NCLEX PREP
The breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. The nurse should tell the mother to avoid which food? A. Milk B. Egg Yolk C. Dried Beans D. Green Leafy Vegetables
A. Milk Rationale: Breast-feeding mothers with lactose-intolerant infants need to be encouraged to limit dairy products. Milk is a dairy product. Alternative calcium sources that can be consumed by the mother include egg yolk, green leafy vegetables, dried beans, cauliflower, and molasses.
The clinic nurse is assessing a child for dehydration. The nurse determines that the child is moderately dehydrated if which finding is noted on assessment? A. Oliguria B. Flat fontanels C. Pale skin color D. Moist mucous membranes
A. Oliguria Rationale: In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present.
A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? A. Elastic wrap B. Sterile 2 × 2 gauze C. Adhesive bandage D. Povidine-iodine swab
B. Sterile 2 × 2 gauze Rationale: A dry sterile dressing such as sterile 2 × 2 gauze is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A povidine-iodine swab would irritate the opened puncture site and would not stop the blood flow. An adhesive bandage or elastic wrap may be used to cover the site once hemostasis has occurred
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? A. Witnessing a murder B. The death of a loved one C. A fire that destroyed the client's home D. A recent rape episode experienced by the client
B. The death of a loved one Rationale: A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).
Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. A. It cushions and protects the baby. B. It maintains the temperature of the baby. C. It is the way the baby gets food and oxygen. D. It prevents all antibodies and viruses from passing to the baby. E. It provides an exchange of nutrients and waste products between the mother and developing fetus.
C. It is the way the baby gets food and oxygen. E. It provides an exchange of nutrients and waste products between the mother and developing fetus. Rationale: The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.
The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd).
1116 Rationale: Accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. To calculate the estimated date of delivery, the nurse would subtract 3 months from the first day of the LMP, then add 7 days, and add 1 year if appropriate. First day of LMP: February 9; subtract 3 months: November 9; add 7 days: November 16; and add 1 year as appropriate.
A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2018, and ended the menses on March 14, 2018. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits (mmddyy).
121419 Rationale: Nägele's rule is a noninvasive method for estimating the date of birth and is based on the assumption that the menstrual cycle is 28 days. The rule states the following: Subtract 3 months from the first day of the last menstrual period, add 7 days, then adjust the year. March 7, 2018, minus 3 months is December 7, 2017. December 7, 2017, plus 7 days is December 14, 2017. Adding 1 year brings the date of delivery to December 14, 2018.
The nurse provides home care instructions to a client undergoing hemodialysis with regard to care of a newly created arteriovenous (AV) fistula. Which client statement indicates that teaching was effective? A. "I should check the fistula every day by feeling it for a vibration." B. "I am glad that the laboratory will be able to draw my blood from the fistula." C. "I should wear a shirt with tight arms to provide some compression on the fistula." D. "I should check my blood pressure in the arm where I have my fistula every week."
A. "I should check the fistula every day by feeling it for a vibration." Rationale: An AV fistula provides access to the client's bloodstream for the dialysis procedure. The client is instructed to monitor fistula patency daily by palpating for a thrill (vibration feeling). The client is instructed to avoid compressing the fistula with tight clothing or when sleeping and that blood pressure measurements and blood draws should not be performed on the arm with the fistula. The client also is instructed to assess the fistula for signs and symptoms of infection, including pain, redness, swelling, and excessive warmth
The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room? A. Wash hands and don a surgical mask. B. Wash hands and wear a gown and gloves. C. Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. D. The nurse needs no precautions. The client is instructed to cover the mouth and nose when coughing.
C. Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. Rationale: The nurse wears an HEPA respirator mask when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Options 1, 2, and 4 offer inadequate protection. In addition, a surgical mask will not protect against Mycobacterium tuberculosis.
Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the health care provider if which diagnosis is documented in the client's history? A. Gout B. Asthma C. Myocardial infarction D. Venous thromboembolism
D. Venous thromboembolism Rationale: Megestrol acetate suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of venous thromboembolism. Options 1, 2, and 3 are not contraindications for this medication.
The nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention should the nurse include in the list? A. Report any signs of respiratory infection to the health care provider. B. Avoid breathing exercises to allow the diaphragm to strengthen. C. Avoid lifting any objects greater than 30 pounds for at least 3 weeks. D. Contact the health care provider if any feelings of weakness and fatigue occur.
