement 42-year old recovering from a C-section delivery

51-year old with hemorrhoids

A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age? 6 months 8 months 10 months 2 months

6 months

To be effective, percutaneous transluminal coronary angioplasty (PTCA) must be performed within what time frame, beginning with arrival at the emergency department after diagnosis of myocardial infarction (MI)? 30 minutes 60 minutes 9 days 6 to 12 months

60 minutes

A physician orders an intravenous infusion of dextrose 5% in quarter-normal saline solution (D5.25 NSS) to be infused at 7 ml/kg/hour for a 10-month-old infant. The infant weighs 22 lb (10 kg). How many milliliters of the ordered solution would the nurse infuse each hour? Record your answer using a whole number.

70

Junctional Tachycardia

>60 bpm (ms. K; 150-250) - KEY: will be regular (consistent) - AV junction produces a rapid sequence of QRS-T cycles - p-wave often inverted/buried/follow QRS A rhythm that begins in the AV bundle with a ventricular rate of more than 100 beats/min.

When teaching a primigravid client at 24 weeks' gestation about the diagnostic tests to determine fetal well-being, which information should the nurse include? Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks' gestation. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample. A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity. A reactive nonstress test is an ominous sign and requires further evaluation with fetal echocardiography.

A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity.

The nurse observes a client's uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest? A diet high in fruits and vegetables A low-sodium diet A diet high in calcium A low-purine diet

A low-purine diet

Glutamate

A major excitatory neurotransmitter; involved in memory

Acetylcholine

A neurotransmitter that enables learning and memory and also triggers muscle contraction

Thyroid crisis

A sudden increase in the output of thyroxine and resultant extreme elevation of all body processes

The nurse is obtaining data regarding the medication that the client is taking on a regular basis. The client states he is taking duloxetine, an antidepressant for the treatment of neuropathic pain. What type of therapy does the nurse understand the client is receiving? Adjuvant drug therapy Replacement drug therapy Withdrawal therapy Alternate drug therapy

Adjuvant drug therapy

The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out? Teach leg lifts and muscle-setting exercises. Administer morphine sulfate. Administer atropine sulfate. Teach deep-breathing exercises.

Administer atropine sulfate.

A female client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia? Acromegaly Type 1 diabetes mellitus Hypothyroidism Deficient growth hormone

Acromegaly

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? Acute Confusion related to cerebral edema Risk for Infection related to inadequate personal hygiene Constipation related to immobility Pain related to surgical incision

Acute Confusion related to cerebral edema

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Acute pain related to biliary spasms Imbalanced nutrition: Less than body requirements related to biliary inflammation

Acute pain related to biliary spasms

The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for Hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse is most correct to understand that this treatment is common in clients with which disease process? Hyperthyroidism Addison's disease Cushing's syndrome Hypoparathyroidism

Addison's disease

Which is an example of artificially acquired active immunity? (Select all that apply.) Administration of the influenza vaccine to an individual who has no immunity to the disease. An individual who is exposed to chickenpox for the first time and has no immunity to the disease. Administration of the varicella vaccine to an individual who has no immunity to the disease. Administration of the rubella vaccine to an individual who has no immunity to the disease. An individual who is exposed to petussis for the first time and has no immunity to the disease.

Administration of the varicella vaccine to an individual who has no immunity to the disease. Administration of the influenza vaccine to an individual who has no immunity to the disease. Administration of the rubella vaccine to an individual who has no immunity to the disease.

A nurse is preparing to teach a 13-year-old adolescent with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? Adolescents have a well-developed sense of self-identity. Adolescents are unable to follow detailed instructions. Adolescents' fine motor coordination isn't sufficiently developed to administer treatments. Adolescents are worried about appearing different from their peers.

Adolescents are worried about appearing different from their peers.

How can a nurse improve his or her transcultural sensitivity and demonstrate culturally competent nursing care? The nurse can perform a cultural and health beliefs assessment and plan care accordingly. All of the responses are correct. The nurse can become familiar with physical differences among ethnic groups. The nurse can learn to speak a second language.

All of the responses are correct.

The mother says that the infant's primary care provider recommends certain foods, but the infant refuses to eat them after breastfeeding. How should the nurse suggest that the mother alter the feeding plan? Mix pureed food with some breast milk in a bottle with a large-holed nipple. Offer dessert followed by some vegetables and meat. Offer breast milk as long as the infant refuses to eat solid foods. Allow the infant to nurse for a few minutes and then offering solid foods.

Allow the infant to nurse for a few minutes and then offering solid foods.

Haloperidol (Haldol)

An antipsychotic drug thought to block receptor sites for dopamine, making it effective in treating the delusional thinking, hallucinations and agitation commonly associated with schizophrenia.

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection? An antiviral agent such as acyclovir An antihistamine such as Benadryl An antibiotic such as amoxicillin An ointment such as bacitracin

An antiviral agent such as acyclovir

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care? Bilateral nasal and tympanic membrane cultures Prepare the client for transillumination of the sinuses An increased need for insulin and blood glucose monitoring Alternation of hot and cold compresses

An increased need for insulin and blood glucose monitoring

When planning to administer medication to a 3-month-old infant, the nurse should keep which consideration in mind? An infant's kidneys excrete drugs more slowly than an adult's. An infant's systemic drug circulation is slower than an adult's. An infant's metabolic rate is slower than an adult's. An infant's liver detoxifies drugs faster than an adult's.

An infant's kidneys excrete drugs more slowly than an adult's.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? A two-bed room with a client who previously had bacterial meningitis A private room down the hall from the nurses' station An isolation room three doors from the nurses' station A semiprivate room with a client who has viral meningitis

An isolation room three doors from the nurses' station

Which nursing action is most appropriate to include in the plan of care for a dying child to meet the child's emotional needs during the last days of life? Encourage the child to play quietly with a roommate to provide pleasure. Restrict visitors to the parents to avoid overtaxing the child. Focus on the child's physical needs to attempt to prevent sadness. Answer the child's questions about illness and death honestly.

Answer the child's questions about illness and death honestly.

According to hospital policy, a nurse in charge of a neurologic floor must facilitate discharges during a disaster event so clients involved in the disaster can be admitted promptly. After quickly reviewing the client census, the nurse identifies five postoperative clients who may be ready for discharge. What should the nurse do next? Assess each client, call the physician, and ask for discharge orders if appropriate. Call the physician to ask for discharge orders for his clients. Notify the physician of the disaster event and ask him to come immediately to discharge his clients. Wait for the physician to make rounds and then ask him to discharge his clients.

Assess each client, call the physician, and ask for discharge orders if appropriate.

Which is the priority intervention for a preschool child with epiglottiditis and a deteriorating respiratory status? Assisting with intubation Monitoring the electrocardiogram for arrhythmias Administering oxygen by face mask Administering parenteral antibiotics

Assisting with intubation

The nurse prepares to administer medication to the patient. The patient states, "I would prefer not to take that medication until I speak with my physician." The nurse honors the patient's desire to make decisions, following which common ethical principle? Autonomy Beneficence Paternalism Fidelity

Autonomy (medication - physician)

The client is ready for discharge after surgery for a deviated septum. Which instruction would be appropriate? Take aspirin to control nasal discomfort. Apply heat to the nasal area to control swelling. Avoid brushing the teeth until the nasal packing is removed. Avoid activities that elicit Valsalva's maneuver.

Avoid activities that elicit Valsalva's maneuver.

A client is taking spironolactone. Which change in the diet should the nurse teach the client to make when taking this drug? Avoid eating foods high in potassium. Maintain a fluid intake of 3,000 mL/day. Incorporate iron-rich foods into the diet. Restrict sodium intake.

Avoid eating foods high in potassium.

A patient with AIDS is being prepared for discharge. The nurse caring for the patient with AIDS knows the patient receives Agenerase. What dietary counseling will the nurse provide based upon the patient's medication regimen? Avoid meals high in protein while taking this medication Limit sodium intake to 2 grams per day. Limit fluid intake to 2 liters a day Avoid high-fat meals while taking this medication

Avoid high-fat meals while taking this medication

After having several Stokes-Adams attacks within 4 months, a client reluctantly agrees to implantation of a permanent pacemaker. Before discharge, the nurse reviews pacemaker care and safety guidelines with the client and his spouse. Which safety precaution is appropriate for a client who has a pacemaker? Never engage in activities that require vigorous arm and shoulder movement. Avoid going through airport metal detectors. Stay at least 2? away from microwave ovens. Avoid undergoing magnetic resonance imaging (MRI).

Avoid undergoing magnetic resonance imaging (MRI).

A client has been diagnosed with genital herpes. Knowing that education is an essential part of nursing care of the client with a genital herpes infection, the nurse plans to include which method(s) to minimize HIV transmission? Select all that apply. Avoiding physical contact with others in crowded places Avoiding unprotected sexual intercourse Avoiding HPV vaccinations Avoiding IV drug use Avoiding multiple sexual partners

Avoiding unprotected sexual intercourse Avoiding multiple sexual partners Avoiding IV drug use

A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client? Blood urea nitrogen (BUN) 15 mg/dl (0.82 mmol/L) Arterial pH 7.25 Plasma bicarbonate 12 mEq/L (12 mmol/L) Blood glucose level 1,100 mg/dl (61.05 mmol/L)

Blood glucose level 1,100 mg/dl (61.05 mmol/L)

The father of a neonate observes that the neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. How should the nurse should interpret this finding? Galant reflex stepping reflex plantar grasp reflex Babinski's sign

Babinski's sign

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? Turkey Banana Yogurt Milk

Banana

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? Be sure to shake the canister before using it. Inhale through the nose instead of the mouth. Inhale two sprays with one breath for faster action. Inhale the medication rapidly.

Be sure to shake the canister before using it.

A physician orders morphine for a client who complains of postoperative abdominal pain. For maximum pain relief, when should the nurse anticipate administering morphine? When the pain becomes severe Every 3 hours, whether or not the client has pain As seldom as possible to avoid morphine dependency Before the pain becomes severe

Before the pain becomes severe

The nurse must administer a unit of packed red blood cells to a 4-year-old child. The child's blood type is Type B. When the unit of blood arrives, it is labeled as Type O. What is the appropriate action for the nurse to take? Document the error with an incident report. Return the blood and order a new unit of Type B. Begin the administration of the blood as ordered. Have the child's blood retested for blood type.

Begin the administration of the blood as ordered.

A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? Blood pressure is 88/46 mm Hg. Serum potassium is 3.5 mEq/L (3.5 mmol/L). ST elevation is present on the electrocardiogram. Heart rate is 61 bpm.

Blood pressure is 88/46 mm Hg.

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding alerts the nurse to an increased risk for fetal distress? Treatment for syphilis at 15 weeks' gestation Total weight gain of 30 lb (13.6 kg) Maternal age of 32 years Blood pressure of 146/90 mm Hg

Blood pressure of 146/90 mm Hg

A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored? White blood cell (WBC) count Sodium level Blood urea nitrogen (BUN) Alkaline phosphatase

Blood urea nitrogen (BUN)

When performing cardiopulmonary resuscitation on a 7-month-old infant, which location would the nurse use to evaluate the presence of a pulse? Radial artery Femoral artery Carotid artery Brachial artery

Brachial artery

A 24-year-old primipara decides to breastfeed her baby but says, "I am worried that I will not be able to breastfeed my baby because my breasts are so small." What would the nurse include in the explanation to the client? Breast milk can be enhanced by occasional formula feeding. The woman's motivation to breast-feed is more important than breast size. Breast size poses no influence on a woman's ability to breastfeed a baby. Because her breasts are small, she will have to feed the baby more often.

