NCLEX Question of the Day
A client is in the terminal stages of carcinoma of the lung. A family member asks the nurse, "How much longer will it be?" Which of the following responses by the nurse would be MOST appropriate? ANSWER SELECTION "I cannot say exactly. What are your concerns at this time?" "I don't know. I'll call the doctor." "This must be a terrible situation for you." "Don't worry, it will be very soon."
"I cannot say exactly. What are your concerns at this time?" is the most appropriate response because it is unclear why the family member has approached the nurse at this point. Perhaps the client is in pain and the family member wants to discuss it with the nurse. This response allows for that possibility. This response is also direct and factually correct. "I don't know. I'll call the doctor," is not the most appropriate response. It shifts the focus of responsibility from the nurse to the physician, which prevents a nurse-family member relationship from developing. "This must be a terrible situation for you," is not the most appropriate response. It is a value-laden statement that fails to explore the family member's reason for approaching the nurse. "Don't worry, it will be very soon," is inappropriate because the nurse offers the family member false reassurance. It also offers advice by telling the family member not to worry. This statement is demeaning and may sound as if the nurse is too busy to discuss the family member's concerns.
The nurse is preparing to set up an intravenous infusion of normal saline 1,000 mL over a 6-hour period. The tubing drop factor is 10 gtt/mL. Which of the following rates of infusion should the nurse choose? Category: Dose calculation
12 gtt/min is not the correct rate of infusion. CORRECT: 28 gtt/min is the correct rate of infusion, arrived at as follows: 1,000 mL/6 hours × 10 gtt/mL/60 min/hour = 27.8 or 28 gtt/min. 33 gtt/min is not the correct rate of infusion. 36 gtt/min is not the correct of infusion.
A public health nurse visits a client at home three days after the client gave birth. In which of the following situations should the nurse instruct the client to report to a clinician? ANSWER SELECTION Vaginal drainage with streaks of bright red blood Some discomfort at the site of her episiotomy Feelings of fatigue late in the afternoon and evening An elevated temperature without other symptoms
Category: Ante/intra/postpartum and newborn care Vaginal drainage with streaks of bright red blood is normal for the first 3-6 weeks. The area will continue to heal and is not a cause for concern, unless the discomfort rises to the level of persistent or increasing pain. Feelings of fatigue are normal after giving birth. CORRECT: A fever above 100.4° F (38° C) is reason to call the physician.
The nurse is performing a 12-lead ECG on a client who has come to the emergency room reporting chest pain. Where should the nurse place lead V1? A B C D
Category: Diagnostic tests CORRECT: Location A is correct. The V1 lead is placed at the fourth intercostal space to the right of the sternum. A 12-lead ECG measures electrical potential and helps make a definitive diagnosis of acute myocardial infarction. The six precordial leads—V1-V6—in combination with other leads, record potential in the horizontal plane. Location B is incorrect for the V1 lead. Location C is incorrect for the V1 lead. Location D is incorrect for the V1 lead.
The medical center encounters a bomb threat. The emergency response team informs the staff that the threat is legitimate and that clients should start being evacuated. Which of the following clients should the nurse begin evacuating FIRST to the safe designated area? ANSWER SELECTION Ambulatory clients Bedridden clients ICU clients Infant clients
Category: Emergency response plan CORRECT: Ambulatory clients have the potential to wander and end up in an unsafe place if not directed correctly. Bedridden clients cannot leave without assistance; therefore they would be evacuated subsequent to the ambulatory clients. ICU clients cannot leave without assistance; therefore they would be evacuated subsequent to the ambulatory clients. Infant clients cannot leave without assistance; therefore they would be evacuated subsequent to the ambulatory clients.
The nurse is preparing to administer a unit of PRBCs to an anemic client. After obtaining the blood from the blood bank, the nurse must begin administering it within which of the following time periods? ANSWER SELECTION 15 minutes 30 minutes 45 minutes 60 minutes
Category: Error prevention The nurse has up to 30 minutes to begin administering the blood product. CORRECT: After obtaining the blood product from the blood bank, the nurse must begin administering the product within 30 minutes. This time period is too long. This time period is too long.
A client is leaving the clinic with a new prescription for lisinopril. Which of the following suggestions can the nurse make to minimize one of the major effects of lisinopril? ANSWER SELECTION Eat fruits and vegetables high in iron. Rise slowly from a lying to a sitting position. Increase fluid intake. Avoid aspirin-containing drugs. Check Answer
Category: Expected actions/outcomes Eating fruits and vegetables high in iron will not minimize the side effects of lisinopril. CORRECT: The hypotensive effect of lisinopril may be reduced by rising slowly from a lying to a sitting position. Increasing fluid intake will not minimize the side effects of lisinopril. Avoiding aspirin-containing drugs will not minimize the side effects of lisinopril.
The nurse has been working with a 45-year-old African American who bicycles to work. Lab tests show low serum lipids. The nurse knows that the client's risk factors for primary (essential) hypertension include which of the following? ANSWER SELECTION Being under the age of 65 Race Low serum lipids Active lifestyle
Category: Health promotion/disease prevention; Health screening Being under the age of 65 is associated with lower risk. CORRECT: African Americans have an increased risk for hypertension. Low serum lipids are associated with lower risk. An active lifestyle is associated with lower risk.
The nurse is taking a history from a client in an outpatient clinic. The client has been taking lorazepam for 6 months. Which of the following is the MOST likely side effect that the nurse would expect to see as a result of the client using Ativan for this time period? ANSWER SELECTION Excessive appetite Physical dependence Suicidal ideation Seizure activity Check Answer
Category: Mental health concepts Excessive appetite is a possibility, but not the most likely. CORRECT: Clients can experience all types of side effects from benzodiazepines, but the most likely side effect from prolonged use is physical dependence. Suicidal ideation is a possibility, but not the most likely. Seizure activity is a withdrawal effect the nurse would monitor for if the client discontinued lorazepam abruptly.
The nurse is taking care of an adult male with bilateral leg fractures. He has a long leg cast on his right leg as well as traction applied to the left femur. Which of the following is the MAIN purpose served by the cast for this client? ANSWER SELECTION Immobilizes the tibia and fibula and corrects deformities Keeps the client, who is in traction, more comfortable Immobilizes the pelvic bones for better healing Encircles the trunk and stabilizes the spine
Category: Mobility/immobility CORRECT: A long leg cast serves to immobilize the tibia and fibula by being placed above and below the knee and ankle joints. A long leg cast is not used for comfort for a client in traction. A long leg cast does not immobilize the pelvis. A body cast, not a long leg cast, encircles the trunk.
The nurse is caring for a client with a history of chronic liver disease and cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following treatments should the nurse question? ANSWER SELECTION Calorie intake 1,800-2,400 cal/day in the form of glucose or carbohydrates Protein 100 g/day An order to administer neomycin Potassium supplements
Category: Potential for complications of diagnostic tests/treatments/procedures Adequate calorie intake in the form of glucose or carbohydrates helps prevent protein catabolism. CORRECT: Rising blood ammonia levels can result from cirrhosis, and hepatic encephalopathy follows. Protein is restricted to 40 g/day and increased up to 100 g/day as symptoms improve. Neomycin is administered to remove ammonia-producing substances from the GI tract and suppress bacterial ammonia production. Potassium supplements are administered to help correct alkalosis from increased ammonia levels.