A. Report any signs of respiratory infection to the health care provider. Rationale: After a pneumonectomy, if any signs of respiratory infection occur, the health care provider should be notified. The client is instructed to perform breathing exercises for the first 3 weeks at home and to space activities to allow for frequent rest periods. The client also should be instructed to avoid heavy lifting of any objects more than 20 pounds until the muscles of the chest wall have healed completely, which takes about 3 to 6 months. The client should be told to expect feelings of weakness and fatigue for the first 3 weeks after surgery
A nurse provides dietary instructions to a client who will be taking warfarin sodium. The nurse should tell the client to avoid which food item? A. Grapes B. Spinach C. Watermelon D. Cottage cheese
B. Spinach Rationale: Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of phytonadione, which is needed for clotting. When a client is taking an anticoagulant, foods high in phytonadione often are omitted from the diet. Phytonadione-rich foods include green leafy vegetables, fish, liver, coffee, and tea.
At what time of day does the nurse recommend that a child prescribed methylphenidate be given the last dose of the day of the medication? A. At bedtime B. With a bedtime snack C. Just before the noontime meal D. In the morning, 2 hours before breakfast
C. Just before the noontime meal Rationale: Methylphenidate is used to treat attention deficit hyperactivity disorder and has stimulant effects. Children with should take the morning dose after breakfast and the last daily dose should be taken at least 6 hours before bedtime (14 hours for extended-release forms) to prevent insomnia. Usually the health care provider recommends that the last dose be given just before the noontime meal. The other options are incorrect
Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? A. Platelet count B. Neutrophil count C. Liver function tests D. Complete blood count
C. Liver function tests Rationale: Zafirlukast is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication. It is not necessary to perform the other laboratory tests before administration of the medication.
A home care nurse is teaching an adolescent with type 1 diabetes mellitus about insulin administration and rotation sites. Which statement, if made by the adolescent, would indicate effective teaching? A. "I should use only my stomach and my thighs for injections." B. "I need to use a different major site for each insulin injection." C. "I should use the same major site for 1 month before rotating to another site." D. "I need to give 4 to 6 injections in one area, about an inch apart, and then move to another area."
D. "I need to give 4 to 6 injections in one area, about an inch apart, and then move to another area." Rationale: The most efficient rotation plan involves giving about four to six injections in one area, each injection about 1 inch (2.5 cm) apart, or the diameter of the insulin vial from the previous injection, and then moving to another area of the major site the next day. All other options are incorrect.
The nurse has a prescription to begin aneurysm precautions for a client with a subarachnoid hemorrhage secondary to aneurysm rupture. The nurse would plan to incorporate which intervention in controlling the environment for this client? A. Keep the window blinds open. B. Turn on a small spotlight above the client's head. C. Make sure the door to the room is open at all times. D. Prohibit or limit the use of a radio or television and reading.
D. Prohibit or limit the use of a radio or television and reading. Rationale: Environmental stimuli are kept to a minimum with subarachnoid precautions to prevent or minimize increases in intracranial pressure. For this reason, lighting is reduced by closing window blinds and keeping the door to the client's room shut. Overhead lighting also is avoided for the same reason. The nurse prohibits television, radio, and reading unless this is so stressful for the client that it would be counterproductive. In that instance, minimal amounts of stimuli by these means are allowed with approval of the health care provider.
The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and also notes that this is the client's first child. Which nursing interventions are most appropriate in assisting the promotion of mother-infant interaction and bonding? Select all that apply. A. Accepting the client's feelings B. Acknowledging the client's apprehension C. Assisting the client with giving the baths to allow her to become more at ease D. Leaving the infant with the client so that she will be required to provide the care E. Taking the newborn back to the nursery to provide rest periods for the new mother
A. Accepting the client's feelings B. Acknowledging the client's apprehension C. Assisting the client with giving the baths to allow her to become more at ease Rationale: Acceptance of the new mother's feelings and acknowledgment of her apprehension can help an unsure mother begin to participate in caring for her newborn. Assistance will help the client become more at ease. A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Leaving the infant with the mother so that she will be required to provide the care will produce additional apprehension. Removing the infant to the nursery does not promote mother-infant bonding.
The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? A. After a shower or bath B. While standing to void C. After having a bowel movement D. While lying in bed before arising
A. After a shower or bath Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE.
The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? A. Assess for signs and symptoms of labor. B. Assess the client's temperature every 2 hours. C. Schedule a daily ultrasound to assess fetal movement. D. Schedule a nonstress test every 4 hours to assess fetal well-being.
A. Assess for signs and symptoms of labor. Rationale: As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours.
The nurse is caring for a client with Paget's disease who has a serum calcium level of 12.3 mg/dL (3.1 mmol/L). The nurse should check to see that which medication is available in the stock medication supply for possible use to reverse this elevation? A. Calcitonin B. Vitamin D C. Calcium chloride D. Calcium gluconate
A. Calcitonin Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. In hypercalcemia, large doses of vitamin D should be avoided. Calcium gluconate and calcium chloride would be used to treat tetany that results from acute hypocalcemia.
The nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by which manifestation? A. Dizziness B. Photophobia C. Bohemianism D. Blurred vision
A. Dizziness Rationale: Ménière's disease is a disorder of the inner ear characterized by dizziness and loss of balance. This requires the addition of safety to the care plan. The clinical manifestations in the remaining options are not found with Ménière's disease.
The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? A. Initiate bleeding precautions. B. Monitor closely for signs of infection. C. Monitor the temperature every 4 hours. D. Initiate protective isolation precautions.
A. Initiate bleeding precautions. Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 mm3 (20.0 × 109/L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Options 2, 3, and 4 are related to the prevention of infection rather than bleeding.
The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? A. Monitor the client for dysrhythmias. B. Encourage increased intake of phosphate antacids. C. Discontinue any magnesium-containing medications. D. Encourage intake of foods such as ground beef, eggs, or chicken breast.
A. Monitor the client for dysrhythmias. Rationale: The normal serum magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.
The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? A. One-to-one suicide precautions B. Suicide precautions with 30-minute checks C. Checking the whereabouts of the client every 15 minutes D. Asking the client to report suicidal thoughts immediately
A. One-to-one suicide precautions Rationale: One-to-one suicide precautions are required for a client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention is constant supervision so that the nurse may intervene as needed if the client attempts to harm himself or herself.
The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client? A. Prepare a private room at the end of the hallway. B. Assign one primary nurse to care for the client during the hospital stay. C. Place a sign on the door that indicates that visitors are limited to 60-minute visits. D. Place a linen bag outside of the client's room for discarding linens after morning care.
A. Prepare a private room at the end of the hallway. Rationale: The client with an internal cervical radiation implant should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. Nurses assigned to this client should be rotated so that one nurse is not consistently caring for the client and being exposed to excess amounts of radiation. The client's room should be marked with appropriate signs (per agency policy) that indicate the presence of radiation. Visitors should be limited to 30-minute visits. All linens should be kept in the client's room until the implant is removed, in case the implant has dislodged and needs to be located.
After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? A. Waves of loud gurgles auscultated in all 4 quadrants B. Low-pitched swishing auscultated in 1 or 2 quadrants C. Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants D. Very high-pitched, loud rushes auscultated especially in 1 or 2 quadrants
A. Waves of loud gurgles auscultated in all 4 quadrants Rationale: Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with nausea and vomiting. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. Bowel sounds are very high-pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. Therefore, options 2, 3, and 4 are incorrect.
The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instruction if the client makes which statement? A. "I need to wear a Medic-Alert tag or bracelet." B. "I need to restrict my activity while this catheter is in place." C. "I need to have a repair kit available in the home for use if needed." D. "I need to keep the insertion site protected when in the shower or bath."
B. "I need to restrict my activity while this catheter is in place." Rationale: The client should be taught that only minor activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a Medic-Alert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use
The nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? A. "I will need to limit the amount of protein in my diet." B. "I should eat foods that have a lot of potassium in them." C. "I am fortunate that I can eat all of the salty foods I enjoy." D. "I am fortunate that I do not need to follow any special diet."
B. "I should eat foods that have a lot of potassium in them." Rationale: A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue
A nursing instructor asks a nursing student to describe the process of quickening. Which statements by the student indicate an understanding of this term? Select all that apply. A. "It is the thinning of the lower uterine segment." B. "It is the fetal movement that is felt by the mother." C. "It is irregular, painless contractions that occur throughout pregnancy." D. "It is the soft blowing sound that can be heard when the uterus is auscultated." E. "It is a process that occurs in the pregnant woman as early as 16 weeks but definitely by week 20."
B. "It is the fetal movement that is felt by the mother." E. "It is a process that occurs in the pregnant woman as early as 16 weeks but definitely by week 20." Rationale: Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements that gradually increase in intensity. A thinning of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, known as uterine souffle. This sound is caused by the blood circulation to the placenta and corresponds to the maternal pulse.
A nursing instructor asks the nursing student to describe the definition of a critical path. Which statement, if made by the student, indicates a need for further teaching regarding critical paths? A. "They are developed based on appropriate standards of care." B. "They are nursing care plans and use the steps of the nursing process." C. "They are developed through the collaborative efforts of members of the health care team." D. "They provide an effective way to monitor care and to reduce or control the length of hospital stay for the client."
B. "They are nursing care plans and use the steps of the nursing process." Rationale: Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. All other options appropriately describe the use of a critical path.