Breast size poses no influence on a woman's ability to breastfeed a baby.

Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper right quadrant. What is the most likely cause of this situation? Occiput posterior position Transverse lie Compound presentation Breech position

Breech position

Which suggestion would be most helpful to the parents of a 2-year-old child when managing separation anxiety during hospitalization? Keep the visit time short. Leave while the child is sleeping. Tell the child the time they are leaving and returning. Bring the child's favorite toys from home.

Bring the child's favorite toys from home.

Aminophylline

Bronchodilator - Decreases SOB Therapeutic levels 10-20 mcg/dl TOXIC > 20 *CANT MIX WITH ANYTHING*

Nalbuphine (Nubain)

Classification: Synthetic opioid agonist-antagonist Action: Produces analgesia by binding to the opioid receptor. Indications: Moderate to severe pain. Adverse Effects: Drowsiness. diaphoresis, headache, nausea/vomiting, dry mouth, respiratory depression, hypotension, bradycardia. Contraindications: Known sensitivity. Dosage: • Adult: 10 mg IV, 10, IM, or Sub-Q. • Pediatric: Not recommended for pediatric patients. Special Considerations: Pregnancy class B

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? Client's risk for falls Client's nutritional status Client's vital signs and breath sounds Client's level of consciousness

Client's level of consciousness

Midazolam Hydrochloride (Versed)

Class: Benzo, short/intermediate acting, schedule IV Indications: sedation for intubation, ventilated patients and cardioversion. Also given for seizures.

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned? Magnesium Calcium Phosphorus Potassium

Calcium

The nurse should review which lab result before advising a client about taking the first dose of ibandronate (Boniva)? Glucose Magnesium Potassium Calcium

Calcium

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Prepare to insert a nasogastric tube. Re-attempt to auscultate bowel sounds. Prepare to administer a stool softener. Call the health care provider.

Call the health care provider.

A female client asks the nurse about the use of progestins. The nurse shares with the client that clients who take this medication are at an increased risk for what serious adverse effect? Seizures Renal failure Respiratory difficulties Cardiovascular complications

Cardiovascular complications

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. 1 Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 2 With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 3 Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 4 Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

Which is true regarding the normal urination? Urinary output does not vary all that much between adults and children. Catheterized clients should drain a minimum of 30 mL of urine per hour. In adults, the average amount of urine per void is 500 mL. In adults, the amount of urine voided typically does not depend on fluid intake and losses.

Catheterized clients should drain a minimum of 30 mL of urine per hour.

Which nursing action associated with successful tube feedings follows recommended guidelines? Check tube placement by adding food dye to the tube feed as a means of detecting aspirated fluid. Check the residual before each feeding or every 4 to 8 hours during a continuous feeding. Prevent contamination during enteral feedings by using an open system. Assess for bowel sounds at least 4 times per shift to ensure the presence of peristalsis and a functional intestinal tract.

Check the residual before each feeding or every 4 to 8 hours during a continuous feeding.

An adult has been admitted to the emergency department diagnosed with food poisoning following an outdoor picnic. What should the nurse do? Select all that apply. Tell the family to discard contaminated food. Monitor fluid and electrolyte status. Provide anti-emetics, as prescribed. Assess vital signs. Collect specimens for lab examination. Initiate support for the respiratory system.

Collect specimens for lab examination. Assess vital signs. Initiate support for the respiratory system. Monitor fluid and electrolyte status. Provide anti-emetics, as prescribed.

The nurse in the emergency department is administering a prescription for 20 mg intravenous furosemide, which is to be given immediately. The nurse scans the client's identification band and the medication barcode. The medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. What should the nurse do next? Report the problem to the information technology team to have the barcode system recalibrated. Ask another nurse to verify the medication and the client so the medication can be given now. Contact the pharmacist immediately to check the order and the barcode label for accuracy. Administer the medication now, knowing the medication is labeled and the client is identified.

Contact the pharmacist immediately to check the order and the barcode label for accuracy.

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise? Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. This type of exercise increases arterial circulation as it returns to the heart. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow.

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

A nurse is caring for a client who has been ordered a clear liquid diet. Which liquid can be included in the client's diet? Low-fat milk Cranberry juice Tomato soup Orange juice

Cranberry juice

Analyzing information for patterns, maintaining a flexible attitude, and making decisions reflecting creativity are all what type of components necessary for nurses? Critical thinking Utilitarianism Moral thinking Rationalism

Critical thinking

A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client? Crush the tablets and wash the powder down the NG tube, using a syringe filled with saline solution. Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube. Cut the tablets in half and wash them down the NG tube, using a water-filled syringe. Heat the tablets until they liquefy; then pour the liquid down the NG tube.

Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube.

A child has been prescribed a 3-day treatment of gentamicin sulfate. Which of the following manifestations would indicate that the child is developing toxicity? Electrolyte disturbances Decreased renal output Visual disturbances Joint discomfort

Decreased renal output

Nursing students are reviewing information about depression. The students demonstrate understanding of the information when they state which of the following? Individuals with depression often seek treatment for it. Depression is commonly underdiagnosed and undertreated. Elderly clients often demonstrate specific symptoms of depression. Depression is more common in men than in women.

Depression is commonly underdiagnosed and undertreated.

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? Epidermis Dermis Papillary layer Stratum corneum

Dermis (true skin)

A school nurse is asked to speak with a 10-year-old child who is constantly bullying other children. When talking with the child, what information would be most helpful for the nurse to obtain to help with understanding the child's actions? Determine why the child dislikes the other school children. Determine whether the child is also a victim of bullying. Determine what actions could be used to punish the child. Determine whether the child's parents are overly protective.

Determine whether the child is also a victim of bullying.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Massage lotion over bony prominences when turning. Develop a written, individual turning schedule. Turn and reposition the client every 4 hours. Use two people when sliding the client up in bed.

Develop a written, individual turning schedule.

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Slide the client, rather than lifting, when turning. Turn and reposition the client at least once every 8 hours. Vigorously massage lotion over bony prominences. Develop a written, individual turning schedule.

Develop a written, individual turning schedule.

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained? Decreased cardiac irregularities Development of an increase in mobility Fewer bruises than on admission Fewer muscular spasms

Development of an increase in mobility

The nurse is assessing a client admitted with a myocardial infarction with the following assessment: dyspnea, heart rate of 140 bpm, and crackles in the posterior chest. The nurse would interpret these findings as which of the following? A hypoglycemic reaction Development of congestive heart failure Cardiogenic shock associated with heart block Acute renal failure

Development of congestive heart failure

What is the best way for a nurse to improve a client's compliance with the ordered medication schedule? Devise the simplest possible medication schedule. Encourage the client to hire a visiting nurse. Lengthen the intervals in the administration schedule. Give all instructions at least three times.

Devise the simplest possible medication schedule.

When teaching a client with bulimia nervosa about possible complications, which condition should the nurse emphasize? Diabetes mellitus Lung cancer Allergies Hepatitis A

Diabetes mellitus

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain? Diaphoresis Hypotension Decreased respiratory rate Bradycardia

Diaphoresis

A nurse administers digoxin 0.125 mg to a client at 1400 instead of the prescribed dose of digoxin 0.25 mg. Which of the following statements should the nurse record in the medical record? Nurse accidentally gave digoxin 0.125 mg to the client at 1400. At 1400, wrong dose of digoxin given due to heavy workload. Digoxin 0.125 mg given at 1400 instead of prescribed dose of 0.25 mg. Digoxin 0.25 mg administered at 1400, physician notified.

Digoxin 0.125 mg given at 1400 instead of prescribed dose of 0.25 mg.

A school nurse is gathering registration data for a child entering first grade. Which immunizations would the school nurse verify that the child has had? Select all that apply. Diphtheria-tetanus-pertussis series. H. influenzae type b series. Varicella vaccine. Pneumonia vaccine. Influenza vaccine. Oral polio series.

Diphtheria-tetanus-pertussis series. H. influenzae type b series. Varicella vaccine.

Which action by the nurse demonstrates ageism? Providing the same high quality of care to all clients Directing all health decisions to the older adult's child Encouraging the older adult to develop routines not associated with work Allowing adequate time for the older adult to complete tasks

Directing all health decisions to the older adult's child

Which of the following is the appropriate intervention to avoid physical dependence on drugs in a client? Discontinue drugs gradually. Administer subtherapeutic doses. Administer adjuvant drugs along with the prescribed drug. Increase dosage of the drug.

Discontinue drugs gradually.

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

Encourage a high-calorie, high-protein diet.

A client receiving chemotherapy for cervical cancer indicates that she has an advance directive. She tells the nurse that she worries her children will not honor her wishes if her condition should worsen. In order to facilitate the honoring of the client's wishes, what should the nurse encourage the client to do? Appoint a proxy who is not a family member. Obtain additional legal documents. Discuss her end-of-life wishes with her family. Recommend that the client contact her attorney.

Discuss her end-of-life wishes with her family.

A nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells her that he doesn't wish to discuss it. The client refuses to allow his family to visit. The nursing diagnosis that best describes the client's problem is: Hopelessness. Disturbed body image. Fear. Powerlessness.

Disturbed body image.

Which instruction should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? Follow a low-protein diet. Take medications with milk to decrease irritation. Limit caffeine intake to two cups of coffee per day. Do not lie down for 2 hours after eating.

Do not lie down for 2 hours after eating.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? Emphasize the rationale for taking the medication now as ordered. Ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue. Try to persuade the client to take the medication as ordered by the doctor. Document the client's choice and re-assess pain in 1 hour.

Document the client's choice and re-assess pain in 1 hour.

While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client's urine has two small blood clots in the measuring container. What should the nurse do next? Review the client's records for the length of the third stage of labor. Massage the client's fundus vigorously. Ask the client if she passed clots with her previous births. Document this observation as a normal finding.

Document this observation as a normal finding.

Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? Provide a clear liquid, low-sodium diet. Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. Put on a mask, gown, and gloves when entering the client's room. Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding.

Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.

A client is menopausal and has been given a prescription for estrogen. She asks the nurse what some of the risks are in taking this medication. The nurse's best response is:

Estrogen increases the risk of certain cancers, myocardial infarctions, and blood clots.

The nurse is teaching the caregivers of a child with cystic fibrosis. What is most important for the nurse to teach this family? Avoid overprotecting the child. Be sure the child exercises daily. Encourage everyone in the family to use good hand-washing techniques. Watch for signs that the family unit is stressed.

Encourage everyone in the family to use good hand-washing techniques.

A nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/L), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/L), and platelet count of 150,000/μL (150 X 109/L). Based on the child's values, what is the highest priority nursing intervention? Encourage meticulous handwashing by the client and visitors. Prepare to give the child a transfusion of packed red blood cells. Encourage mouth care with a soft toothbrush. Prepare to give the child a transfusion of platelets.

Encourage meticulous handwashing by the client and visitors.

To address the needs of a chronically ill patient and promote the concept of wellness, a nursing care plan should outline steps to: Encourage positive health characteristics within the limits of the disease. Inform the patient about all the possible complications of the disease process. Restrict most activities to protect the patient from additional deterioration. Encourage activity, beyond the scope of tolerance, to prevent progressive deterioration.

Encourage positive health characteristics within the limits of the disease.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? Teach the family to anticipate the client's needs to care for the client. Encourage the client to provide as much self-care as possible. Perform all care activities for the client to facilitate rest. Arrange with the nurse case manager for an early discharge.