The nurse is preparing to discharge a client with rheumatic heart disease who is recovering from endocarditis. Which of the following statements from the client indicates that the client understands the teaching? ANSWER SELECTION "I'm so glad I don't need any more antibiotics now that I'm feeling better." "I can restart my exercise program in a day or two." "I will watch for signs of relapse the first few days after discharge." "I will inform my dentist should I ever need any dental work." Check Answer
Category: Standard precautions/transmission-based precautions/surgical asepsis The client must take the full course of prescribed antibiotics even if feeling better. The client must restrict activity as directed by the physician. Relapse may occur, but not until about 2 weeks after treatment stops. CORRECT: Susceptible clients must understand the need for prophylactic antibiotics before, during, and after dental work.
The nurse monitors clients' medications in a day program for clients with disabilities. The nurse notices a teenage client who is frequently alone and often quiet. It would be MOST appropriate for the nurse to take which of the following actions? ANSWER SELECTION Allow the client alone time since the client seems to prefer this. The client has the right to make that choice. Make an effort to interact with the client periodically. Encourage the client to join a youth group. Encourage other clients in the program to interact more frequently with the client.
Category: Support systems It appears that the client has enough alone time, which could stunt the client's social growth. It could also defeat the purpose of a day program, which is to promote interaction among clients. Making an effort to interact with the client periodically does not lead to the client's personal growth. Therefore, it is not the best option. CORRECT: Participating in a youth group can help a teenage client with a disability develop social skills, use support systems, and feel more like a typical teenager. It would not be appropriate to talk about one client with other clients, for reasons of confidentiality and privacy.
The nurse is assessing a young-adult pregnant client with no allergies who has tested positive for gonorrhea. Which of the following medications should the nurse expect to be part of the treatment plan? ANSWER SELECTION Tetracycline Ciprofloxacin Azithromycin Ceftriaxone
The nurse is assessing a young-adult pregnant client with no allergies who has tested positive for gonorrhea. Which of the following medications should the nurse expect to be part of the treatment plan? Category: Potential for complications of diagnostic tests/treatments/procedures Tetracyclines are contraindicated in pregnancy. Fluoroquinolones are contraindicated in pregnancy. Azithromycin is the treatment for chlamydia. CORRECT: Ceftriaxone, a third-generation cephalosporin, is the recommended treatment for gonorrhea in pregnancy.
The nurse noticed an increase in the prevalence of pressure ulcers among clients in an intensive care unit. She documented her findings and worked with her manager to develop and implement a new policy using a pressure ulcer risk assessment scale. Which of the following BEST describes the nurse's actions? ANSWER SELECTION Quality improvement Collaboration Advocacy Case management
The nurse noticed an increase in the prevalence of pressure ulcers among clients in an intensive care unit. She documented her findings and worked with her manager to develop and implement a new policy using a pressure ulcer risk assessment scale. Which of the following BEST describes the nurse's actions? Category: Performance improvement (quality improvement) CORRECT: Quality improvement includes activities such as identifying opportunities and developing policies for improving the quality of nursing practice. Identifying an increase in pressure ulcers and implementing a policy aimed at improving the assessment and prevention of pressure ulcers best fits the definition of quality improvement. The nurse may have collaborated (or worked together) with colleagues, but this is not the best choice. Advocacy refers to the nurse's duty to act on behalf of the client. Although reducing pressure ulcers may indirectly advocate for the client, it is not the best answer choice. Case management refers to the coordination of care to reduce fragmentation and costs, as well as to improve quality and outcomes.
The nurse is working with a middle-aged female after a knee injury. Ambulation is still difficult for the client, and the physical therapist has suggested the client use a cane. The nurse states which of the following with respect to using a cane rather than a walker for this injury? ANSWER SELECTION "The cane is just a reminder to use good posture." "The cane can be more dangerous than helpful, and another type of assistive device should be considered for this client." "The cane will help with fatigue while assisting the client with balance and support." "A cane does not offer any relief on weight-bearing joints." Check Answer
Category: Assistive devices A cane is not used as a reminder for good posture; it is used for comfort and support. A cane is safe when used properly. CORRECT: A cane offers support and can give the client relief of joint pain and fatigue, and promote a safe way to ambulate when a lower extremity is injured. A cane does offer relief on weight-bearing joints when used properly.
A client is admitted to the postpartum unit following a miscarriage. The next day the nurse finds the woman crying while looking at the babies in the newborn nursery. Which of the following approaches by the nurse would be MOST appropriate? ANSWER SELECTION Assure the woman that the loss was "for the best," Explain to her that she is young enough to have more children. Ask her why she is looking at the babies. Acknowledge the loss and be supportive.
"Acknowledge the loss and be supportive," is the best answer choice. It promotes the nurse-client relationship, and allows for the identification of feelings and the expression of sadness. The client is in an acute stage of grief. This type of response addresses this issue. "Assure the woman that the loss was 'for the best,'" is incorrect. This statement is insensitive to the client, offers false reassurance, and belittles the client's most immediate concerns. "Explain to her that she is young enough to have more children," is inappropriate because it is insensitive to the grief that the client is experiencing. The nurse offers false reassurance by telling the woman that she can have other children. "Ask her why she is looking at the babies," is also incorrect. This is inappropriate because it is a "why" question and because the woman may become defensive when answering such a question. This response also fails to respond to the client's immediate grief.
The nurse is caring for an elderly client who has been on long-term nutritional support. The nurse is reviewing the infusion procedure with the client's daughter. The nurse states which of the following as the rationale for removing the formula from the refrigerator and infusing it through the gastrostomy tube at room temperature? ANSWER SELECTION "The formula tastes better at room temperature." "This method will be the least likely to give your father gastric discomfort." "There is no need to bring the formula to room temperature." "Room-temperature prepared formula reduces aspiration."
The nurse is caring for an elderly client who has been on long-term nutritional support. The nurse is reviewing the infusion procedure with the client's daughter. The nurse states which of the following as the rationale for removing the formula from the refrigerator and infusing it through the gastrostomy tube at room temperature? Category: Nutrition and oral hydration There would not be a taste to formula given through the G-tube. CORRECT: Cold formula through the G-tube can cause discomfort and cramping. It is most appropriate for the comfort of the client to bring the formula to room temperature before administering. Temperature has nothing to do with the risk of aspiration.
The nurse is working on a surgical unit. Which of the following tasks would be appropriate for the nurse to delegate to nursing assistive personnel (NAP)? ANSWER SELECTION Assist a new postoperative client to the bathroom. Set up the clients' lunch trays. Change a central line dressing. Teach a client how to administer discharge medications. Check Answer
The nurse is working on a surgical unit. Which of the following tasks would be appropriate for the nurse to delegate to nursing assistive personnel (NAP)? Category: Delegation Assisting a new postoperative client to the bathroom is a task the registered nurse or another licensed individual, such as an LVN/LPN, should perform. CORRECT: Setting up the client's lunch trays is an appropriate task to delegate to the UAP. Changing a central line dressing is a task the registered nurse or another licensed individual, such as an LVN/LPN, should perform. Teaching a client how to administer discharge medications is a task the registered nurse or another licensed individual, such as a pharmacist, should perform.