A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? A. "Do you think that having asthma will kill you?" B. "You seem very distressed over learning you have asthma." C. "Asthma is a treatable condition when medications are taken properly, so let's practice with your inhalant." D. "It will be difficult to work with you if you can't view this as a challenge rather than 'a nail in your coffin."
B. "You seem very distressed over learning you have asthma." Rationale: Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Eliminate options that are sarcastic or punitive. The only correct option is the one that respectfully addresses the concern presented by the client.
The nurse checks the laboratory results of a serum medication level assay for a newly admitted client taking digoxin 0.125 mg orally daily. Which value would indicate a therapeutic level? A. 0.1 ng/mL (0.13 nmol/L) B. 0.6 nag/mL (0.76 nmol/L) C. 1.8 ng/mL (2.30 nmol/L) D. 2.4 ng/mL (3.07 nmol/L)
B. 0.6 ng/mL (0.76 nmol/L) Rationale: The normal therapeutic range for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A value of 0.6 ng/mL (0.76 nmol/L) falls within the therapeutic range, and the medication would be continued as at home. A values of 0.1 (0.13 nmol/L) is lower than the therapeutic range and would require additional medication to be given. A value of 1.8 ng/mL (2.30 nmol/L) and 2.4 ng/mL (3.07 nmol/L) exceeds the therapeutic range, could be toxic to the client, and would be held.
A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? A. On arising B. After meals C. On an empty stomach D. 30 minutes before meals
B. After meals Rationale: Salicylate compounds, such as sulfasalazine, act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. The other options are incorrect and could cause gastric irritation
Tobramycin sulfate is prescribed. The nurse is administering the medication by intermittent intravenous infusion every 8 hours. The nurse monitors the client for signs of an adverse effect related to this medication and determines that which, if noted on assessment, would indicate its presence? A. Client complaint of diarrhea B. Client complaint of ringing in the ears C. A white blood cell count of 6000 mm3 (6 × 109/L) D. A blood urea nitrogen (BUN) of 10 mg/dL (3.6 mmol/L)
B. Client complaint of ringing in the ears Rationale: Adverse effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). A normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). The correct option is the only one that indicates an adverse effect of the medication
The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38 (7.38), Paco2 of 38 mm Hg (38 mm Hg), Pao2 of 86 mm Hg (86 mm Hg), and HCO3 of 23 mEq/L (23 mmol/L). What action should the nurse take in response to these results? A. Discontinue the oxygen. B. Continue monitoring the client. C. Call 911 to have the client intubated immediately. D. Have another set drawn because these results are not possible
B. Continue monitoring the client. Rationale: The client's results fall in the normal range for pH (7.35 to 7.45), Paco2 (35 to 45 mm Hg), and bicarbonate level (21 to 28 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis were present.
A child's fasting blood glucose levels range between 100 and 120 mg/dL (5.7 and 6.9 mmol/L) daily. The before-dinner blood glucose levels are between 120 and 130 mg/dL (6.9 and 7.4 mmol/L), with no reported episodes of hypoglycemia. Mixed insulin is administered before breakfast and before dinner. The nurse should make which interpretation about these findings? A. Exercise should be increased to reduce blood glucose levels. B. Insulin doses are appropriate for food ingested and activity level. C. Dietary needs are being met for adequate growth and development. D. Dietary intake should be increased to avoid hypoglycemic reactions.
B. Insulin doses are appropriate for food ingested and activity level. Rationale: Blood glucose levels are a measure of the balance among diet, medication, and exercise. Options 1 and 4 imply that the data analyzed are abnormal. The question presents no data for determining growth and development status, such as height, weight, age, or behavior. Supporting normal growth and development is an important goal in managing diabetes in children, but that is not what is being evaluated here.
The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which action to maintain the infant's safety? A. Covering the back dressing with a binder B. Placing the infant in a head-down position C. Strapping the infant in a baby seat sitting up D. Elevating the head with the infant in the prone position
B. Placing the infant in a head-down position Rationale: Elevating the head will decrease the chance that cerebrospinal fluid will accumulate in the cranial cavity. The infant needs to be prone or side-lying to decrease the pressure on the surgical site on the back. Binders and a baby seat should not be used because of the pressure they would exert on the surgical site
The nurse is caring for a client who has just returned from having a right-sided renal biopsy. Which action by the unlicensed assistive personnel (UAP) requires immediate follow-up by the nurse? A. Obtaining the client's vital signs B. Positioning the client on the left side C. Providing the client with reading materials D. Assisting the client to drink sips of fluid as prescribed
B. Positioning the client on the left side Rationale: A client who has undergone a renal biopsy should be positioned on the affected side or back (if prescribed); positioning on the affected side maximizes pressure to the area to prevent bleeding. Options 1, 3, and 4 are correct interventions.