Encourage the client to provide as much self-care as possible.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? Elevating the head of the bed 30 degrees Maintaining a cool room temperature Encouraging increased fluid intake Turning the client every 2 hours

Encouraging increased fluid intake

The nurse is caring for a client with a subdural hematoma. Which of the following is the priority outcome? Ensure airway patency and optimal oxygen levels and protect from injury. Restore blood pressure to the normal range. Provide psychological support and maintain skin integrity and effective thermoregulation. Ensure adequate nutrition, hydration, and elimination.

Ensure airway patency and optimal oxygen levels and protect from injury.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? Ensure that the prescribed solution is clear and transparent. Select a primary tubing of about 37 inches (94 cm) long. Use half-instilled IV solutions before infusing a new one. Avoid replacing IV solution every 24 hours.

Ensure that the prescribed solution is clear and transparent.

A client receiving a blood transfusion complains of shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the healthcare provider? Remove the intravenous line. Place the client in a recumbent position with legs elevated. Administer prescribed PRN anti-anxiety agent. Ensure there is an oxygen delivery device at the bedside.

Ensure there is an oxygen delivery device at the bedside.

A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)? Levothyroxine sodium 0.125 mcg po daily. Acetaminophen 550 mg po every 4 hours for fever greater than 102 degrees F. Diazepam 5 mg po on-call to the OR. Epoetin alfa 6500 U SQ daily.

Epoetin alfa 6500 U SQ daily.

Nurses are aware that variety and diversity occur both within and across groups. Which of the following factors leads to cultural benefits as a result of diversity? The dominant culture overpowers outward expressions of other cultures. Other cultures experience the lasting effects of disempowerment. Suppression occurs in people of differing cultural orientations. Equal opportunity exists for various cultural perspectives.

Equal opportunity exists for various cultural perspectives.

Enoxaparin (Lovenox)

Low molecular weight heparin anticoagulant

The nurse needs to carefully monitor a client with traumatic injuries. How often should the nurse check and document the client's pain? Upon admission and discharge Every time the client's vital signs are assessed An hour after analgesics are administered After every meal consumed by the client

Every time the client's vital signs are assessed

Which of the following situations is an indication of the benefit of self-awareness in professional nursing practice by a nurse? Select all that apply. Understands the meaning of cultural diversity Questions all situations for underlying meanings No longer is affected by biases and assumptions Examines own biases and is open to new ideas Appears more tolerant to different practices

Examines own biases and is open to new ideas Understands the meaning of cultural diversity

Lazarus Theory

Experience of emotion depends on how the situation is labelled. We label the situation, which then leads to emotional and physiological response

A male nurse is assigned to care for a female client with a new colostomy. Upon entering the room, the spouse tells the nurse that it is considered immodest for a woman's body to be seen by any male that is not her husband in their Muslim culture. Which actions demonstrate culturally competent nursing care in this situation? Select all that apply. Explain that the unit is made up of mostly male nurses so it may not be possible. Explain that it is discriminatory to not accept male nursing care. Explore the possibility of a female nurse being willing to swap clients. Report to the charge nurse to make them aware of the situation. Notify the facility patient-advocate to make them aware of the situation.

Explore the possibility of a female nurse being willing to swap clients. Report to the charge nurse to make them aware of the situation. Notify the facility patient-advocate to make them aware of the situation.

A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication? Flare Extravasation Thrombosis Erythema

Extravasation

The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? Extravasation Stomatitis Bone pain Nausea and vomiting

Extravasation

A typically developing preschool child is experiencing pain after an appendectomy. Which data collection tool is the most appropriate for the nurse use to assess the pain? FLACC scale numerical pain scale FACES Pain Rating Scale visual analog scale

FACES Pain Rating Scale

Which statement regarding gender and suicide is correct? Females are more likely to die by firearm than males. Females choose more violent means of suicide than males. Females are more likely than males to die from suicide. Females engage in suicidal behaviors more frequently than males.

Females engage in suicidal behaviors more frequently than males.

The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering? Buprenex Stadol Nubain Fentanyl

Fentanyl

A nulligravid client with gestational diabetes tells the nurse that she had a reactive nonstress test 3 days ago and asks, "What does that mean?" The nurse explains that a reactive nonstress test indicates which of the following about the fetus? Evidence of some compromise that will require birth soon. Evidence of late decelerations occurring during the test. Fetal well-being at this point in the pregnancy. No accelerations demonstrated within a 20-minute period.

Fetal well-being at this point in the pregnancy.

A health care provider (HCP) has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which information should the nurse teach the client about taking valproic acid? Follow-up blood tests are necessary while on this medication. The extended-release tablet can be crushed if necessary for ease of swallowing. Consumption of a moderate amount of alcohol is safe if the medication is taken in the morning. Tachycardia and upset stomach are common side effects.

Follow-up blood tests are necessary while on this medication.

The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? Primarily, water supplements should be used to prevent jaundice. Formula supplements can provide nutrients not found in breast milk. Formula feeding should be avoided to prevent interfering with the breast milk supply. More vigorous sucking is needed for a bottle feeding, so supplements should be avoided.

Formula feeding should be avoided to prevent interfering with the breast milk supply.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. Breastfeeding is not recommended, because the neonate needs increased fat in the diet. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

A client's fasting blood sugar (FBS) is 63 mg/dL (3.5 mmol/L) at 0700. The client is alert and oriented. What should the nurse do first? Give 15 g of carbohydrate and recheck the blood glucose in 15 minutes. Give one ampule of 50% dextrose via rapid IV infusion. Give the prescribed dose of insulin. Give the client a large glass of orange juice with two packages of sugar.

Give 15 g of carbohydrate and recheck the blood glucose in 15 minutes.

A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? Make contact between two clean surfaces. Make contact between two contaminated surfaces. Remove the garments that are most contaminated. Handwashing before leaving the client's room.

Handwashing before leaving the client's room.

The nurse identifies the nursing diagnosis of risk for infection related to chemotherapy-induced immunosuppression. What would the nurse include in the teaching plan for the child and parents about reducing the child's risk? Select all that apply. Encouraging frequent close contact with numerous visitors Cheering up the environment with fresh flowers and plants Providing a low-carbohydrate, low-protein diet Having the child sleep in a single bed and room Encouraging frequent, thorough handwashing

Having the child sleep in a single bed and room Encouraging frequent, thorough handwashing

A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron? Milk Kidney beans Orange juice Leafy green vegetables

Orange juice

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? Breathing patterns, circulation patterns, and responses to hospitalization Health habits, family relationships, affect, and thought patterns Rest and sleep patterns, activity and exercise patterns, and coping and stress tolerance General survey results, eating habits, and ability to perform activities of daily living

Health habits, family relationships, affect, and thought patterns

The National Center for Health Statistics uses data from healthcare agencies to issue quarterly and annual reports on performance related to goals for improving the health of the U.S. population. Which initiative is targeted with improving the health of all Americans? The Joint Commission Quality Indicators Agency for Healthcare Research and Quality Healthy People 2020

Healthy People 2020

When assessing a client's level of stress caused by significant life events, the nurse should use: Selye's general adaptation syndrome theory. the general systems theory. Lazarus's theory. Holmes and Rahe's theory.

Holmes and Rahe's theory.

Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes? Nystagmus Scotoma Homonymous hemianopsia Diplopia

Homonymous hemianopsia

A nurse is monitoring a client receiving tranylcypromine sulfate. Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor? Hypertensive crisis Hypotensive episodes Muscle flaccidity Hypoglycemia

Hypertensive crisis

A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance? Hypernatremia Hypokalemia Hyperkalemia Hypervolemia

Hypokalemia

At 8 a.m.(0800), a nurse assesses a client who's scheduled for surgery at 10 a.m.(1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next? Check to see that the client had a chest X-ray the previous day as ordered. Sign the preoperative checklist for this client. Check the client's serum electrolyte levels and complete blood count (CBC). Immediately notify the physician of these findings.

Immediately notify the physician of these findings.

The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is: Decreased bruising. Less scaling on the skin. Decreased swelling in the area. Improved circulation to the area.

Improved circulation to the area.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 mL/hr) with high specific gravity (> 1.025), the nurse suspects: Inadequate fluid volume Normal glomerular filtration Overhydration Anuria

Inadequate fluid volume

The nurse is caring for a child with cystic fibrosis who is admitted to the floor with an upper respiratory tract infection. The child has labored breathing and a congested, nonproductive cough. Which nursing diagnosis is the immediate priority for the nurse? Compromised family coping related to the child's chronic illness Risk for infection related to bacterial growth and impaired body defenses Ineffective airway clearance related to thick, tenacious mucus production Imbalanced nutrition (less than body requirements) related to impaired absorption

Ineffective airway clearance related to thick, tenacious mucus production

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Ineffective peripheral tissue perfusion related to venous congestion Risk for injury related to edema Impaired gas exchange related to increased blood flow Excess fluid volume related to peripheral vascular disease

Ineffective peripheral tissue perfusion related to venous congestion

What should the school nurse working in the elementary school setting be aware is one of the most frequent health care problems to affect this population? Eating disorders Drug abuse Infections Emotional problems

Infections

Bronchiolitis

Inflammation of the bronchioles that usually occurs in children younger than 2 years and is often caused by the respiratory syncytial virus.

A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which approach by the nurse is most therapeutic? Initiate contact with the client frequently. Question the client until he responds. Sit outside the client's room. Wait for the client to begin the conversation.

Initiate contact with the client frequently.

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites? Insulin is absorbed rapidly regardless of the injection site. Insulin is absorbed more rapidly at abdominal injection sites than at other sites. Insulin is absorbed more slowly at abdominal injection sites than at other sites. Insulin is absorbed unpredictably at all injection sites.

Insulin is absorbed more rapidly at abdominal injection sites than at other sites.

A client is talking with the nurse about unsightly varicose veins and their discomfort. What information should the nurse provide to the client? Contact a surgeon to perform a femoral-popliteal bypass graft. Keep the legs elevated when sitting or lying down. Avoid walking to reduce the discomfort. Sclerotherapy can be used for cosmetic improvement.

Keep the legs elevated when sitting or lying down.

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority? Offering the client the urinal every 3 hours Maintaining a fluid intake of 1 L/day Applying moist, warm compresses to the client's groin Keeping the perineal area clean and dry

Keeping the perineal area clean and dry

After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first? Fluid restriction Artificial sphincter use Kegel exercises Self-catheterization

Kegel exercises

The nurse is preparing a talk on health issues in the LGBTQ population. Which statistic would the nurse include? Lesbians are more likely to get preventive services for cancer. LGBTQ populations have lower rates of tobacco, alcohol, and other drug use. LGBTQ youth are 2 to 3 times more likely to attempt suicide. Lesbians and bisexual females are more likely to be underweight or anorexic.

LGBTQ youth are 2 to 3 times more likely to attempt suicide.

The nurse is caring for a child with history of strep throat. Upon current assessment, the child states abdominal pain and joint achiness. Which laboratory data would the nurse communicate to the health care provider immediately? Anemia Low hemoglobin level Normal erythrocyte sedimentation rate Leukocytosis

Leukocytosis

Effleurage

Light, continuous-stroking massage movement applied with fingers and palms in a slow and rhythmic manner.

The nurse is caring for a 33-year-old male client. Which clinical screening should the client have, based on his age? Lipid panel Electrocardiogram Hemoccult screening Colonoscopy

Lipid panel

Lithium Carbonate

Lithonate, Lithotabs, Lithobid A simple chemical compound that is highly effective in dampening the extreme mood swings of bipolar disorder.