The physician orders an MRI of the brain for an adult male client. Which of the following findings in the client's history should the nurse report to the physician? ANSWER SELECTION Allergy to contrast dye Implanted cardiac pacemaker Chronic obstructive pulmonary disease (COPD) Hernia repair
The physician orders an MRI of the brain for an adult male client. Which of the following findings in the client's history should the nurse report to the physician? Category: Accident/injury prevention; Safe use of equipment Allergy to contrast dye is contraindicated in CT scans with contrast, not MRI. CORRECT: Metallic items, including metallic implants such as a cardiac pacemaker, are contraindicated in MRI. COPD is not a contraindication for MRI. Hernia repair is not a contraindication for MRI.
The nurse is working on a pediatric unit. The client is a 13-month-old child diagnosed with failure to thrive. The parents report that the child cries frequently, does not like to be held, and will not eat. The nurse learns that the child's uncle lives in the house with the family. When the uncle visits in the hospital, the nurse notices the child acting differently and turning away from the uncle. Sometimes the child's heart rate increases when the uncle is present. The nurse should take which of the following actions FIRST? ANSWER SELECTION Immediately report the possible situation of abuse to the authorities. Call the physician, who will probably have more long-term knowledge. Discuss it with other nurses to see which approaches they have taken. Encourage the team that's caring for the client to have a family meeting including the parents, but not the uncle, to gather more information.
Category: Abuse/neglect Although nurses are mandated to report child abuse in almost every state, the question stem does not present enough solid, verifiable facts to know whether abuse should be suspected. Thus the nurse should use the support of other colleagues and the interdisciplinary team to make this decision. Although the nurse might want to eventually notify the physician of abuse suspicions, this is not the first step. Most importantly, the NCLEX-RN® exam wants to see what the test taker would do rather than passing the responsibility to someone else. Although the nurse might ask for advice from peers on the client's care team, the nurse should not discuss a client's information with those who are not part of the care team. CORRECT: The nurse should utilize other disciplines in a team fashion and attempt to gather more facts before deciding appropriate further steps.
Prior to administering digoxin 0.125 mg PO to a client with chronic heart failure, the nurse determines that the apical pulse is 56. Which of the following should the nurse do FIRST? ANSWER SELECTION Administer the drug and recheck the pulse in one hour. Withhold the drug and notify the physician. Obtain an EKG. Send a blood sample to the laboratory for a digoxin level.
Category: Adverse effects/contraindications/side effects/interactions CORRECT: Unless the physician's order specifies otherwise, when the client's apical pulse drops below 60, the nurse should hold the dose and notify the physician. Although an EKG may be indicated, it is not generally the first course of action. Although obtaining a digoxin level may be indicated, it is not generally the first course of action.
The medical floor nurse receives report from the Emergency Department on a 42-year-old client who is admitted to the hospital for hyperphosphatemia related to end-stage renal disease. The client receives continuous ambulatory peritoneal dialysis (CAPD), and the physician has ordered continuation of treatment during hospitalization. The nurse should do which of the following? ANSWER SELECTION Maintain a permanent peritoneal catheter with flushes of 0.9% normal saline (0.9% NS) every 4-6 hours. Obtain a pump in preparation for dialysate infusion. Ensure the dialysate is refrigerated until ready to infuse, and obtain a warming pad or a warming machine to warm the dialysate to body temperature prior to exchange. Weigh the client at the same time every day, and use sterile technique while working with a permanent peritoneal catheter. Check Answer
Category: Alterations in body systems The nurse would not flush a CAPD permanent peritoneal catheter with normal saline solution. The dialysate bag is raised to shoulder level and is infused by gravity into the peritoneal cavity after the dwell dialysate solution is drained. Dialysate for CAPD is not refrigerated but should be warmed to body temperature prior to infusion, if a warmer is available. Never use a microwave to warm the dialysate; this method creates an unpredictable temperature. CORRECT: The nurse would weigh the client at the same time daily. The nurse would use sterile technique and equipment when working with the peritoneal catheter to infuse and drain the dialysate, including having the client and nurse wear a surgical mask while the peritoneal catheter and hub are exposed.
The nurse in an outpatient clinic has received an order from the physician to remove the client's sutures. The nurse should do which of the following? ANSWER SELECTION Use gloves when removing sutures. Apply hydrogen peroxide gauze pads to cleanse the area first, then remove the sutures. Use sterile technique when removing sutures. Nothing, suture removal is outside of the nurse's scope of practice. Check Answer
Category: Alterations in body systems To prevent incision contamination, this is should be a sterile procedure. Wearing regular gloves is not sufficient. To prevent incision contamination, this should be a sterile procedure. This answer choice does not provide enough information to determine if proper sterile procedures are being followed. CORRECT: A sterile field is maintained, a sterile suture removal tray is used, and sterile gloves are applied. In many facilities, nurses do remove sutures and staples following a physician's order.
A client who has chronic pain asks the nurse about alternative therapy in conjunction with traditional treatment. Which of the following forms of alternative therapy could the nurse provide for this client? ANSWER SELECTION Music therapy or guided imagery Acupuncture Kegel exercises None, nurses do not participate in providing alternative treatments
Category: Alternative therapy; Non-pharmacological comfort interventions CORRECT: Music therapy and guided imagery have been proven to increase a client's ability to perform activities of daily living by helping to focus on something other than pain. Acupuncture must be performed by a skilled practitioner and is not done by a nurse. Kegel exercises are done independently by the client to tighten the muscles of the pelvic floor. They do not provide pain relief. Nurses may participate in many forms of alternative therapies as nursing interventions when trained properly.
A 20-year-old client has just given birth. The baby looks healthy, with the exception of giving a grimace instead of a cry. Which of the following would the nurse expect the obstetrician to say? ANSWER SELECTION "The APGAR score is 3." "The APGAR score is 6." "The APGAR score is 9." "The APGAR score is 12."
Category: Ante/intra/postpartum and newborn care An APGAR score of 3 indicates a baby in poor health. An APGAR score of 6 indicates a less healthy baby. CORRECT: In 4 of the 5 categories of rating, the baby scored a 2. In the category of reflex irritability, the baby scored a 1, for a total APGAR score of 9. An APGAR score of 12 does not exist; the highest score is 10.
A client with acne has been using isotretinoin. She tells the nurse that she recently learned she is pregnant. She asks "Will my pregnancy interfere with the medication's effectiveness?" Which of the following is the appropriate response by the nurse? ANSWER SELECTION "The medication is contraindicated for pregnant women." "You will have to change the route of administration, because you are pregnant." "There is no reason you can't continue taking it." "If the medication helps you look better, that will help feel better about yourself."
Category: Ante/intra/postpartum and newborn care CORRECT: Severe fetal abnormalities may occur if isotretinoin is used during pregnancy. The nurse should stress that the priority is the high risk of fetal abnormalities that the medication can cause rather than the effectiveness of the medication. The nurse would not tell the client to continue taking this drug. The nurse would not tell the client to continue taking this drug. The nurse would not tell the client to continue taking this drug.
The client is 7 months pregnant with her first child. She is anxious because she feels some mild contractions at times. The nurse tells her which of the following? ANSWER SELECTION She should increase her bed rest to prevent those contractions. The contractions are normal unless they increase in severity. The contractions are a way of her body asking for more exercise. She should avoid getting constipated and having gas as a result.