The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? A. Possible trauma B. Possible sexual abuse C. Presence of an allergy D. Presence of a respiratory infection
B. Possible sexual abuse Rationale: Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Trauma, allergy, and infection can cause conjunctivitis, but the causative organism is not likely to be Chlamydia.
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? A. Sodium level of 145 mEq/L (145 mmol/L) B. Potassium level of 3.0 mEq/L (3.0 mmol/L) C. Magnesium level of 1.3 mEq/L (0.65 mmol/L) D. Phosphorus level of 3.0 mg/dL (0.97 mmol/L)
B. Potassium level of 3.0 mEq/L (3.0 mmol/L) Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.
The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? A. Frostbite B. Skin Breakdown C. Venous Insufficiency D. Arterial Insufficiency
B. Skin Breakdown Rationale: When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. Options 1, 3, and 4 are not complications
A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis? A. Depression B. Somatization disorder C. Posttraumatic stress disorder D. Obsessive-compulsive disorder
B. Somatization disorder Rationale: Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. None of the other options are associated with loss of physical function.
The nurse is caring for a client who is receiving feedings by nasogastric tube. The client suddenly begins to vomit, and the nurse quickly repositions the client. The client is coughing and having difficulty breathing. What is the nurse's priority action? A. Call a code. B. Suction the client. C. Check the client's vital signs. D. Call the health care provider (HCP).
B. Suction the client. Rationale: This client is at high risk for aspiration due to vomiting with a nasogastric tube in place. If the client aspirates a feeding, the nurse should immediately suction the client's airway. The client's respiratory status will then be monitored closely until a normal respiratory pattern resumes. The question presents no data indicating the need to call a code. The client's vital signs may need to be monitored, but this is not the priority action. Although the HCP may need to be notified, ensuring a patent airway is the priority.
The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. A. Pressure support is added to the oxygen system. B. The T-piece is connected to the client's artificial airway. C. The client is removed from the mechanical ventilator for a short period of time. D. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. E. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting
B. The T-piece is connected to the client's artificial airway. C. The client is removed from the mechanical ventilator for a short period of time. E. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen (FiO2) that is 10% higher than a ventilator setting Rationale: The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting. Option 4 describes intermittent mandatory ventilation/synchronized intermittent mandatory ventilation. Pressure support may be prescribed to open alveoli in some clients while on mechanical ventilation.
During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior? A. The client is not ready to be discharged. B. The client is displaying typical behaviors. C. The client requires further outpatient treatment. D. The client has not benefited from the relationship
B. The client is displaying typical behaviors. Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal feeling during the termination phase and does not necessarily indicate the need for hospitalization or treatment.
The nurse is preparing for a client's postoperative return to the unit after a parathyroidectomy procedure. The nurse should ensure that which piece of medical equipment is at the client's bedside? A. Cardiac monitor B. Tracheotomy set C. Intermittent gastric suction device D. Underwater seal chest drainage system
B. Tracheotomy set Rationale: Respiratory distress caused by hemorrhage and swelling and compression of the trachea is a paramount concern for the nurse managing the care of a postoperative client who has had a parathyroidectomy. An emergency tracheotomy set is routinely placed at the bedside of the client who has undergone this type of surgery, in anticipation of this complication. The items in the remaining options are not specifically needed with this surgical procedure.
A client is prescribed fluphenazine daily. The nurse teaches the client to take which measure to minimize a common side/adverse effect of this medication? A. Monitor the temperature daily. B. Use hard sour candy or sugarless gum. C. Eat snacks at midmorning and at bedtime. D. Have the blood pressure checked once a week.
B. Use hard sour candy or sugarless gum. Rationale: Fluphenazine is an antipsychotic. Dry mouth is a common side effect of this medication. Frequent mouth rinsing with water, sucking on hard candy, and chewing sugarless gum will alleviate this common side effect. Mild leukopenia may occur, but the temperature does not need to be taken daily. Weight gain is a common side effect, and frequent snacks would worsen the problem. Hypotension and hypertension are rare side effects of fluphenazine.
A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition? A. "Are the stools ribbon-like, and is the infant eating poorly?" B. "Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?" C. "Does the vomit contain sour, undigested food without bile, and is the infant constipated?" D. "Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?"
C. "Does the vomit contain sour, undigested food without bile, and is the infant constipated?" Rationale: Vomiting undigested food that is not bile stained and constipation are classic symptoms of pyloric stenosis. Stools that are ribbon-like and a child who is eating poorly are signs of congenital megacolon (Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic.