The nurse is administering a beta blocker to a patient in order to decrease automaticity. Which medication will the nurse administer? Lopressor Cordarone Rythmol Cardizem

Lopressor

Tranylcypromine (Parnate)

MAOI. Increases norepinephrine, dopamine, and serotonin by blocking MAO-A. Avoid foods containing tryamine. Antihypertensives have additive hypotensive effect. Contraindicated with SSRIs, tricyclics, heart failure, CVA, renal insufficiency. Side effects: CNS stimulation, orthostatic hypotension, hypertensive crisis with intake of tryamine, SSRIs, and tricylics.

A client with eclampsia begins to experience a seizure. Which intervention should the nurse do immediately? Insert a padded tongue blade into the mouth. Pad the side rails. Place a pillow under the left buttock. Maintain a patent airway.

Maintain a patent airway.

A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy? Maintaining the client's fluid and electrolyte balance Providing adequate management of pain Maintaining a caloric intake to meet metabolic needs Providing emotional support to the client and family

Maintaining the client's fluid and electrolyte balance

The nurse is caring for a Hispanic client who is very ill. The client's spouse has asked to speak with the physician, who makes her rounds between 0900 and 1000 every morning. The nurse tells the spouse to be at the bedside at that time in order to talk with the physician, but the spouse never arrives until afternoon. Knowing that some Hispanic people view time in a wider frame of reference, the appropriate response to this behavior is which of the following? Make other arrangements with the physician to facilitate a meeting with the spouse. Report the issue to the nurse supervisor and ask her to talk to the spouse. Talk to the spouse and be firm about the time issue; let the spouse know that the physician cannot see her in the afternoon. Do nothing; let the spouse handle the issue.

Make other arrangements with the physician to facilitate a meeting with the spouse.

uric acid level

Male: 4.4-7.6 mg/dL Female: 2.3-6.6 mg/dL

What is the rationale that supports multidrug treatment for clients with tuberculosis? Multiple drugs potentiate the drugs' actions. Multiple drugs allow reduced drug dosages to be given. Multiple drugs reduce development of resistant strains of the bacteria. Multiple drugs reduce undesirable drug adverse effects.

Multiple drugs reduce development of resistant strains of the bacteria.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following? Pro-choice Informed consent Nonmaleficence Self-determination

Nonmaleficence

The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on the leg. What should the nurse do first? Document the prednisone with current medications. Notify the anesthesiologist of the prednisone administration. Notify the surgeon of the poison ivy. Send the client to surgery.

Notify the anesthesiologist of the prednisone administration.

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? Store gabapentin in the refrigerator. Take gabapentin with an antacid to protect against ulcers. Notify the health care provider (HCP) if vision changes occur. Take all the medication until it is gone.

Notify the health care provider (HCP) if vision changes occur.

During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate? Ask the mother to consent to genetic studies. Explain these deviations to the newborn's mother. Document these findings as minor deviations. Notify the health care provider (HCP) immediately.

Notify the health care provider (HCP) immediately.

When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next? Determine the length of the mother's labor. Keep the neonate under the radiant warmer for 2 hours. Obtain a blood sample to check for hypoglycemia. Notify the health care provider (HCP) immediately.

Notify the health care provider (HCP) immediately.

The nurse is preparing to administer the second dose of ordered antibiotics to a client and notes that the first dose of medication is still in the automated medication-dispensing system. The medication administration record (MAR) does not show that the initial dose was given. What is the appropriate nursing action? Notify the healthcare provider. Give the first and second doses of antibiotics. Proceed with administration of the second dose. Call the pharmacy before notifying anyone else.

Notify the healthcare provider.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation? Notify the supervisor and call the police. Report the incidents to the facility's lawyer. Pass the information on to the doctor and the next shift staff. Remind the residents and family members not to leave valuables unattended.

Notify the supervisor and call the police.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions? Sign off the chart but flag that vital signs are abnormal; allow the client to go down to the operating room. Have the LPN take the vital signs again, phone the operating room, and cancel the surgery. Notify the surgeon and await his/her decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. Take the vital signs, and in the future do not delegate this preoperative responsibility.

Notify the surgeon and await his/her decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.

Which guidelines define and regulate what the nurse may and may not do as a professional? Facility policies and procedures Nurse practice act Standards of care State legislature

Nurse practice act

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the last 24 hours, but the client now has a temperature of 38.4° C (101.1° F), a heart rate of 116 bpm, and a respiratory rate of 26 breaths/minute. The client has an IV infusion running at a keep-open rate. The nurse contacts health care provider (HCP) and receives several prescriptions (see chart). Which prescription should the nurse implement first? Chart vital signs. Obtain CT of abdomen. Increase the rate of the intravenous infusion. Obtain blood cultures.

Obtain blood cultures.

A nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? On the day of discharge When the client's vomiting has stopped On admission to the facility When the client expresses readiness to learn

On admission to the facility

A male client has always prided himself in maintaining good health and is consequently shocked at his recent diagnosis of diabetes. The nurse has asked the client, "How do you think your diabetes is going to affect your lifestyle?" The nurse has utilized which of the following interviewing techniques? Validating question Reflective question Closed question Open-ended question

Open-ended question

Which type of surgery is used in an attempt to relieve complications of cancer? Palliative Reconstructive Prophylactic Salvage

Palliative

A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include? Participation in decision making that is shared by all involved A discussion of a centralized organizational structure Nurses and physicians playing major roles in clinical decsions Accountability that is primarily attributed to the patient

Participation in decision making that is shared by all involved

A teenage client is admitted to the burn unit with burns over 49% of the body surface area, including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused, with reports of minor pain. When assessing the client, which of the following is an immediate priority for the nurse to evaluate? Reports of pain Mental status changes Emotional reaction to the fire Patency of airway

Patency of airway

Which of the following measures should a home healthcare nurse implement to minimize the potential for lawsuits? Have the client sign a waiver prior to the entry phase of a visit. Perform thorough, accurate, and timely documentation. Apply more conservative interventions than those used in a hospital setting. Integrate the client's learning needs and goals into plans of care.

Perform thorough, accurate, and timely documentation.

A 6-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery? Explain how to use a patient-controlled analgesia (PCA) pump for pain control. Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask. Show the child a video about the surgery. Show the child a visual analog scale (VAS) based on a scale from 0 to 10.

Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.

Which instruction should a nurse include in a home-safety teaching plan for a pregnant client? Avoid having area rugs around your house. Place a nonskid mat on the floor of the tub or shower. It's OK to clean your cat's litter box. It's OK to wear high heels.

Place a nonskid mat on the floor of the tub or shower.

A nurse is providing a fall prevention clinic for a group of older adults. What information should the nurse include? Select all that apply. Review medications routinely for side effects Place grab bars in the shower and tub Frequently change the furniture layout in the home Have routine vision and hearing screenings Wear nonslip shoes or socks when walking Use scatter rugs on hard wood surfaces.

Place grab bars in the shower and tub Have routine vision and hearing screenings Wear nonslip shoes or socks when walking Review medications routinely for side effects

An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery? Provide distraction with music. Teach client to massage the painful area. Apply moist heat to the abdomen. Place the client in semi-Fowler's position with the knees to the chest.

Place the client in semi-Fowler's position with the knees to the chest.

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? Lung infarction Bacterial pneumonia Bronchogenic carcinoma Pleurisy

Pleurisy

A nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer? Hemorrhoids Polyps Weight gain Duodenal ulcers

Polyps

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing? Femoral Posterior tibial Brachial Dorsalis pedis

Posterior tibial

A 77-year-old client has newly diagnosed stage 2 hypertension. The physician has prescribed a thiazide and an angio-converting enzyme inhibitor. About what is the nurse most concerned? Postural hypertension and resulting injury Rebound hypertension Postural hypotension and resulting injury Sexual dysfunction

Postural hypotension and resulting injury

Which statement is a guideline to help nurses protect themselves from liability? Follow all physician's orders. Practice within the scope of the nursing standards of practice.. Obtain malpractice insurance. Do what the client desires even though the nurse may disagree.

Practice within the scope of the nursing standards of practice.

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? Administering a sedative such as secobarbital or pentobarbital Practicing effleurage on the abdomen Immersing the client in warm water in a pool or hot tub Administering an opioid such as meperidine or fentanyl

Practicing effleurage on the abdomen

repaglinide

Prandin Meglitinide Analog; Antidiabetic Agent

Encouraging fantasy play and participation by children in their own care is a useful developmental approach for which pediatric age-group? Toddler (1 to 3 years) Adolescence (10 to 19 years) School age (5 to 10 years) Preschool age (3 to 5 years)

Preschool age (3 to 5 years)

A nurse is teaching a diabetic support group about the causes of type 1 diabetes. The teaching is determined to be effective when the group is able to attribute which factor as a cause of type 1 diabetes? Obesity Rare ketosis Presence of autoantibodies against islet cells Altered glucose metabolism

Presence of autoantibodies against islet cells

The nurse knows that for a client who still has her ovaries intact, estrogen must be paired with what other drug when used to treat menopausal symptoms? Antispasmodics Aromatase inhibitors Androgen hormone inhibitors Progestins

Progestins

On a client's second postpartum visit, a physician reviews the chart. What's the best term for the lochia described? Thrombic Alba Rubra Serosa

Rubra

A child with type 1 diabetes is admitted to the emergency department with hot and dry skin, rapid and deep respirations, and a fruity odor to her breath. Which task, when performed by a new-graduate registered nurse (RN), requires the RN preceptor to intervene? Assessment of child's vital signs every 15 min. Verification of child's prescription for IV insulin infusion. Verification of child's glucose by finger stick. Providing encouragement to the child to drink some orange juice.

Providing encouragement to the child to drink some orange juice.

A nurse is assessing a client's pulse and notices a weak and thready pulse in both lower extremities. How should the nurse document this finding? Poor quality of peripheral pulses Pulse amplitude +1 bilateral lower extremities Pulses weak Pulse amplitude +2 bilaterally

Pulse amplitude +1 bilateral lower extremities

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? Pulse oximetry Spirometry Peak expiratory flow rate Thoracentesis

Pulse oximetry

A client who is legally blind must undergo a colonoscopy. The nurse is helping the physician obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step? Encourage the client to read the form. Read the consent form to the client and ask him if he has any questions. Make sure the client's family is present when he signs the consent form. Document on the consent form that the client is unable to sign the consent because he is legally blind.

Read the consent form to the client and ask him if he has any questions.

The nurse is caring for a patient with Parkinson disease. The patient informs the nurse that he has been angry with God because of his worsening illness, but after talking to the hospital chaplain, he is ready to return to the church choir and become active again in the men's group at the church. What is an appropriate nursing diagnosis for this patient? Risk for Loneliness Spiritual Distress Readiness for Enhanced Spiritual Well-Being Impaired Religiosity

Readiness for Enhanced Spiritual Well-Being

A nurse arriving for duty notes that a nursing assistant (or unregulated care provider [UCP]) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UCP? Supervise the UCP during the treatments involving sterile technique. Reassign the UCP to a client requiring basic tasks that the UCP has mastered. Make sure the UCP has practiced sterile technique on at least one other occasion. Provide the UCP with a list of resources to guide the implementation of care.

Reassign the UCP to a client requiring basic tasks that the UCP has mastered.

A 4-year-old boy presents to the emergency department. His father tearfully reports that he was in the driveway and had his son on his shoulders when the child began to fall. The father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. What action should the nurse take? Record the father's story in the medical record. Restrict the father's visitation. Refer the father for parenting classes. Notify the police immediately.

Record the father's story in the medical record.

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client? Registered nurse who just completed orientation Charge nurse with 10 years of experience Registered practical nurse/licensed practical or vocational nurse with 5 years of experience Registered nurse (RN) with 2 years of experience

Registered nurse (RN) with 2 years of experience

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which of the following would be the priority for this client after the stockings are applied? Teach the client isotonic leg exercises. Elevate the client's legs while out of bed. Remove elastic stockings once per day and observe lower extremities. Order a second pair of stockings to be rotated each day.