Category: Ante/intra/postpartum and newborn care Increasing bed rest is not necessary; Braxton Hicks contractions are normal at this stage in the pregnancy. CORRECT: Braxton Hicks contractions are normal at this stage in the pregnancy. More exercise is not necessary: Braxton Hicks contractions are normal at this stage in the pregnancy. Gas is not likely to be the cause of the contractions; Braxton Hicks contractions are normal at this stage in the pregnancy.
A client is receiving a blood transfusion. The nurse observes that the client is experiencing diarrhea, abdominal pain, and chills. Which of the following actions should the nurse take FIRST? ANSWER SELECTION Assist the client to the bathroom. Stop the transfusion. Administer meperidine. Get a warming blanket.
Category: Blood and blood products Assisting the client to the bathroom may be an appropriate comfort measure but should not be performed first. CORRECT: Signs and symptoms of a transfusion reaction may include chills, diarrhea, fever, hives, pruritus, flushing, and abdominal or back pain. The nurse's first action should be to stop the transfusion. Meperidine may alleviate rigors, which the client was not experiencing. Getting a warming blanket may be an appropriate comfort measure but should not be performed first.
The client is an intoxicated male on the medical/surgical unit who attempts to get out of bed every few minutes. He is unsteady on his feet, and the nurse is concerned that he will fall if he does get out of bed. The doctor writes an order for the nurse to place wrist restraints to maintain the client's safety and prevent him from falling. The man refuses the restraints. The nurse should take which of the following actions? ANSWER SELECTION Place the restraints in compliance with hospital policy. Refrain from placing restraints to honor the client's wishes, because he has the right to refuse care. Call the physician for advice on how to proceed. Check on the client every hour to ensure his safety.
Category: Chemical and other dependencies CORRECT: The nurse should place the restraints in compliance with hospital policy. This is a circumstance where the client's risk of harm and promotion of safety trumps the client's right to refuse. The client is at risk and intoxicated, so the nurse should place the restraints. The nurse, at some point, may call the physician for further assistance, but the NCLEX-RN® exam wants to know what the test taker would do rather than passing the responsibility to someone else. The nurse could check on the client every hour, but only in addition to the needed ongoing safety measure of restraints or constant observation. A client could fall within minutes; an hour is too long to leave an at-risk client alone.
The nurse is working in an outpatient clinic. The nurse has a client who appears intoxicated and who drove to the appointment. The nurse is concerned about the client's ability to drive home. Which of the following should the nurse do FIRST? ANSWER SELECTION Call the police immediately. Ask the client's permission to call a family member or friend for a ride. Give the client a ride home to protect his privacy. Call clinic security to detain the client to protect his safety.
Category: Chemical and other dependencies The nurse's goal is to protect the client (and in this scenario, potentially the public as well), but calling the police immediately is not the best first option. The nurse may end up doing this but should first take the time to review other options. CORRECT: Asking the client's permission to call a family member is a better option because it includes the client in the choice. An intoxicated client may not make good choices, but the client may be amenable to good suggestions. Ideally, the nurse would find somebody (not the police) to get the client home safely. That would allow maintaining a trusting nurse-client relationship. The nurse should not overstep the boundaries and drive the client home. Calling clinic security to detain the client sounds less threatening than calling the police and might be done eventually, but the first option would be answer choice 2.
A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine is being transferred in stable condition from the intensive care unit to the medical unit. There are 4 beds available. The nurse knows the BEST choice of roommates for this client is which of the following? ANSWER SELECTION A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA) A 28-year-old woman diagnosed with diarrhea A 72-year-old man with fever of unknown origin A 68-year-old woman with atrial fibrillation
Category: Concepts of management A client with MRSA may be an infection risk for an individual with altered skin integrity. A client diagnosed with diarrhea may be an infection risk for an individual with altered skin integrity. A client with fever of unknown origin may be an infection risk for an individual with altered skin integrity. CORRECT: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues, including blistering and skin shedding, which can place the client at high risk for infection. Atrial fibrillation is not an infectious process.
A client with post-traumatic stress disorder (PTSD) appears to be having a flashback. It would be MOST appropriate for the nurse to perform which of the following interventions? ANSWER SELECTION Encourage the client to tell the nurse how the client is feeling in that moment. Calmly reorient the client to the current situation. Assist the client in acting out the event. Tell the client loudly that what the client is experiencing is not real.
Category: Crisis intervention The patient is in crisis mode. Encouraging the client to verbalize feelings is not going to bring the client back to reality. CORRECT: The nurse wants to calmly orient the client back to the reality of the moment, to the actual safe environment. Assisting the client in acting out the event is not an appropriate intervention. The nurse wants to encourage the client back to reality and not go further into the flashback. Although the nurse wants to orient the client to reality, this would not be done loudly. This could possibly cause more hostility or violence if the client feels a sense of heightened danger.
The nurse is caring for a newly admitted client in a hospital setting. The client was recently diagnosed with cancer but is alert and oriented. The client is a Greek immigrant, but does speak English. During the admission process, the nurse inquires about advance directives with the client. The client tells the nurse: "I do not want to make any medical decisions. I want my daughter to make these decisions for me." The nurse should take which of the following actions? ANSWER SELECTION Make sure that the written advance directives document the client's wishes. Tell the client that, being alert and oriented, the client should make his or her own medical decisions. Tell the client that due to confidentiality, the daughter will not be informed of details of the client's care. Encourage both the daughter and the client to work together on making medical decisions.
Category: Cultural diversity CORRECT: As long as the client is not pressured into this decision and the nurse believes that it is being made of the client's free will, it is acceptable for the daughter to take over medical decision making for the ill parent. The client is entitled to have her daughter make the medical decisions for the client, if that is what the client wishes to do. The client is entitled to allow her daughter to be informed of the details of the client's care. The client is entitled to have her daughter make the medical decisions for the client, and the nurse should not encourage her to do otherwise.
The nurse is preparing to administer a red blood cell transfusion to a client with a low hemoglobin level and low hematocrit. The nurse knows which of the following statements about blood transfusion practice is true? ANSWER SELECTION The client should be monitored for at least one hour after the start of the transfusion. The transfusion should be completed within 2 hours. The transfusion should be started within 30 minutes of removing the blood or blood components from the blood bank. The only solution that should be added to blood or blood components is 0.45% sodium chloride (half normal saline solution).
Category: Diagnostic tests; Potential for complications of diagnostic tests/treatments/procedures The client should be monitored for at least 15 minutes after the start of the transfusion. The transfusion needs to be completed within 4 hours, not 2 hours. CORRECT: The transfusion should be started within 30 minutes of removing the blood or blood components from the blood bank. The only solution that should be added to blood or blood components is 0.9% sodium chloride (normal saline solution).
The nurse is caring for a young child who has recently had a vesicostomy. Which of the following nursing interventions should the nurse undertake to assist this child with basic comfort and elimination? ANSWER SELECTION Offer fluids, apply an absorbent diaper or incontinence pads, and dilate the opening once or twice a day as ordered by the physician. Double-diapering the area is the only intervention needed. Apply a urine bag and change it daily. Double-diaper the area after applying a urine bag.