A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique? A. "I will ask the client to raise the legs up to the waist and then to lower the legs slowly." B. "I will ask the client to raise the legs and to try to lower them against pressure from my hand." C. "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." D. "I will ask the client to extend the legs flat on the bed, and I will grasp the foot and sharply extend it backward."
C. "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." Rationale: To elicit Homans' sign, the nurse asks the client to extend the legs flat on the bed. The nurse then grasps the foot and dorsiflexes it forward. If this causes any discomfort or resistance, the nurse should notify the health care provider that Homans' sign may be present. The statements in the remaining options are incorrect descriptions of this assessment technique
The nurse is caring for a postoperative client who has just returned from surgery for creation of a colostomy. The nurse inspects the colostomy stoma and recognizes that which is a normal assessment finding for this client? A. A pale color B. A purple color C. A brick-red color D. A large amount of red drainage
C. A brick-red color Rationale: Normal characteristics of a stoma include a rose to brick-red color indicating viable mucosa, mild to moderate edema during the initial postoperative period, and a small amount of oozing blood from the stoma mucosa (because of its high vascularity) when it is touched. A pale color may indicate anemia. A stoma that is dark red to purple indicates inadequate blood supply to the stoma or bowel due to adhesions, low blood flow state, or excessive tension on the bowel at the time of construction. A small amount of bleeding is considered normal, but a moderate to large amount of bleeding from the stoma mucosa could indicate coagulation factor deficiency, stomal varices secondary to portal hypertension, or lower gastrointestinal bleeding.
A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary? A. Encourage intake of fluids B. Shave the anticipated entry area C. Ask the client about allergies and previous reactions D. Contact OR regarding need for the procedure
C. Ask the client about allergies and previous reactions. Rationale: A computed tomography scan is not performed in the operating room; therefore, it is not necessary that the nurse contact this department. There is no surgical entry site; therefore, shaving is not necessary. The procedure is explained to the client, who also is asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water is avoided for 4 to 6 hours before the test.
Glyburide is prescribed for a client with type 2 diabetes mellitus. What is the most important instruction the nurse should provide to the client? A. Monitor for signs of infection. B. Weigh himself or herself daily. C. Assess for signs of hypoglycemia. D. Observe for lower extremity edema.
C. Assess for signs of hypoglycemia. Rationale: Glyburide is a sulfonylurea that acts primarily by stimulating the release of insulin from pancreatic islets. It causes a dose-dependent reduction in blood glucose and can thereby cause hypoglycemia. Importantly, regardless of what the glucose level is—high, normal, or low—sulfonylureas will lead to a low blood glucose level. If the level is high, reducing it will be therapeutic. However, if the level is normal, reducing it will cause mild hypoglycemia. If the level is already low, reducing it can cause severe hypoglycemia. The correct option is 3. Option 1 is incorrect, as infections are not a side or adverse effect of sulfonylureas. Option 2 is incorrect; although weight gain is associated with sulfonylureas, it is not the most important instruction. Option 4 is incorrect, as edema is an adverse effect of thiazolidinediones, not sulfonylureas.
Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route? A. Orally B. By inhalation C. By intravenous infusion D. Through a Sengstaken-Blakemore tube
C. By intravenous infusion Rationale: If bleeding occurs, the health team intervenes quickly to control it by combining vasoactive medications with endoscopic therapies. Vasoactive medications reduce portal pressure. Vasopressin is a synthetic antidiuretic hormone. Administration of this hormone reduces bleeding. It acts directly on gastrointestinal smooth muscle as a vasoconstrictor. To take advantage of these effects, it should be administered via continuous intravenous infusion. It can also be administered via the subcutaneous route. Therefore, the remaining options are incorrect.
The nurse is providing instructions regarding home care measures to a client with diabetes mellitus and instructs the client about the causes of hypoglycemia. The nurse determines that additional instruction is needed if the client identifies which as a cause of hypoglycemia? A. Omitted meals B. Increased intensity of activity C. Decreased daily insulin dosage D. Inadequate amount of fluid intake
C. Decreased daily insulin dosage Rationale: Decreasing the dose of insulin will lead to hyperglycemia. Causes for hypoglycemic reactions include delayed consumption of meals and lack of necessary amounts of food. Other causes include the administration of excessive insulin or oral hypoglycemic medications, vomiting associated with illness, and strenuous exercise, which may potentiate the action of insulin.