Remove elastic stockings once per day and observe lower extremities.

When removing protective covering, what action should this nurse (see figure) take to avoid spreading nosocomial infections? Tie the dangling strings of the mask around the neck. Place the face mask over the mouth and nose before removing the hair covering. Wash hands before tying the strings on the mask. Remove the face mask.

Remove the face mask.

A nurse is providing disaster care in an event that is known to involve gamma radiation. When admitting victims of the disaster, what should the nurse do to best reduce victims' risks of injury? Remove victims' clothing and have them wash themselves thoroughly. Carefully apply personal protective equipment over victims' clothing. House victims in a well-ventilated area. Apply chlorhexidine to all skin surfaces that may have been contaminated.

Remove victims' clothing and have them wash themselves thoroughly.

A nurse is caring for an elderly client in a long-term care facility. This client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard him express feelings of hopelessness to other residents. Which intervention should the nurse perform first? Referring the client to a mental health professional Removing items that the client could use in a suicide attempt Communicating a nonjudgmental attitude Setting aside time to listen to the client

Removing items that the client could use in a suicide attempt

A client has been declared to have a terminal illness. What intervention will a nurse perform regarding the final decision of a dying client? Share emotional pain Respect the client's and family members' choices Abide by the dying client's wishes Ask the family members about spiritual care

Respect the client's and family members' choices

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? Share emotional pain. Respect the client's and family members' choices. Abide by the dying client's wishes. Ask the family members about spiritual care.

Respect the client's and family members' choices.

A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition? Metabolic alkalosis Respiratory alkalosis Metabolic acidosis Respiratory acidosis

Respiratory acidosis

Telling the truth (veracity) is one of the basic principles of North American culture. Three ethical dilemmas in clinical practice can directly conflict with this principle. Choose the three from the list below. Not revealing a diagnosis to a client Revealing a diagnosis to people other than the client with the diagnosis Teaching a client how to perform self care measuress Using placebos Discussing a client's health information with the physician on call

Revealing a diagnosis to people other than the client with the diagnosis Using placebos Not revealing a diagnosis to a client

After the nurse administers haloperidol 5 mg PO to a client with acute mania, the client refuses to lie down on her bed, runs out on the unit, pushes clients in her vicinity out of the way, and screams threatening remarks to the staff. What should the nurse do next? Tell the client to lie down on the sofa in the community room. Follow the client and ask her to calm down. Tell the staff to ignore the client's remarks. Seclude the client and use restraints if necessary.

Seclude the client and use restraints if necessary.

The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of a fractured femur. What should the nurse do when transporting the client to the operating room? Transfer the client to a cart with manually suspended traction. Call the surgeon to request a prescription to temporarily remove the traction. Remove the traction, and send the client on a cart. Send the client on the bed with extra help to stabilize the traction.

Send the client on the bed with extra help to stabilize the traction.

Which of the following statements best describes the relationship between biologic sex and gender identity? Biologic sex and gender identity are considered synonymous in nursing practice. Biologic sex and gender identity are both modifiable by surgery and medical interventions. Sex is chromosomally determined, while gender is a psychosocial construct. Biologic sex is genetically determined but gender identity is chosen during adolescence.

Sex is chromosomally determined, while gender is a psychosocial construct.

A client and her partner come to the clinic stating they have been unable to have sexual intercourse. The female client states she has pain and her "vagina is too tight." The client was raped at age 15 years of age. Which nursing problem is most appropriate for this client? Sexual Dysfunction related to sexual trauma Vaginismus related to vaginal constriction Risk for Trauma related to fear of vaginal penetration Dysfunctional Grieving related to loss of self- esteem because of lack of sexual intimacy

Sexual Dysfunction related to sexual trauma

The nurse is teaching a class about sexuality at a public health clinic. After class the nurse is approached by Cathleen, a 54-year-old female, who eventually discloses to the nurse that she is having a sexual affair with a female partner. The term for an individual's preference for a partner of a particular gender is which of the following? Sexual orientation Gender role behavior Transvestite Transsexual

Sexual orientation

In a family with a 7-year-old child with a chronic illness, which family members feel jealousy, resentment, embarrassment, shame, fear of becoming ill, and guilt at causing the illness? Child with the illness Parents Grandparents Siblings

Siblings

The nurse is answering questions regarding fecal matter for a client who is scheduled for a colon resection. The client is asking questions regarding the composition of the fecal matter and when it becomes a formed mass. The nurse is most correct to state at which location? Sigmoid colon Ileum Cecum Duodenum

Sigmoid colon

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality? Chloride Potassium Calcium Sodium

Sodium

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? heart rate 110 beats/minute SpO2 92% clubbing of fingers respirations 26 breaths/minute

SpO2 92%

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? Spinach Eggs Chicken Apples

Spinach

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? Pain medication should be taken before completing deep breathing and coughing exercises. Splint the incision site using a pillow during deep breathing and coughing exercises. Deep breathing and coughing exercises should be completed every 8 hours. Deep breathing and coughing exercises may be used as relaxation techniques.

Splint the incision site using a pillow during deep breathing and coughing exercises.

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? All options must be used. 1 Splint the incisional site. 2 Inhale through the nose. 3 Cough deeply from the lungs. 4 Exhale through pursed lips.

Splint the incisional site. Inhale through the nose. Exhale through pursed lips. Cough deeply from the lungs.

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage IV: medullary depression Stage III: surgical anesthesia Stage I: beginning anesthesia Stage II: excitement

Stage II: excitement

The nurse is caring for a client with a blood pressure of 210/94 mm Hg. The health care provider prescribes enalapril 20 mg b.i.d. Which nursing action is best when instructing on the new medication regimen? Inform the client about the new medication and provide a handout on the use. Use the package insert for medication instruction. Teach the client the name and frequency of the new medication. State the new medication, including name, use, and reason for the new medication.

State the new medication, including name, use, and reason for the new medication.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? Give the feedings at room temperature. Stop the feedings and check for residual volume. Place the client in semi-Fowler's position while feeding. Change the feeding container daily.

Stop the feedings and check for residual volume.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next? Increase the infusion rate by 5 gtt/minute. Continue monitoring per standards of care. Stop the magnesium sulfate infusion. Decrease the infusion rate by 5 gtt/minute.

Stop the magnesium sulfate infusion.

A client's husband enters the room and becomes very agitated with the fact that the nurse is taking so long to assess his wife. He starts pacing within the room and raises his voice, asking, "What is taking so long?" Which of the following is the nurse's best response? Ask the husband to leave the room and come back later. Succinctly and respectfully explain the need to do a proper assessment. Hurry with the assessment to avoid agitating the husband further. Tell the husband to calm down.

Succinctly and respectfully explain the need to do a proper assessment.

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent? Vecuronium Atracurium Pancuronium Succinylcholine

Succinylcholine

A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased work of breath, and a decreased oxygen saturation level. What should the nurse do first? Perform chest physiotherapy. Turn the child to a side-lying position. Administer pain medication. Suction the tracheostomy.

Suction the tracheostomy.

The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea? Orthopneic Supine Fowler's Contour

Supine

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia? Polyuria, polydipsia, and polyphagia Dry skin, bradycardia, and somnolence Sweating, tremors, and tachycardia Bradycardia, thirst, and anxiety

Sweating, tremors, and tachycardia

Ortolani's sign

TESTING: congenital dislocation of hip of infant POSITION: (supine) flex infant's hips and grasp legs so thumbs are against the insides of the knees and thighs and the fingers are placed along the outsides of the thighs to the buttocks; thighs are abducted and pressure is applied against the greater trochanters; resistance will begin to be felt to abduction and lateral rotation at approximately 30- 40 deg (+) TEST: feel a "click" or "jerk" ***only valid for the first few weeks after birth

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? Administer a phospho-soda enema when necessary. Administer a tap-water enema weekly. Take a mild laxative such as magnesium citrate when necessary. Take a stool softener such as docusate sodium daily.

Take a stool softener such as docusate sodium daily.

The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication? Take the total dose at bedtime. Avoid taking it with food. Stop taking it if urine turns orange-yellow. Take it with a full glass (240 mL) of water.

Take it with a full glass (240 mL) of water.

A client says he's stressed by his job but enjoys the challenge. What should the nurse suggest? Spend more time with his family. Change jobs. Take stress-management classes. Leave work at work.

Take stress-management classes.

A 14-year-old adolescent tells the nurse that she's in love with her 22-year-old neighbor and that they've had sex on several occasions. She doesn't want her parents to know because she loves him and is afraid they'll be angry. What is the nurse's best course of action? State that she'll consult the unit's charge nurse and talk with the adolescent later. Tell the adolescent that she won't say anything to her parents, but that she must tell the physician. Inform the adolescent that any information she shares is privileged and confidential. Tell the adolescent that the law requires her to report the sexual contact because of the age difference.

Tell the adolescent that the law requires her to report the sexual contact because of the age difference.

A nurse says she's forgotten her computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage? Telling the nurse that she may use the password Writing down the password so the nurse won't forget it Telling the nurse that she may not use the password Telling the nurse to ask someone else for her password

Telling the nurse that she may not use the password

A grandson calls the crisis center expressing concern about his grandmother, who lost her husband a month ago. He states, "She has been in bed for a week and is not eating or showering. She told me that she did not want to kill herself, but it is not like her to do nothing for herself. She will not even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which reason? The behaviors reflect altered role performance. The behaviors may reflect passive suicidal thoughts. Refusing to talk to the grandson alone indicates a major problem. Seeing the grandson and grandmother together will be helpful.

The behaviors may reflect passive suicidal thoughts.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? The physician, so he can provide education about HELLP syndrome The chaplain, because his educational background includes strategies for handling grief The human resource director, so she can arrange vacation time for the staff The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff

The chaplain, because his educational background includes strategies for handling grief

A client is being discharged with a prescription for enoxaparin. What will the nurse document to address that medication teaching occurred? Select all that apply. The client's response to teaching The client's ability to pay for the medication The client knows the time for the next dose The client knows adverse effects such as bleeding, bloody or black stools. The client can select a site for injection

The client's response to teaching The client knows the time for the next dose The client can select a site for injection The client knows adverse effects such as bleeding, bloody or black stools.

The school health nurse is conducting a teaching session for parents to provide information about the human papillomavirus (HPV) vaccination. What prevention information should the nurse include in the session? The HPV vaccination prevents the future need for cervical cancer screening in women. The effect of the vaccination is optimized if it is administered before the child becomes sexually active. The vaccination is available only to girls but, in the long term, protects both genders from sexually transmitted infections. A Pap smear test is required prior to administration of the HPV vaccination.

The effect of the vaccination is optimized if it is administered before the child becomes sexually active.

The nurse is working in a hospital. Which example(s) of a nurse executing a healthcare provider's orders are correct? Select all that apply. The nurse clarifies a medication dose of metoprolol 200mg intravenous as needed for systolic blood pressure > 160mmHg The nurse accepts a fax order for bisacodyl 10mg suppository now. The nurse accepts a telephone order for non-rebreather mask oxygen for a client with a pulse oximetry of 98%. The nurse repeats back the healthcare provider telephone order. The nurse telephones the healthcare provider for routine admission orders.

The nurse repeats back the healthcare provider telephone order. The nurse accepts a fax order for bisacodyl 10mg suppository now. The nurse clarifies a medication dose of metoprolol 200mg intravenous as needed for systolic blood pressure > 160mmHg

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should include a note on the client's chart that mentions the report. The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse should await results of the x-ray before filing the report. The nurse should make a copy of the safety event report and place it in the client's medical record.