Category: Elimination CORRECT: A vesicostomy is performed when chronic neurogenic bladder and frequent urinary tract infections become problematic. Hydration, cleansing and drying of the area, absorbent diapers, and daily dilation of the opening are all appropriate care to prevent infection and to provide comfort. Double diapers alone are not enough to keep the child comfortable and free from infection. It is not customary to apply a urine bag over the opening of a vesicostomy. The addition of a urine bag to double diapers will not keep the child comfortable and free from infection.
The physician verbally orders a medication for a client during an emergency code. Which of the following should the nurse do? ANSWER SELECTION Repeat the order back to the physician for confirmation and administer it. Retrieve the medication and administer it. Write the order down, retrieve the medication, and administer it. Read the order to another nurse, have that nurse retrieve the medication, and stay with the client.
Category: Error prevention CORRECT: In an emergency code situation, the order can be repeated back to the physician for confirmation and given, as there is another nurse recording events of the code. The medication order should be confirmed with the physician first. The order should be repeated back to the physician for verification before it is administered. The nurse should confirm the order with the physician first.
The client has experienced multiple episodes of hyperglycemia not manageable by subcutaneous insulin injections. The client has an active order for infusion of an insulin drip for glycemic management to be discontinued at bedtime, after which the client is NPO. The client's most recent blood sugar level, taken at 3 p.m., was 60. Which of the following actions by the nurse is the MOST appropriate? ANSWER SELECTION The nurse should follow the order and allow the insulin to infuse until bedtime. The nurse should recheck the client's blood sugar. The nurse should bring this blood sugar level to the physician's attention and discuss stopping the infusion. The nurse should seek advice from other nurses.
Category: Error prevention The nurse has a duty to verify the order, given the change in circumstances. The blood sugar is now low, and continuing an insulin drip has the potential to drop it to a dangerous level. The nurse would recheck the client's blood sugar level only if there was reason to believe it might be in error. CORRECT: The most appropriate action is to contact the physician and discuss stopping the infusion, based on the last blood sugar level. The nurse might ask a colleague for advice, but the most appropriate action is to discuss the situation with the physician.
A 70-year-old male presented to the Emergency Department with shortness of breath, crackles in the bases and middle of the lung fields bilaterally, +2 pitting edema bilaterally of the lower extremities, and a weight increase of 6 lb. in one week. His heart rate is 82 and his blood pressure is 162/90. Per physician's order, the nurse administers 40 mg of furosemide intravenously. The nurse knows that which of the following indicates effectiveness of the medication? ANSWER SELECTION A heart rate of 58 A blood pressure of 100/52 Urine output increase of 200 mL over the next hour Diminished lung sounds bilaterally with crackles in the bases
Category: Fluid and electrolyte imbalances A heart rate of 58 could indicate a side effect of the medication rather than effectiveness. This significant drop in heart rate would be cause for alarm, especially after the administration of furosemide. A blood pressure of 100/52 could indicate a side effect of the medication rather than effectiveness. This significant drop in blood pressure would be cause for alarm, especially after the administration of furosemide. CORRECT: The nurse would expect an increase in urine output after the administration of furosemide. The client presented with signs and symptoms of hypervolemia or fluid overload, including shortness of breath, crackles in lung bases, and edema. Weight gain and hypertension can also be indicative of hypervolemia. The goal of treatment using furosemide is diuresis, with care not to send the client into hypovolemia. The nurse would expect to auscultate a reduction, if not elimination, of crackles in the lung bases. The nurse would also not expect diminished lung sounds, because this could indicate atelectasis and/or decreased air flow through the lungs. The goal would be baseline or clear lung sounds bilaterally, with minimal to no crackles in the lung bases upon auscultation.
The nurse discovers a hospice client has expired. The family members are regrouping in the facility's waiting room. Which of the following actions by the nurse would be the MOST appropriate? Tell the family it would not be in their best interests to see their loved one. Encourage the family to view the body to help accept the situation. Provide condolences to the family and offer them viewing time. Tell the family "I will give you some time to spend with your loved one. Let me know if you need anything."
Category: Grief and loss It is not the nurse's decision whether a family wants to view a body or not. This is a paternalistic attitude to be avoided in this setting. The nurse should react to that particular family's needs or wishes, and not encourage or discourage in either direction. CORRECT: The nurse acknowledges the loss, expresses sympathy, and offers the viewing opportunity. This statement assumes the family wants to view the body without the nurse inquiring first.
The nurse is giving a lecture at the senior center about preventative health activities for people over age 60. The nurse tells the clients that the Centers for Disease Control and Prevention (CDC) now recommends which of the following vaccines for this age group? ANSWER SELECTION Shingles (herpes zoster) Diphtheria Pertussis (whooping cough) Meningitis
Category: Health promotion/disease prevention CORRECT: The shingles vaccine reduces the risk of shingles by about half and the risk of postherpetic neuralgia by two-thirds. The diphtheria vaccine is given much earlier in life. The pertussis (whooping cough) vaccine is given much earlier in life. The CDC recommends that college freshmen living in dormitories get the meningitis vaccine, but this is unlikely to apply to those over age 60.
The nurse is designing a diet plan for a 70-year-old with poorly fitting dentures who has been recently diagnosed with type 2 diabetes. The nurse knows that which of the following is the LEAST likely risk to the client? ANSWER SELECTION Malnutrition Dehydration Hyperglycemia Low blood sugar
Category: Health promotion/disease prevention Malnutrition is a possibility due to difficulty in eating. Dehydration is a possibility. CORRECT: Hypoglycemia is more likely than hyperglycemia. Often a client with denture problems will only be able to tolerate liquid or pureed foods eaten slowly. This decreases the chances of adequate nutrition. Low blood sugar is a possibility.
The critical care nurse is caring for a client with an arterial line (A-line). The nurse can utilize this line for which of the following? ANSWER SELECTION Monitoring blood pressure and heart rate, and infusing medications Monitoring blood pressure and heart rate, and obtaining blood gases and other laboratory samples Monitoring heart rate, obtaining blood gases and other laboratory samples, and infusing medications Obtaining blood gases and other laboratory samples, and infusing medications
Category: Hemodynamics *Medications should never be infused through an arterial line*. CORRECT: Arterial lines are used for monitoring blood pressure and heart rate, especially in clients requiring the use of vasopressor medications intravenously. They are also used for clients requiring frequent blood draws. The nurse may also draw arterial blood gases and other laboratory samples from the line, following the proper procedure. This saves the client from frequent arterial and venous draws. Medications should never be infused through an arterial line. Medications should never be infused through an arterial line.
An 82-year-old woman is admitted with a diagnosis of rapid atrial fibrillation. The nurse has initiated telemetry monitoring per the physician's order. Two hours after initiation of monitoring, an alarm sounds at the central monitoring station: the client is in what appears to be ventricular tachycardia. Which of the following actions should the nurse take FIRST? ANSWER SELECTION Call a code blue. Silence the alarm and change the alarm parameters. Notify the physician of a change in rhythm. Assess the client and check lead placement.