A child is diagnosed with impetigo. The health care provider prescribes a topical medication for treatment. The nurse anticipates that which medication will be prescribed? A. Cortisone B. Acyclovir C. Mupirocin D. Benzoyl peroxide
C. Mupirocin Rationale: Mupirocin is a topical antibacterial agent active against impetigo caused by staphylococci or streptococci. Cortisone would not be effective in treating impetigo. Benzoyl peroxide is a keratolytic. Acyclovir is a topical antiviral agent that inhibits DNA replication in the virus. It inhibits the activity of herpes simplex types 1 and 2, varicella zoster, Epstein-Barr virus, and cytomegalovirus.
The nurse is creating a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care? A. Promote complete independence in the client. B. Strengthen the client's ability to manage stress. C. Reward the client when a desired behavior is performed. D. Provide consistent negative reinforcement to promote appropriate behaviors.
C. Reward the client when a desired behavior is performed. Rationale: Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. None of the remaining options are characteristics or appropriate components of the plan of care for this form of therapy.
The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? A. The client reports some pain before meals. B. The client frequently is awakened at 2 a.m. with heartburn. C. The client has eliminated any irritating foods from the diet. D. The client's pain is minimal with histamine H2-receptor antagonists.
C. The client has eliminated any irritating foods from the diet. Rationale: Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self-reporting of absence of pain with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2-receptor antagonist administration or an additional dose of antacid before the time when pain usually awakens the client.
The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle? A. Members should be of the same gender. B. The group will decide the focus of the sessions. C. The group should be limited to no more than 10 members. D. The focus of the group will determine when the group will meet.
C. The group should be limited to no more than 10 members. Rationale: The ideal number of clients in a psychotherapy group ranges from 7 to 10. Having more than 10 members is not recommended because the group will subdivide, which is counterproductive. Too large a group also can create more opportunities for acting out as opposed to working through issues. None of the other options is necessarily true.
The nurse is reading the laboratory results for a client being treated with carbamazepine for prophylaxis of complex partial seizures. When evaluating the client's laboratory data, the nurse determines that which value is consistent with a side or adverse effect of this medication? A. Sodium level, 136 mEq/L (136 mmol/L) B. Platelet count, 350,000 mm3 (350 × 109/L) C. White blood cell count, 3200 mm3 (3.2 × 109/L) D. Blood urea nitrogen (BUN), 19 mg/dL (6.84 mmol/L)
C. White blood cell count, 3200 mm3 (3.2 × 109/L) Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia. Other adverse effects include cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects.
The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? A. "Caution should be used when straddling the infant on a hip." B. "Vital signs should be taken daily to check for bladder infection." C. "Catheterization will be necessary when the infant does not void." D. "Circumcision has been delayed to save tissue for surgical repair."
D. "Circumcision has been delayed to save tissue for surgical repair." Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder.
Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication? A. "I will apply the ointment at bedtime and in the morning." B. "I will apply the ointment once a day and leave it open to the air." C. "I will apply the ointment twice a day and leave it open to the air." D. "I will apply the ointment once a day and cover it with a sterile dressing."
D. "I will apply the ointment once a day and cover it with a sterile dressing." Rationale: Collagenase is used to promote debridement of dermal lesions and severe burns. It is applied once daily and covered with a sterile dressing. The remaining options are incorrect.
The nurse has provided instructions to the mother of a child with cystic fibrosis about appropriate dietary measures. Which statement by the mother indicates an understanding of these dietary measures? A. "The diet needs to be low in fat." B. "The diet needs to be low in protein." C. "The diet needs to be low in calories." D. "The diet needs to be high in calories."
D. "The diet needs to be high in calories." Rationale: Children with cystic fibrosis are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and water-soluble vitamin supplements (A, D, E, and K) are administered. If nutritional problems are severe, supplemental tube feedings or parenteral nutrition is administered. Fats are not restricted unless steatorrhea cannot be controlled by administration of increased pancreatic enzymes.
The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider? A. Bradypnea B. Diaphoresis C. Decreased blood pressure D. A weight gain of 1 lb (0.5 kg) in 1 day
D. A weight gain of 1 lb (0.5 kg) in 1 day Rationale: Heart failure (HF) is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. A weight gain of 1 lb (0.5 kg ) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the health care provider. Tachypnea and increased blood pressure occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and usually occurs with exertional activities.
A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse should plan to address which client problem? A. Pain related to fluid accumulation in the scrotum B. Uneasiness related to inability to reduce scrotal swelling C. Guilt related to the possibility of sterility secondary to scrotal swelling D. Altered body appearance related to change in the appearance of the scrotum
D. Altered body appearance related to change in the appearance of the scrotum Rationale: Altered body appearance is a problem when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. Pain may apply but does not correlate with the information in the question. There are no data in the question that uneasiness, inability to reduce scrotal swelling, or sterility is a client concern.