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

The nurse's unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught? The percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity The amount of education the acute MI clients received on the telemetry unit The quality of teaching by the nurses who educate the acute MI clients on the telemetry unit The clients' perception of the quality of the discharge instructions

The percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity

Unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene? The call light is pinned to the head of the bed in the client's reach. The night light is dimmed, giving low-level lighting to the room. The side rails on the head and foot of the bed are in the up position. There is a clear path to the bathroom.

The side rails on the head and foot of the bed are in the up position.

The new nurse is caring for a client of Asian descent. What should the nurse expect when caring for this client? The nurse should sit close to the client. This client will require the nurse to keep an arm's length distance. This client will touch the nurse during conversations. Maintain eye contact when communicating.

This client will require the nurse to keep an arm's length distance.

Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? Diabetic ketoacidosis Thyroid crisis Tetany Hypoglycemia

Thyroid crisis

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? Functional residual capacity Vital capacity Maximal voluntary ventilation Tidal volume

Tidal volume

A nurse is counseling a client at a crisis center after her house burned down and her daughter was killed. Which action by the nurse is a priority? To establish a basis for long-term therapy To provide a basis for admission to an acute care facility To assist in psychological resolution of the immediate crisis To solve the client's problems for her

To assist in psychological resolution of the immediate crisis

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care? Encourage coughing and deep breathing, and limit fluid intake. Provide only passive range of motion (ROM), and decrease stimulation. Turn the client every 2 hours, and encourage coughing and deep breathing. Have the client lie as still as possible, and give adequate pain medication.

Turn the client every 2 hours, and encourage coughing and deep breathing.

A nurse is caring for a 55-year-old postoperative client. The client returns to the ICU after surgery intubated and mechanically ventilated with a Salem sump nasogastric tube, a Foley catheter, and a PICC line in place. Based on the nurse's knowledge of the most common hospital-acquired infections, which apparatus is most important to remove first? PICC line Salem sump nasogastric tube Endotracheal tube Urinary catheter

Urinary catheter

The nurse in the intensive care unit is giving a report to the nurse in the postsurgical unit about a client who had a gastrectomy. What is the most effective way for the nurse to assure essential information about the client is reported? Use a printed checklist with information individualized for the client. Give the report face-to face with both nurses in a quiet room. Document essential transfer information in the client's electronic health record. Audiotape the report for future reference and documentation.

Use a printed checklist with information individualized for the client.

In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? Use imagery, humor, and progressive relaxation Encourage the patient to sleep Gently massage the arms and legs Offer small amounts of nourishment frequently

Use imagery, humor, and progressive relaxation

A nurse in a rural health center meets a new client, age 4. The nurse notices as the client enters the clinic that his legs appear to be bowed. When he smiles, the nurse also notes that his dentition is quite malformed for a child his age. What vitamin deficiency would the nurse most suspect? Vitamin D Vitamin A Vitamin B Vitamin C

Vitamin D

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy. Which of the following vitamins would be affected by this? Vitamin A Vitamin E Vitamin D Vitamin K

Vitamin K

A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi? Adenosine (Adenocard) Warfarin (Coumadin) Atropine Amiodarone (Pacerone)

Warfarin (Coumadin)

Which finding is considered normal in the neonate during the first few days after birth? Weight loss of 25% Birth weight of 4½ to 5½ lb (2,000 to 2,500 g) Weight loss then return to birth weight Weight gain of 25%

Weight loss then return to birth weight

The charge nurse is making client care assignments for the evening shift. One of the licensed practical nurses (LPNs) is a new graduate in orientation. Which client would be an appropriate care assignment for this LPN? a 32-year-old client hospitalized for chemotherapy treatment a 41-year-old client with unstable angina a 5-year-old client with Kawasaki's disease a 72-year-old client with diverticulitis

a 72-year-old client with diverticulitis

A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order from first to last should the nurse assess these clients? All options must be used. 1 a client with type 2 diabetes who had a cerebrovascular accident 4 days ago 2 a client receiving D5W IV at 125 mL/h with 75 mL remaining 3 a client who has an endotracheal tube and who will be transferred to a long-term respiratory care unit that day 4 a client with cellulitis of the left lower extremity with a fever of 100.8° F (38.2° C)

a client who has an endotracheal tube and who will be transferred to a long-term respiratory care unit that day a client with cellulitis of the left lower extremity with a fever of 100.8° F (38.2° C) a client receiving D5W IV at 125 mL/h with 75 mL remaining a client with type 2 diabetes who had a cerebrovascular accident 4 days ago

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first? a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular a client with cirrhosis who is depressed and has refused to eat for the past 2 days a client with pancreatitis whose family requests to speak with the HCP regarding the treatment plan a client with stable vital signs that has been receiving IV cipro following a cholecystectomy for 1 day and has developed a rash on the chest and arms

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular

A client has been taking furosemide for 2 days. The nurse should assess the client for: an elevated sodium level. an elevated blood urea nitrogen (BUN) level. an elevated potassium level. a decreased potassium level.

a decreased potassium level.

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer? headaches in the morning discomfort when drinking cold liquids a feeling of swelling at the back of the throat weight loss

a feeling of swelling at the back of the throat

A client with schizophrenia hears a voice telling him that he is evil and must die. The nurse understands that this client is experiencing: a hallucination. a delusion. ideas of reference. flight of ideas.

a hallucination.

To help prevent the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use a hip-abductor pillow. pillows under the lower legs. a trochanter roll extending from the crest of the ilium to the midthigh. a footboard.

a trochanter roll extending from the crest of the ilium to the midthigh.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: advance the affected leg. advance both legs. advance the unaffected leg. advance both crutches.

advance both crutches.

For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via MDI, and beclomethasone, two puffs twice a day via MDI. The nurse should instruct the client to administer: beclomethasone inhaler first and follow with albuterol. albuterol first and follow with beclomethasone 2 times a day. albuterol on awakening and alternate the medications every 4 hours. medications 1 hour apart, 2 times a day.

albuterol first and follow with beclomethasone 2 times a day.

A client will receive IV midazolam hydrochloride during surgery. Which finding indicates a therapeutic effect? amnesia mild agitation blurred vision nausea

amnesia

Pudendal block

an anesthetic administered to block sensation around the lower vagina and perineum

celiac disease

an inherited autoimmune disorder characterized by a severe reaction to foods containing gluten

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note: severe abdominal pain radiating to the shoulder. eructation and constipation. abdominal ascites. anorexia, nausea, and vomiting.

anorexia, nausea, and vomiting.

The nurse manager has noticed a sharp increase in medication errors associated with IV antibiotic administration over the past 2 months. The nurse manager should discuss the situation with each nurse involved and then: report them to the supervisor. ask them to attend in-service training for administration of IV medications. document it on their evaluations. report the incidents to the hospital attorney.

ask them to attend in-service training for administration of IV medications.

The nurse is assessing a new client who states being allergic to nonsteroidal anti-inflammatories (NSAIDs. What subsequent assessment should the nurse prioritize? asking the client what the client's response is to taking NSAIDs asking if the client has tolerated narcotics and acetaminophen in the past assessing the client's pain tolerance and expectations for pain control assessing the client for signs and symptoms of inflammation

asking the client what the client's response is to taking NSAIDs

To obtain subjective data about a newly admitted client's sleep pattern, the nurse: documents the client's affect and yawning. asks the client what promotes sleep. determines how frequently the client naps. inspects the client's eyes for redness.

asks the client what promotes sleep.

A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should: reposition the pulleys so the traction is looser. assess the feet for signs of neurovascular impairment. remove the weight from the left leg. place a pillow under the child's buttocks to provide support.

assess the feet for signs of neurovascular impairment.

After a 3-month trial of dietary therapy, a client with type 2 diabetes still has blood glucose levels above 180 mg/dl (9.99mmol/L). The physician adds glyburide, 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take the glyburide: 30 minutes after dinner. at bedtime. at breakfast. in mid-morning.

at breakfast.

Aripiprazole (Abilify)

atypical antipsychotic

Olanzapine (Zyprexa)

atypical antipsychotic

A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. The nurse should instruct the client to: take aspirin to control nasal discomfort. apply heat to the nasal area to control swelling. avoid activities that elicit the Valsalva maneuver. avoid brushing the teeth until the nasal packing is removed.

avoid activities that elicit the Valsalva maneuver.

The nurse teaches the client with iron deficiency anemia that food sources with high iron content include: cheese. apples. beef. squash.

beef.

When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem? blindness secondary to gonorrhea strabismus resulting from neonatal maturation chorioretinitis from cytomegalovirus cataracts from beta-hemolytic streptococcus

blindness secondary to gonorrhea

The nurse is checking the laboratory results of an adult client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed? blood glucose total cholesterol low-density lipoprotein (LDL) cholesterol hemoglobin

blood glucose

A client diagnosed with cancer is receiving chemotherapy. The nurses should assess which diagnostic value while the client is receiving chemotherapy? liver tissues pancreatic enzymes heart tissues bone marrow cells

bone marrow cells

A parent brings a 7-month-old infant to the well-baby clinic for a check-up. The parent feeds the infant formula whenever the infant is hungry but is concerned that the infant is overweight. The nurse should instruct the parent to: give the infant 2% milk formula and add vitamins. decrease the amount of formula feedings to 16 oz (480 ml) daily and supplement with juice and water. use skim milk because it is high in protein and lower in calories. bring a 3-day record of the infant's intake back for further evaluation.

bring a 3-day record of the infant's intake back for further evaluation.

A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug? diuretic nitrate calcium-channel blocker beta-adrenergic blocker

calcium-channel blocker (Cardizem category)

A client is scheduled for an intravenous pyelogram (IVP). The evening before the procedure, the nurse learns that the client is allergic to shellfish. The nurse should: keep the client on nothing-by-mouth (NPO) status. cancel the IVP and notify the health care provider (HCP). administer an antiflatulent to the client to relieve gas. administer a cathartic to the client to empty the colon.

cancel the IVP and notify the health care provider (HCP).

A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" The nurse's reply should be based on the knowledge that COAG: leads to detachment of the retina. results from chronic eye inflammation. causes increased intraocular pressure. is caused by decreased blood flow to the retina.

causes increased intraocular pressure.

A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for: irregular contractions. changes in cervical effacement and dilation after 1 to 2 hours. contractions that feel like pressure in the abdomen and groin. increased fetal movement.

changes in cervical effacement and dilation after 1 to 2 hours.

parental

characteristic of a mother or father

Which behavior by a neonate attempting an initial feeding should indicate to the nurse that the neonate may have tracheoesophageal fistula? sucking attempts that are too poorly coordinated to be effective projectile vomiting that occurs after drinking 4 oz (120 mL) sleeping that occurs after taking 10 mL of formula coughing, choking, and cyanosis that occur after several swallows of formula

coughing, choking, and cyanosis that occur after several swallows of formula

A client's abdominal incision eviscerates. The nurse should first: take the client's vital signs and call the health care provider (HCP). cover the incision with a dressing moistened with sterile normal saline solution. lower the client's head and elevate the feet. start an emergency infusion of IV fluids.

cover the incision with a dressing moistened with sterile normal saline solution.