Category: Hemodynamics 1. This would be premature on the part of the nurse—assessment of the client may yield different information than what is reported by the monitor. 2. Verify alarm limits with the physician, and only change parameters following an order from the physician. 3. The nurse would first check the lead wires and assess the client to ensure that information given to the physician is accurate. 4. CORRECT: Assess the client first, then the equipment for disconnections or malfunctions. Check lead placement to determine if the monitoring results are indeed accurate, and not due to interference or an artifact. If assessment of the client reveals true ventricular tachycardia, follow advance directives as established by the client, including, but not limited to, calling a code.
The nurse takes report on a client returning from left-sided cardiac catheterization. The client also underwent a percutaneous transluminal coronary angioplasty (PTCA), with drug-eluding stents placed in the right coronary artery and left coronary artery, and the site was closed with a collagen plug. The nurse would expect to assess the entry site on the client at which of the following locations? [insert labeled picture]
Category: Hemodynamics A: This is not the correct location. CORRECT: B is the correct answer. The nurse would expect to assess the entry site in the left femoral artery. This is the preferred site for left-sided cardiac catheterization and PTCA. C: This is not the correct location. D: This is not the correct location.
A 39-year-old client has been diagnosed with end-stage renal disease and is on the transplant waiting list. The client has been receiving dialysis through a subclavian central vein catheter while an arteriovenous fistula is maturing. Besides dialysis access, the surgical floor nurse can utilize this subclavian central vein catheter for which of the following? ANSWER SELECTION Nothing Blood draws only Infusion of normal saline (0.9% NS) and obtaining blood draws Infusion of medications, all intravenous fluids, and obtaining blood draws
Category: Hemodynamics CORRECT: The nurse is not to access the subclavian central vein catheter that is being used for dialysis for blood draws, for infusions, or for any reason other than dialysis. Only in the event of a life-threatening emergency may the access be used for anything other than dialysis, and that is only under the physician's direct order. Any other use could jeopardize the access that must be patent for dialysis until the fistula matures. Any other use could jeopardize the access that must be patent for dialysis until the fistula matures. Any other use could jeopardize the access that must be patent for dialysis until the fistula matures.
The nurse is providing discharge instructions to a client going home on enoxaparin. Which of the following responses by the client indicates to the nurse that the teaching was effective? ANSWER SELECTION "Prior to injection, I will rub the site with an alcohol wipe." "I will use the same site for each injection." "I will not pull back the plunger after inserting the needle into the site." "After injection, I will massage the site to increase absorption." Check Answer
Category: Illness management The area would be cleansed with an alcohol wipe, with care not to rub. Rubbing may cause damage to the skin and could contribute to formation of a hematoma. Sites for injection should be rotated, focusing on areas that have an easily accessible, fatty, subcutaneous layer. This is also minimizes tissue damage from repeated injections, which may affect absorption. CORRECT: Aspiration, or pulling back the plunger after needle insertion, can cause damage to small capillaries and blood vessels and can lead to hematoma formation and bleeding. Massaging the area postinjection may cause damage to the skin and could contribute to hematoma formation.
A 76-year-old man is brought into the Emergency Department by his spouse. The client's spouse tells the nurse he is confused, disoriented, and weak, and has not been eating well. The nurse obtains blood work as ordered by the physician, including a complete blood count (CBC) and a comprehensive metabolic panel (CMP). For which result should the nurse immediately notify the physician? ANSWER SELECTION Potassium (K+) 3.8 mEq/L Sodium (Na+) 122 mEq/L Magnesium (Mag+) 1.9 mg/dL Hemoglobin (Hgb) 12 g/dL
Category: Illness management This lab value is within normal range. CORRECT: Symptoms of hyponatremia include confusion, disorientation, weakness, and poor appetite. The physician should be notified immediately for this critical level of sodium. This lab value is within normal range. This lab value is within normal range.
The surgical floor nurse is working with a client on coughing and deep breathing. The mildly obese client is six days postoperative, and has a large midline abdominal incision that is not well approximated. The client stops the exercise and states she felt a popping sensation in her abdominal area. Upon assessment, the nurse finds a small portion of the viscera to be protruding through the incision. Which of the following actions should the nurse take FIRST? ANSWER SELECTION Do nothing; this is a normal finding for a large midline abdominal incision. Call the surgeon who operated on the client and inform the physician of the finding. Place sterile dressings moistened with sterile normal saline (0.9% NS) over the viscera and hold in place with a sterile gloved hand. Place an abdominal binder on the area, elevate the head of the bed no more than 20 degrees, and have the client recline with her knees bent.
Category: Medical emergencies This is not a normal finding for a large midline abdominal incision. It is very important for someone to stay with the client due to the anxiety that the client will be feeling. The surgeon must be notified, and possible surgery could ensue, but this is not the first thing the nurse would do. CORRECT: This medical emergency is known as wound dehiscence with evisceration. The nurse would saturate sterile dressings with normal saline and hold the dressings over the viscera, which is most likely part of the bowel loop. The nurse should attempt to minimize any additional stress on the incision by having the client lie in a low Fowler's position with knees bent. An abdominal binder is used in the prevention of dehiscence and not in the treatment of evisceration.
The mother of a teenage client who has permission to be involved in the plan of care is asking the nurse questions, after it has been explained to her that her child has bipolar disorder. Which of the following statements by the mother indicates that further teaching is needed? ANSWER SELECTION "My child will be cured after being on medications for a few months." "My child will require support and encouragement." "My child will be on psychiatric medications probably for the rest of her life." "The goal of the medication is to reduce symptoms associated with bipolar disorder and to hopefully help with the mood swings."
Category: Mental health concepts CORRECT: Bipolar disorder is not curable. Clients can suffer from bipolar disorder throughout their entire lives. The mother's statement that the child will be cured after being on medication indicates further teaching about the disorder is needed. This is an accurate statement. Somebody suffering from this mental illness would need support and encouragement. This is an accurate statement. Psychotropic medications are used to treat bipolar disorder, usually for life. This is an accurate statement. The goal of the medication is to reduce symptoms associated with bipolar disorder and to lessen mood swings.
The nurse is taking care of an elderly male client who has shortness of breath, cough, and fluid in his pleural space. The physician asks the nurse to assist in the performance of a therapeutic and diagnostic thoracentesis. Which of the following nursing interventions should the nurse perform to assist this client? ANSWER SELECTION Make certain the consents are signed, witnessed, and filed in the chart. Offer oral fluids, because the client will not be able to take a drink during the procedure. Help the client to lie flat with a pillow under his feet for comfort during the procedure. Help the client to sit up and place his arms over a bedside table, encouraging him to remain still during the procedure.
Category: Non-pharmacological comfort interventions The nurse should make certain that consents are signed before the start of a procedure, but that does not affect the client's comfort. Fluids should not be offered right before a procedure to avoid nausea and vomiting if pain is experienced. Lying flat with feet elevated is not the position of choice for a thoracentesis. CORRECT: Placing the client in a sitting position over a bedside table is the most comfortable and allows the best opportunity to remove fluid at the base of the chest.
The nurse caring for a child burned over 20% of her body assists the physician in performing dressing changes on day 5 after the initial injury. The child appears disoriented, has a fever of 101º F (38.3º C), and is crying in pain. Which of the following nursing interventions would be the MOST appropriate in caring for this client? Gather equipment for the dressing change and explain the procedure to the child. Do a complete physical assessment and notify the physician of the findings. Administer appropriate analgesics and gather equipment for the dressing change. Offer the child an enticing distraction from pain, such as a video, music, or toy.