The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? A. Wash the burn site. B. Apply 1/16-inch (1.5 mm) film directly to the burn sites. C. Apply the medication with a sterile gloved hand. D. Apply saline-soaked dressings over the medication
D. Apply saline-soaked dressings over the medication Rationale: Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in second- and third-degree burns when bacterial resistance to other agents is a potential problem. The burn site is washed before medication application. A film of 1/16 inch (1.5 mm) is applied directly to the burn using a sterile gloved hand. Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned
Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client? A. Restrict the client smoking for 12 hours. B. Enforce nothing by mouth (NPO) status for 16 hours. C. Limit the client's participation in unit activities for 24 hours. D. Assure that an electrocardiogram is performed within 24 hours.
D. Assure that an electrocardiogram is performed within 24 hours. Rationale: Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.
A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? A. CO 5 L/min, PCWP low B. CO 3 L/min, PCWP low C. CO 4 L/min, PCWP high D. CO 3 L/min, PCWP high
D. CO 3 L/min, PCWP high Rationale: The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure.
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? A. Check vital signs. B. Check laboratory test results. C. Notify the health care provider. D. Continue to monitor for any rhythm change.
D. Continue to monitor for any rhythm change. Rationale: Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.
A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered demeanor? A. Continue to assess the client's behaviors and document clearly in the chart. B. Report to the health care provider that the client is adapting to the unit and is feeling safe. C. Notify the health team of these observations and alert them to the suspicion that the client is contemplating suicide. D. Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide.
D. Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide. Rationale: The sudden change in the depressed client's mood and affect may indicate that the client has come to a decision about suicide. The only way to be sure is to ask the client directly. Eliminate options that present strategies that would be used with any client. Avoid options that make unfounded assumptions such as a meaning of the behavior. Notifying others of your concern may be necessary at some point but does nothing to address the problem directly.
The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? A. Eat only when hungry. B. Eliminate snacks during the day. C. Avoid meals in fast-food restaurants. D. Monitor for appropriate weight gain patterns.
D. Monitor for appropriate weight gain patterns. Rationale: The nurse should teach the adolescents about appropriate weight patterns and how to monitor these patterns. The adolescent is more likely to follow suggestions and adhere to the appropriate dietary patterns if the nurse explains why the weight gain is important for the fetus and the mother. Advising an adolescent to eat only when hungry could lead to a deficit in nutrients. Telling an adolescent to avoid fast-food restaurants and eliminate snacks may cause the adolescent to rebel
Sucralfate is prescribed for a client. The nurse determines that the client understands the instructions for medication administration if the client states to take the medication at what time? A. At bedtime B. One hour after meals C. At noontime with a meal D. One hour before meals and again at bedtime
D. One hour before meals and again at bedtime Rationale: Sucralfate is an antiulcer medication that forms a barrier over the ulcer and protects against acid and pepsin. The medication should be taken 1 hour before meals and at bedtime to allow it to form a protective coating over the ulcer to prevent irritation from food, gastric acid, and mechanical movement. The other time frames are incorrect
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the client's medical history? A. Hypotension B. Hypothyroidism C. Diabetes mellitus D. Peripheral vascular disease
D. Peripheral vascular disease Rationale: Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids
A client is seen in the hospital emergency department after injury to the right ankle. The client tells the nurse that she twisted her ankle while playing volleyball. The health care provider (HCP) has prescribed a topical analgesic cream for the injury. The nurse providing instruction about the medication should provide the client with which information? A. To avoid hazardous activities while using the cream because it causes drowsiness B. To apply the medication three times a day and place a heating pad on top of the area C. That the onset of headache indicates a systemic reaction and the HCP must be notified D. That the medication contains a combination of medications, one of which is an analgesic
D. That the medication contains a combination of medications, one of which is an analgesic Rationale: Topical analgesics are used for the temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. These types of products contain combinations of analgesics, menthol, local antiseptics, and counterirritants. Heat or a heating pad should never be applied because irritation or burning of the skin could occur. The medication does not act in a systemic manner, nor does the medication produce drowsiness.
A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? A. Platelet count B. Cholesterol level C. Blood urea nitrogen D. White blood cell count
D. White blood cell count Rationale: Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.
A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action? A. Sit the client in a high Fowler's position. B. Call the pharmacy for a tocolytic medication. C. Get intravenous (IV) therapy equipment and solution from the storage area. D. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.
D. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. Rationale: When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help accomplish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified Sims' position. The health care provider is also notified immediately. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.