The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory finding should be reported to the surgeon and anesthesiologist? red blood cells, 4.5 million/mm3 (4.5 X 1012/L) hemoglobin, 12.2 g/dL (122 g/L) creatinine, 2.6 mg/dL (230 µmol/L) blood urea nitrogen, 15 mg/dL (5.4 mmol/L)

creatinine, 2.6 mg/dL (230 µmol/L)

A nurse is caring for a 55-year-old man from Thailand. The client has bacterial pneumonia and a temperature of 104°F (40.0°C); yesterday his temperature was 102°F (38.9°C). The physician on call prescribes cool compresses for the client to help lower the fever. However, the client insists that the nurse bring him warm blankets because they will help him recover more quickly. The nurse recognizes that the client's request is an example of: cultural competence. ethnocentrism. cultural ritual. cultural stereotyping.

cultural ritual.

When developing the discharge plan for the parents of an infant who has undergone a myelomeningocele repair, what information is most important for the nurse to include? chaplain referral for psychological support schedule for daily home health care daily care required by the infant a list of available hospital services

daily care required by the infant

What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate? decreased amnesia decreased secretions increased respiratory rate increased heart rate

decreased secretions

The nurse is reviewing laboratory reports for a client who is taking allopurinol. Which finding indicates that the drug has had a therapeutic effect? increased serum calcium level decreased serum uric acid level decreased urine alkaline phosphatase level increased urine calcium excretion

decreased serum uric acid level

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating ordered antibiotic therapy, the nurse should prepare the client for: amniocentesis. sonography. delivery. tocolytic therapy.

delivery.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: increase the amount of scarring. decrease circulation to the fingers. increase edema in the arms. dislodge the autografts.

dislodge the autografts.

The nurse is preparing to start an IV infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to: immobilize the arm. stabilize the veins. distend the veins. occlude arterial circulation.

distend the veins.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: eat food on only half of the plate. not be able to swallow liquids. forget the names of foods. have a preference for foods high in salt.

eat food on only half of the plate.

A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean birth because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain to the client that the decreased variability is most likely caused by which factor? maternal fatigue fetal malposition small-for-gestational-age fetus effects of analgesic medication

effects of analgesic medication

When discussing appropriate iron-rich food selections with the mother of an 11-month-old infant with iron deficiency anemia, which food choices verbalized by the mother indicates successful teaching? eggs, fruits, milk, and mixed vegetables fruits, cereals, milk, and yellow vegetables eggs, fortified cereals, meats, and green vegetables juices, fruits, fortified cereals, and milk

eggs, fortified cereals, meats, and green vegetables

The primigravid client is at +1 station and 9 cm dilated. Based on these data, the nurse should first: assist the client to push if she feels the need to do so. encourage the client to breathe through the urge to push. support family members in providing comfort measures. ask the anesthesiologist to increase epidural rate.

encourage the client to breathe through the urge to push.

Two days after an ileostomy, the client refuses care and requests to be left alone. The nurse should first: instruct the client about appropriate coping skills. allow the client privacy. invite a member of the ostomy association for a visit. encourage the client to verbalize feelings.

encourage the client to verbalize feelings.

The nurse is planning an educational program about the prevention of osteoporosis for a group of women. Which preventive measures would be appropriate for the nurse to include in the teaching plan? increasing daily intake of protein encouraging weight-bearing exercise on a regular basis ingesting 2,000 mg of calcium supplements daily sunbathing for 1 hour a day during the summer months

encouraging weight-bearing exercise on a regular basis

A client with chronic renal failure who receives hemodialysis three times weekly has a hemoglobin (Hb) level of 7 g/dl (70mmol/L). The most therapeutic pharmacologic intervention would be to administer: ferrous sulfate. filgrastim. epoetin alfa. enoxaparin.

epoetin alfa.

extravasation

escape of blood from the blood vessel into the tissue

At 0800, the nurse reviews the amount of t-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), the nurse should: clamp the t-tube. irrigate the t-tube. evaluate the tube for patency. report the 24-hour drainage amount at 12 noon.

evaluate the tube for patency.

FDA approval of a drug for OTC availability includes: analysis of the diagnoses for which the medication may be used by the consumer. analysis of the cost of the drug to the consumer. studies involving the safe use of the medication by the consumer. evaluation of evidence that the consumer can use the drug safely, using information on the product label.

evaluation of evidence that the consumer can use the drug safely, using information on the product label.

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? at least every hour for the first 48 hours every 4 to 5 hours for the first 5 days after childbirth whenever she desires, until weaning occurs every 2 to 3 hours for the first 48 hours

every 2 to 3 hours for the first 48 hours

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding? an episode of nausea after administration of an epidural anesthetic evidence of spontaneous rupture of the membranes contractions 3 minutes apart and lasting 40 seconds sleeping after administration of IV nalbuphine

evidence of spontaneous rupture of the membranes

While making a home visit to a multigravida 2 weeks after the birth of viable twins at 38 weeks' gestation, the nurse observes that the client looks pale, has dark circles around her eyes, and is breastfeeding one of the twins. The client's apartment is clean, and nothing appears out of place. The client tells the nurse that she completed three loads of laundry this morning. A priority need for this client is: anxiety related to inability to cope with twins who are breast-feeding. fatigue related to home maintenance and caring for twins. possible anemia related to large volume of blood loss and twin birth. risk for imbalanced nutrition: Less than body requirements related to twin birth.

fatigue related to home maintenance and caring for twins.

A client in severe respiratory distress is admitted to the hospital. When assessing the client, the nurse should: complete a comprehensive physical examination. focus assessment on the respiratory system and distress. delay assessment until client's respiratory distress is resolved. conduct a complete health history.

focus assessment on the respiratory system and distress.

For the client with a substance abuse problem, which intervention would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs? recreation individual therapy group sessions solitary activities

group sessions

When planning the care of a client experiencing aggression, the nurse incorporates the principle of "least restrictive alternative," meaning that less restrictive interventions must be tried before more restrictive measures are employed. Which measure should the nurse consider to be the most restrictive? voluntary seclusion or time-out tension reduction strategies haloperidol given orally haloperidol given intramuscularly

haloperidol given intramuscularly

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps are kept in the client's hospital room for: handling of the dislodged radiation source. disposal of the client's eating utensils. storage of the radiation dose. disposal of emesis or other bodily secretions.

handling of the dislodged radiation source.

A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates the client is ready to try a liquid diet? The client: has had a bowel movement. has not requested pain medication for 8 hours. is hungry. has frequent bowel sounds.

has frequent bowel sounds.

A unit-based infection control task force was developed in an attempt to reduce catheter-acquired infections. The group consists of 10 team members. During the past three meetings, one person dominated the meeting and did not allow other members ample time to speak. The best way to address the team dysfunction is to: plan a meeting where the dominant person cannot attend. have group members confront the dominant member to promote the needed team work. pick a team leader who is not the dominant member. have group members issue a written warning to the dominant member.

have group members confront the dominant member to promote the needed team work.

A client with cancer is uncertain about how to cope with all the issues that will arise. The nurse can best support the coping behaviors of a client with cancer by: assisting the client to prepare for adverse treatment effects. encouraging compliance with treatment regimens. relieving the client of decision making as much as possible. helping the client identify available resources.

helping the client identify available resources.

HELLP syndrome

hemolysis, elevated liver enzymes, low platelet count

The client with a diagnosis of schizophrenia walks into group naked. The nurse should: instruct the client to go to his room and to put on some clothes. wrap a blanket around him and tell him to be seated for the remainder of group. ask a male client to take off his sweater and wrap it around the client's waist. lead the client to his room and help him dress if he needs assistance.

lead the client to his room and help him dress if he needs assistance.

Hirschsprung disease

hereditary defect causing absence of enteric nervous system

cystic fibrosis (CF)

hereditary disorder of the exocrine glands characterized by excess mucus production in the respiratory tract, pancreatic deficiency, and other symptoms

What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis (CF)? high-fat diet high-calorie diet low-carbohydrate diet low-protein diet

high-calorie diet

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? hold her breath throughout the length of the contraction flex her thighs onto her abdomen before bearing down be in a semi-Fowler's position or a position of comfort exert downward pressure as if she were having a bowel movement

hold her breath throughout the length of the contraction

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect? dysuria hyperkalemia constipation irregular pulse

hyperkalemia

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask: is too small because it obstructs the nose. is too large because it covers the neonate's eyes. is appropriate for the neonate. should be covered with a soft cloth before being placed against the skin.

is appropriate for the neonate.

A client has told the nurse that the client began taking black cohosh, a herbal supplement, a few weeks ago. In addition to informing the care provider, the nurse should: learn as much about the herbal supplement as possible. suggest over-the-counter alternatives to the herbal supplement. inform the client that the use of herbs and supplements is dangerous. ask the client to stop taking the supplement immediately.

learn as much about the herbal supplement as possible.

After teaching the mother of a 7-month-old diagnosed with bronchiolitis, the nurse determines that the teaching has been effective when the mother states she will immediately report which sign or symptom? longer periods of sleep than usual seven wet diapers a day clear nasal discharge for longer than 2 days temperature of 100° F (37.8° C) for 2 days

longer periods of sleep than usual

A school-age child diagnosed with attention deficit hyperactivity disorder is prescribed methylphenidate. What finding should alert the school nurse to the possibility that the child is experiencing a common side effect of the drug? photosensitivity loss of appetite vomiting weight gain

loss of appetite

The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a: high glucose level. low sodium level. high calcium level. low potassium level.

low potassium level.

The nurse is reviewing the laboratory test results of a patient who is suspected of having a nutritional deficiency. Which of the following would the nurse identify as helping to support this diagnosis? high transferrin levels high lymphocyte count low serum albumin levels high prealbumin level

low serum albumin levels

The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which topic is most important to include in the plan? maintaining a safe environment engaging in diversional activity enhancing the immune system maintaining a balanced nutritional diet

maintaining a safe environment

Crede maneuver

massage from top of bladder to bottom by starting above the pubic bone and rocking the palm of the hand steadily downward

A client diagnosed with paranoid personality disorder is hospitalized for physically threatening his wife because he suspects her of having an affair with a coworker. What approach should the nurse employ with this client? controlling authoritarian matter-of-fact parental

matter-of-fact

The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore? mobility status circulatory status nutritional status orientation status

mobility status

Following a subtotal gastrectomy, a client has a nasogastric (NG) tube connected to low suction. The nurse should: reposition the tube if it is not draining well. change to high suction if the drainage is sluggish on low suction. irrigate the tube with 30 ml of sterile water every hour, if needed. monitor the client for nausea, vomiting, and abdominal distention.

monitor the client for nausea, vomiting, and abdominal distention.

myelomeningocele

most severe form of spina bifida in which the spinal cord and meninges protrude through the spine

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn mediciations would the nurse administer next? magnesium hydroxide (Maalox) meperidine (Demerol) ondansetron (Zofran) loperamide (Imodium)

ondansetron (Zofran)

The nurse who is caring for a client in contact isolation is preparing to conduct an assessment. Which stethoscope will the nurse choose to auscultate the client's bowel sounds? one that remains directly outside the client's room one that the client has personally purchased for use one that remains in the client's room one that is the nurse's personal stethoscope

one that remains in the client's room

When preparing a 20-month-old for removal of a foreign body in the nasal passage by the health care provider (HCP), the nurse should use which method of restraint? use of father to hold elbow restraint papoose board jacket restraint

papoose board

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: preoperative cleansing of jewelry worn by the surgical team. performing a preoperative surgical scrub for at least 3 to 5 minutes. using sterile surgical scrubs. applying bandages to cover any wounds surgical team members have.

performing a preoperative surgical scrub for at least 3 to 5 minutes.