Category: Non-pharmacological comfort interventions The nurse would gather equipment, but not before addressing the crying child. CORRECT: The child may be suffering from an infection. The nurse recognizes that disorientation and fever are the first signs of sepsis in burn clients. It would be most appropriate to assess for the causes of fever and pain and notify the physician before proceeding. Analgesics may be appropriate but not before assessing the pain and source of fever and disorientation. Distractions may be offered after the assessment but they do not take priority over notifying the physician regarding the findings about the source of fever and pain.
An adult diagnosed with pancreatic cancer is having a consultation with the nurse about nutrition and hydration. Which of the following suggestions might the nurse include when providing education to this client? ANSWER SELECTION Drink clear water, progress diet rapidly as tolerated, and weigh daily. Puree foods, choose low-protein foods for easier digestion, and weigh weekly. Take herbal therapies, avoid vitamins, and don't monitor weight. Use spices to stimulate taste buds, eat cool foods to decrease odor, and eat small but frequent high-protein and high-carbohydrate meals. Check Answer
Category: Nutrition and oral hydration It is more appropriate to progress the diet slowly to avoid nausea and vomiting. Pureed foods may cause nausea and gagging, low-protein foods do not offer enough nutrients, and daily weights are the norm. Herbal therapies have not been researched enough to be certain that they would not interfere or compromise cancer treatments when ingested. Topical herbal treatments may be of use for comfort. CORRECT: Flavored foods high in both protein and carbohydrates will help to increase calorie intake. Foods that have less odor, and small, frequent meals help ward off nausea.
A client is admitted with severe back pain and is requesting pain medication. During her assessment, the nurse notes the client has been taking acetaminophen 650 mg every 4 hours at home with minimal relief. Based on this information, which of the following PRN-ordered drug(s) should the nurse consider administering? ANSWER SELECTION Hydrocodone with acetaminophen Acetaminophen Ibuprofen Acetaminophen with oxycodone
Category: Pharmacological pain management Hydrocodone with acetaminophen would increase the client's intake of acetaminophen. The maximum recommended dose of acetaminophen in a 24 hour period is 4 g. Giving the client more acetaminophen would increase intake above the maximum recommended dose of 4 g in a 24-hour period. CORRECT: *Ibuprofen is the only pain relief medication listed that does not contain acetaminophen.* Acetaminophen with oxycodone would increase the client's intake of acetaminophen. The maximum recommended dose of acetaminophen in a 24-hour period is 4 g.
A client is admitted with sickle-cell anemia and voices concerns about becoming addicted to pain medicine. The nurse explains the difference between physical dependence, tolerance, and addiction. Which of the following symptoms or behaviors does the nurse know is BEST associated with addiction? ANSWER SELECTION Withdrawal symptoms when the drug is abruptly stopped Withdrawal symptoms when the drug dose is reduced Habitual and compulsive use of a drug A state of adaptation
Category: Pharmacological pain management Withdrawal symptoms when the drug is abruptly stopped are associated with physical dependence on a particular drug, not addiction. Withdrawal symptoms when the drug dose is reduced are associated with physical dependence on a particular drug, not addiction. CORRECT: Addiction is characterized by compulsive use of a drug for reasons other than therapeutic benefit. A state of adaptation is associated with tolerance to a particular drug, not addiction.
The physician orders a CT scan of the client's chest with IV contrast. Which of the following findings in the client's history should the nurse report to the physician? ANSWER SELECTION Hypertension Allergy to shellfish Urinary tract infection (UTI) Allergy to penicillin
Category: Potential for complications of diagnostic tests/treatments/procedures Hypertension is not a contraindication for a CT scan with IV contrast. CORRECT: A client with an allergy to iodine or shellfish may have an adverse reaction to the contrast medium. A UTI is not a contraindication for a CT scan with IV contrast. An allergy to penicillin is not a contraindication for a CT scan with IV contrast.
A 36-year-old primigravid client with a history of diabetes is admitted with preeclampsia. Which of the following actions should the nurse take FIRST? ANSWER SELECTION Administer low-dose aspirin as ordered. Ask the physician for an order for calcium supplements. Monitor the client's blood pressure. Prepare the client for delivery.
Category: Potential for complications of diagnostic tests/treatments/procedures Using low-dose aspirin has not been successful and is not recommended for routine use in pregnancy. Using calcium supplements has not been successful and is not recommended for routine use in pregnancy. Although frequent monitoring of blood pressure is a part of the management of preeclampsia, this is not the first thing the nurse should do. CORRECT: The nurse should prepare the client for delivery, which is the most effective treatment for preeclampsia.
The nurse is caring for a 41-year-old man with a new colostomy. As part of the care planning for this client, the nurse knows a referral to which of the following will be the priority? ANSWER SELECTION A certified wound, ostomy, and continence nurse (CWOCN) Social services Physical therapy Occupational therapy
Category: Referral CORRECT: A referral to a certified wound, ostomy, and continence nurse (CWOCN), if available, is important to the management of a client with a colostomy during and after hospitalization. Although a referral to social services might be necessary based on other factors, it is not the priority in the situation described. Although a referral to physical therapy might be necessary based on other factors, it is not the priority in the situation described. Although a referral to occupational therapy might be necessary based on other factors, it is not the priority in the situation described.
A client requires a lifesaving blood transfusion per hospital guidelines. The client refuses based on religious beliefs. It would be MOST appropriate for the nurse to take which of the following actions? ANSWER SELECTION Confirm with the client that the client understands the potential risks of not having the blood transfusion. Tell the client that, regardless of personal beliefs, the client has to have the lifesaving transfusion. Call the Legal Department of the hospital immediately. Try to gently encourage the client to change his or her mind.
Category: Religious and spiritual influences on health CORRECT: The nurse must be sure the client understands the potential risks of not receiving the transfusion. Clients do have the right to refuse care on religious grounds. Although the nurse may call the Legal Department at some future time, this would not be the first course of action in this situation. The nurse must be sure that the client comprehends the choice he or she is making, including risks and benefits. However, the nurse does not want to coerce the client into changing his or her mind.
The nurse is assessing an irritable 6-month-old infant during a well-baby checkup. The infant's weight is 19 lb., 6.4 oz. (8.8 kg). The infant does not have an elevated temperature, the heart rate is 102, and the respiratory rate is 32. The mother states that the infant wakes every hour or two throughout the night. The infant wants a bottle, and falls asleep while eating, but doesn't stay asleep. Which of the following instructions should the nurse give the parents? Instruct the parents to offer acetaminophen 325 mg orally for comfort, and diphenhydramine 25 mg orally for sleep. Instruct the parents to offer high-calorie solid foods during daytime hours so the infant does not wake up hungry during the night. Instruct the parents to offer the last feeding as late as possible, and put the infant to bed awake without a bottle. Suggest using pacifiers, taking the infant to the parent's bed, or rocking the infant to sleep.