A nurse in the telemetry unit is caring for a client with diagnosis of postoperative coronary artery bypass graft (CABG) surgery from 2 days ago. On assessment, the nurse notes a paradoxical pulse of 88. Which surgical complication would the nurse suspect? complete heart block aortic regurgitation left-sided heart failure pericardial tamponade

pericardial tamponade

A primigravida in active labor is about 10 days postterm. The client desires a pudendal block anesthetic before childbirth. After the nurse explains this type of anesthesia to the client, which location if identified by the client as the area of relief would indicate to the nurse that the teaching was effective? fundus perineum abdomen back

perineum

A client has short-term memory loss. To help the client cope with memory loss, the nurse should: ask the client to try harder to remember things. tell the client in the morning what activities will be expected to be performed that day. instruct family members to ignore the behavior. place a single-date calendar where the client can view it.

place a single-date calendar where the client can view it.

A parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to: help the child assume a comfortable position with the head tilted backward. tilt the child's head backward and place firm pressure on the nose. place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum. help the child lie on the stomach and collect the blood on a clean towel.

place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum.

The nurse is interested in serving as an expert nursing witness in the court of law. What actions will support the nurse expert witness role? Select all that apply. researching legal medical lawsuits attaining an advanced nursing degree gaining work experience as a paralegal achieving a solid educational background practicing in multiple clinical experiences

practicing in multiple clinical experiences achieving a solid educational background

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

progressively deeper breaths followed by shallower breaths with apneic periods.

hyperemesis gravidarum

severe nausea and vomiting in pregnancy that can cause severe dehydration in the mother and fetus

During assessment of a child with celiac disease, the nurse should most likely note which physical finding? enlarged liver protuberant abdomen periorbital edema tender inguinal lymph nodes

protuberant abdomen

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should wear gloves when: entering the room. delivering the client's food tray. taking a blood pressure. providing mouth care.

providing mouth care.

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level? body temperature blood pressure respiratory rate pulse rate

pulse rate

A client recently admitted to the hospital with sharp, substernal chest pain suddenly reports palpitations. The client ultimately admits to using cocaine 1 hour before admission. The nurse should immediately assess the client's: neurobehavioral functioning. pulse rate and character. level of consciousness. anxiety level.

pulse rate and character.

The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the health care provider (HCP) because these signs are indicative of which problem? diaphragmatic hernia pyloric stenosis esophageal atresia hiatal hernia

pyloric stenosis

Parents who bring a 3-week-old neonate to the hospital report that he's been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm: diaphragmatic hernia. imperforate anus. pyloric stenosis. gastroschisis.

pyloric stenosis.

The nurse in the emergency department is triaging victims of an airplane crash. Prioritize the clients in the order in which they should be treated from first to last. All options must be used. 1 a 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes 2 q 14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing 3 a 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm 4 a 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused

q 14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing a 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused a 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes a 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm

Glycopyrrolate (Robinul)

quaternary anticholinergic agent used for treatment of peptic ulcers-- less likely to cross BBB

Lung Infarction

rarely happens as a result of pulmonary infarction due to dual ciruclation from the pulmonary and bronchial systems (collateral ciruclation)

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: control chest pain. revascularize the blocked coronary artery. reduce coronary artery vasospasm. control the arrhythmias associated with MI.

revascularize the blocked coronary artery.

A female client is treated for trichomoniasis with metronidazole. The nurse instructs the client that: the medication should not alter the color of the urine. she should avoid alcohol during treatment and for 24 hours after completion of the drug. her partner does not need treatment. she should discontinue oral contraceptive use during this treatment.

she should avoid alcohol during treatment and for 24 hours after completion of the drug.

A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which symptom? bleeding gums slow pulse epistaxis petechiae

slow pulse

An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element? fluids protein sodium potassium

sodium (vertigo)

Chvostek's sign

spasm of the facial muscles produced by sharply tapping over the facial nerve in front of the parotid gland and anterior to the ear; suggestive of latent tetany in patients with hypocalcemia

A nurse is providing dietary teaching to a pregnant client. To help meet the client's iron needs, the nurse should advise her to eat: eggs and citrus fruit. grains and milk. tomatoes and fish. spinach and beef.

spinach and beef.

A male neonate with a 3 X 5-cm sac in the lumbar region of his back is diagnosed with myelomeningocele. What should the nurse expect to find when inspecting this sac? serosanguineous fluid and fatty tissue spinal fluid, nerve tissue, and spinal bony defect spinal fluid and meninges bits of hair covered by skin

spinal fluid, nerve tissue, and spinal bony defect

Assertive behavior involves: expressing an air of superiority. standing up for one's rights while respecting the rights of others. avoiding unpleasant situations and circumstances. saying what is on one's mind at the expense of others.

standing up for one's rights while respecting the rights of others.

Which action would not be appropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc? starting an IV line at keep-open rate checking for previous reports of claustrophobia informing the client that the procedure is painless taking a thorough history of past surgeries

starting an IV line at keep-open rate

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: fill out the menu for the client. stay with the client and encourage him to eat. give the client privacy during meals. help the client fill out his menu.

stay with the client and encourage him to eat.

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: give the client privacy during meals. fill out the menu for the client. stay with the client and encourage him to eat. help the client fill out his menu.

stay with the client and encourage him to eat.

An older adult client in a long term care facility is concerned about bowel regularity. During a client education session, the nurse reinforces the medically acceptable definition of "regularity." What is the actual measurement of "regular"? stool consistency and client comfort one bowel movement daily two bowel movements daily one bowel movement every other day

stool consistency and client comfort

One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: stop smoking. avoid eating low-fat foods. elevate the legs above the heart. begin a jogging program.

stop smoking.

When planning home care for a 3-year-old child with eczema, what should the nurse teach the mother to remove from the child's environment at home? wooden blocks stuffed animals plastic figures metal toy trucks

stuffed animals

vesicant

substance that can broduce blistering on direct blistering on direct contact with skin or mucous membrane

A client with rheumatoid arthritis is taking high doses of nonsteroidal anti-inflammatory medications. The nurse should instruct the client to: take prescribed medication with food to lessen the likelihood of an upset stomach. not drive if dizziness occurs. use mouthwash to rinse the mouth after taking this medication. not stop taking the medication suddenly; the dose needs to be decreased gradually.

take prescribed medication with food to lessen the likelihood of an upset stomach.

A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine sulfate I.V. by patient-controlled analgesia (PCA) 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should: discontinue the PCA pump. administer oxygen. assist the client back to bed. take the client's blood pressure.

take the client's blood pressure.

A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. The nurse should tell the client to: take the medication immediately. restart the medication in the morning. take two pills tonight before bedtime. use another form of contraception for 2 weeks.

take the medication immediately.

A newly pregnant woman tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to: switch brands. take the vitamin first thing in the morning. take the vitamin with orange juice for better absorption. take the vitamin on a full stomach.

take the vitamin on a full stomach.

After treatment with radioactive iodine (RAI, 1-131) I, the nurse should teach the client to: take thyroxine replacement for the remainder of the client's life. monitor for signs and symptoms of hyperthyroidism. assess for hypertension and tachycardia resulting from altered thyroid activity. rest for 1 week to prevent complications of the medication.

take thyroxine replacement for the remainder of the client's life.

A 77-year-old client is brought to the emergency department by her son. The client has a severe headache and lack of sleep because "I am so worried about everything." Her son says that she has heart failure and chronic schizophrenia. "In addition to all of her heart medicines, she is on aripiprazole, which was increased to 30 mg by her health care provider (HCP) 3 days ago." In addition to documenting all of the client's medications and exact dosages, the nurse should particularly investigate which factors? Select all that apply. the client's symptoms of heart failure the client's symptoms of schizophrenia the qualifications of the client's HCP the client's relationship with her son the dose of aripiprazole

the client's symptoms of schizophrenia the dose of aripiprazole the client's symptoms of heart failure

diplopia

the perception of two images of a single object

The nurse instructs a client who is taking iron supplements that: a daily bulk laxative such as psyllium hydrophilic mucilloid should be avoided. liquid iron supplements will not discolor teeth. the stools will become darker. iron supplements should be taken on an empty stomach.

the stools will become darker.

The nurse is conducting an educational program for unlicensed personnel on the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The nurse determines that the unlicensed personnel understand HIPAA when they state that it prohibits two physicians from discussing their patient's condition. interdisciplinary team care-planning sessions. the use of genetic information to establish insurance eligibility. insurance coverage exclusions based on specific conditions.

the use of genetic information to establish insurance eligibility.

the general systems theory

theory that organizations are a system composed of many subsystems and embedded in larger systems, and that organizations should develop communication strategies that serve both

thiazide

thiazide diuretic (water pill)

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. to ensure efficient and accurate communication to make data entry into a computerized health record easier to prevent medication errors to make it easier for clients to understand the medication prescription to ensure client safety

to ensure efficient and accurate communication to prevent medication errors to ensure client safety

The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to: place a few milliliters of water on the client's tongue and note whether the client swallows. touch the back of the client's throat with a tongue blade. observe the client's response to the introduction of a catheter for endotracheal suctioning. observe the client for evidence of spontaneous swallowing when the neck is stroked.

touch the back of the client's throat with a tongue blade.

A client, age 87, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find: permanent long-term memory loss and hypomania. transitory short-term memory loss and permanent long-term memory loss. transitory short- and long-term memory loss and confusion. permanent short-term memory loss and hypertension.

transitory short- and long-term memory loss and confusion.

The client has tearfully described her negative feelings about herself to the nurse during their last three interactions. Which goal would be most appropriate for the nurse to include in the plan of care at this time? The client will: write her negative feelings in a daily journal increase her self-esteem verbalize her work-related accomplishments verbalize three things she likes about herself

verbalize three things she likes about herself

Sympathomimetic drugs

type of stimulant - act on adrenergic receptors from nerve endings -acting indirectly on catecholamines ex: ephedrine which can cause mental stimulation and increased blood flow - often found in cold remedies

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings signify: an infection. umbilical cord prolapse. the start of the second stage of labor. the need for labor induction.

umbilical cord prolapse.

A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: inability to function as a responsible parent. somatic symptoms. coldness, detachment, and lack of tender feelings. unpredictable behavior and intense interpersonal relationships.

unpredictable behavior and intense interpersonal relationships.

When preparing a 3-year-old child to have blood specimens drawn for laboratory testing, the nurse should: use distraction techniques during the procedure. explain the procedure in advance. provide verbal explanations about what will occur. explain why the blood needs to be drawn.

use distraction techniques during the procedure.

When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, which information should the nurse expect to include? use of sponge baths until the stitches are removed use of prophylactic antibiotics before receiving any dental work restriction of the child's activities for the next 3 weeks maintenance of a pressure dressing until a return visit with the health care provider (HCP)

use of prophylactic antibiotics before receiving any dental work

A nurse is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should: perform only two-person CPR. use the heel of one hand for sternal compressions. deliver 12 breaths/minute. compress the sternum with both hands at a depth of 1½″ to 2″ (4 to 5 cm).

use the heel of one hand for sternal compressions.

The primary health care provider (HCP) prescribes whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first: administer 100 ml of 5% dextrose solution intravenously. validate client information and the blood product with another nurse. check the vital signs before transfusing over 5 to 6 hours. ask the client if she has ever had any allergies.

validate client information and the blood product with another nurse.

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse should first: place the mitt on top of the hand. verify the prescription to use the restraint. place a folded pillow under the wrist. secure the mitt with ties around the wrist tied to the bed frame.

verify the prescription to use the restraint.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse makes which observation? use of protective goggles during a cesarean birth placement of bloody sheets in a container designated for contaminated linens disposal of used scalpel blades in a puncture-resistant container wearing of sterile gloves to bathe a neonate at 2 hours of age

wearing of sterile gloves to bathe a neonate at 2 hours of age