Category: Rest and sleep Tylenol may be appropriate for teething pain, and Benadryl is an antihistamine that may cause drowsiness, but the doses as given are for adults. The infant's weight is within normal limits, so high-calorie foods may not be appropriate. CORRECT: The infant is having sleep disturbances related to nighttime feeding. Feeding late and putting the infant to bed awake help the infant learn to recognize bedtime and to self-soothe to fall asleep. The Academy of Pediatrics does not promote putting infants to bed with parents. Rocking the infant will not help learning to self-soothe.
An elderly man is admitted to the hospital from the Emergency Department during the night shift. The nurse is assessing the client's cerebellar function. Which of the following questions should the nurse ask the client? ANSWER SELECTION 1. "Who is the current president of the United States?" 2. "Do you have trouble swallowing fluids or foods?" 3. "Do you have any muscle pain?" 4. "Do you have problems with balance?"
Category: System specific assessments 1. This question will not help the nurse assess the client's cerebellar function, which is related to balance and coordination. 2. Trouble swallowing fluids or foods is not related to cerebellar function. 3. Muscle pain is not related to cerebellar function. 4. CORRECT: The nurse evaluates cerebellar function by testing the client's balance and coordination. -The cerebrum consists of the right & left hemispheres. It governs sensory, motor, thought and learning. Cerebral cortex--> 5 lobes -Thalamus relays sensory impulses to cortex, provides pain gate -hypothalamus- regulates sympa & parasympa responses- stress, sleep, appetite, body temp, fluid balance, and emotions; produces hormones secreted by pituitary and hypothalamus -Brainstem- motor coordination, visual reflex & auditory (midbrain), respiratory and regulates breathing (pons), cardiac, resp, vomiting, vasomotor [aka blood vessels], swallowing, sneezing, coughing (medulla oblongata); *brainstem= vital functions* *normal CSF pressure is 50-175 mm H20; normal volume 125-150ml*
The nurse is assessing a client admitted with a cerebrovascular accident (CVA). The physician has ordered a swallow study. The nurse knows which of the following lobes of the cerebral hemisphere is involved in the control of voluntary muscle movement, including those necessary for the production of speech and swallowing? ANSWER SELECTION Frontal Parietal Temporal Occipital
Category: System specific assessments CORRECT: The frontal lobe deals with higher levels of cognitive functions, such as reasoning and judgment. It also contains several cortical areas involved in the control of voluntary muscle movement, including those necessary for the production of speech and swallowing. The parietal lobe is associated with sensation, and is involved in writing and some aspects of reading. The temporal lobe is associated with auditory processing, olfaction, and word meaning (speech comprehension) The occipital lobe is involved in vision.
A client with Raynaud's disease is experiencing an acute attack. The nurse should anticipate which of the following assessment findings? ANSWER SELECTION Involuntary muscle contractions and twitching Unilateral facial weakness and drooping mouth Numbness and tingling of fingers and blanching of the skin at the fingertips Photophobia
Category: System specific assessments Involuntary muscle contractions and twitching may be signs of amyotrophic lateral sclerosis (ALS). Unilateral facial weakness and drooping mouth are signs of Bell's palsy. CORRECT: The cause of Raynaud's disease is unknown; however, after exposure to cold or stress, the client typically experiences blanching of the skin at the fingertips and numbness and tingling of the fingers. Photophobia is not a symptom of Raynaud's disease.
An elderly man is admitted to the hospital from the Emergency Department during the night shift. The nurse is assessing the client's cerebellar function. Which of the following questions should the nurse ask the client? ANSWER SELECTION "Who is the current president of the United States?" "Do you have trouble swallowing fluids or foods?" "Do you have any muscle pain?" "Do you have problems with balance?" Check Answer
Category: System specific assessments This question will not help the nurse assess the client's cerebellar function, which is related to balance and coordination. Trouble swallowing fluids or foods is not related to cerebellar function. Muscle pain is not related to cerebellar function. CORRECT: The nurse evaluates cerebellar function by testing the client's balance and coordination.
The nurse is assessing a client with Addison's disease. The nurse expects to note which of the following? ANSWER SELECTION Anorexia Weight gain Yellow skin coloration A craving for sweets Check Answer
Category: System specific assessments; Potential for alterations in body systems CORRECT: Anorexia is associated with Addison's disease. Weight loss, not weight gain, is a sign of Addison's disease. Bronze skin coloration (not yellow skin coloration) is a sign of Addison's disease. A craving for salty foods (not sweets) is a sign of Addison's disease.
A client is scheduled to have surgery the following day. The client tells the nurse, "I'm very scared. I have never had surgery before and am afraid that I might not make it through." Which of the following responses by the nurse is the MOST appropriate? ANSWER SELECTION "Why do you feel this way?" "Don't worry, you will be fine." "Why don't we take some time to explore why you feel this way?" "It's completely normal to be scared. You will be taken care of. Tell me how you are feeling."
Category: Therapeutic communications Avoid asking "Why" questions because they imply disapproval with what the client is saying. Telling the client not to worry, and that the client will be fine, dismisses the client's feelings and provides for false reassurances. The nurse must remain within the nursing scope of practice. The nurse is not a therapist, so asking the client to explore his feelings with the nurse would not be appropriate. CORRECT: A response that tells the client that it is normal to be scared, and that he will be taken care of, and asks how he is feeling, normalizes the client's experience, provides some reassurance, and allows for him to verbalize.
The nurse is working on a busy locked psychiatric unit. The alarm gets tripped when somebody tries to go through the locked doors without permission from the front desk. Which of the following actions should the nurse take after the alarm is tripped? ANSWER SELECTION Reset the alarm from the front desk after verifying that everybody is safe and nobody has escaped from the unit. Reset the alarm from the location where the alarm was tripped after verifying that everybody is safe and nobody has escaped from the unit. Reset the alarm from a client's room after doing a quick scan of the hallway. Reset the alarm from the front desk once the receptionist says everybody is accounted for
Category: Therapeutic environment Resetting the alarm from the front desk is not proper procedure. CORRECT: An alarm is a safety mechanism meant to alert staff to somebody at risk attempting to leave. When an alarm is activated, the nurse should first make sure that all clients are accounted for and safe, and then reset the alarm by going to the place where it was tripped. The nurse must be sure, based on firsthand knowledge, that all clients are safe. Resetting the alarm without doing so would not be appropriate. The nurse must be sure, based on firsthand knowledge, that all clients are safe. Resetting the alarm without doing so would not be appropriate.
The nurse is initiating cefazolin therapy following a physician's order. The nurse notes that the client has an allergy to penicillin. The client states he becomes a little short of breath and itches after receiving penicillin. The nurse should do which of the following? ANSWER SELECTION Call the pharmacy to therapeutically change the medication and notify the physician of this change. Hold the medication and call the physician to double-check the order. Give the medication as ordered—cefazolin is not a penicillin. After asking another nurse, give the medication as ordered.
Category: Unexpected response to therapies The physician should be made aware of this allergy prior to the client receiving the medication. In some instances, the physician will confirm the order and not change the medication, depending on the severity of the past or prior reaction to penicillin or cephalosporins. More often, though, the physician will change the antibiotic to a different family, but that is for the physician to decide and not the pharmacist or the nurse. CORRECT: The nurse would call the physician and double-check this order. Cefazolin is not a penicillin; it's a first-generation cephalosporin, which can cause a reaction in clients with penicillin allergies. It is for the physician to decide to change the medication, not the nurse.
