NCLEX questions

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which of the following points? a) Halfway between the client's symphysis pubis and umbilicus. b) At about the level of the client's umbilicus. c) Between the client's umbilicus and xiphoid process. d) Near the client's xiphoid process and compressing the diaphragm.

B) At about the level of the client's umbilicus. Reason: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.

The wife of a 67-year-old client who has been taking imipramine (Tofranil) for 3 days asks the nurse why her husband isn't better. The nurse should tell the wife: a) "It takes 2 to 4 weeks before the full therapeutic effects are experienced." b) "Your husband may need an increase in dosage." c) "A different antidepressant may be necessary." d) "It can take 6 weeks to see if the medication will help your husband."

a) "It takes 2 to 4 weeks before the full therapeutic effects are experienced." Reason: Imipramine, a tricyclic antidepressant, typically requires 2 to 4 weeks of therapy before the full therapeutic effects are experienced. Because the client has been taking the drug for only 3 days, it is too soon to determine if the current dosage of imipramine is effective. It is also too soon to consider taking another antidepressant.

A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When she informs him that the physician has ordered a wound care nurse to examine his foot, the client asks why he should see anyone other than this nurse. He states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." What is the nurse's best response? a) "We're very concerned about your foot and we want to provide the best possible care for you." b) "This is a big deal and you need to recognize how serious it is." c) "This is the physician's recommendation. The wound care nurse will see you today." d) "You could lose your foot if you don't see the wound care nurse."

a) "We're very concerned about your foot and we want to provide the best possible care for you." Reason: The client's response indicates that he's in denial and needs further insight and education about his condition. Letting the client know that the nurse has his best interests in mind helps him accept the wound-care nurse. Although telling the client that his condition is serious and that the wound care nurse will see him that day are true statements, they're much too direct and may increase client resistance. Telling the client he could lose his foot is inappropriate and isn't therapeutic communication.

Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by: a) flight of ideas and inflated self-esteem. b) increased sleep and greater distractibility. c) decreased self-esteem and increased physical restlessness. d) obsession with following rules and maintaining order

a) flight of ideas and inflated self-esteem. Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.

Which of the following laboratory findings is present in nephrotic syndrome? a) Decreased total serum protein. b) Hypercalcemia. c) Hyperglycemia. d) Decreased hematocrit.

a) Decreased total serum protein. Reason: A decreased total serum protein occurs as extensive amounts of protein are excreted from the body through the urine. Clients may develop hypocalcemia. Hyperglycemia is not a finding related to nephrotic syndrome. A decreased hematocrit is not a finding related to nephrotic syndrome.

A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, which nursing diagnosis should be the nurse's priority? a) Deficient knowledge related to food restrictions associated with anesthesia b) Fear related to surgery c) Risk for impaired skin integrity related to upcoming surgery d) Ineffective coping related to the stress of surgery

a) Deficient knowledge related to food restrictions associated with anesthesia Reason: The client's statement reveals a Deficient knowledge related to food restrictions associated with general anesthesia. Fear related to surgery, Risk for impaired skin integrity related to upcoming surgery, and Ineffective coping related to the stress of surgery may be applicable nursing diagnoses but they aren't related to the client's statement.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Endotracheal suctioning b) Encouragement of coughing c) Use of a cooling blanket d) Incentive spirometry

a) Endotracheal suctioning Reason: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

Which nursing action is required before a client in labor receives epidural anesthesia? a) Give a fluid bolus of 500 ml. b) Check for maternal pupil dilation. c) Assess maternal reflexes. d) Assess maternal gait.

a) Give a fluid bolus of 500 ml. Reason: One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to prevent hypotension in the client who wishes to receive an epidural for pain relief. Assessing maternal reflexes, pupil response, and gait isn't necessary.

When performing a physical assessment on an 18-month-old child, which of the following would be best? a) Have a parent hold the toddler. b) Assess the ears and mouth first. c) Carry out the assessment from head to toe. d) Assess motor function by having the child run and walk.

a) Have a parent hold the toddler. Reason: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically these include assessments of the cardiac and respiratory systems. The ears and throat are typically examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.

On initial assessment of a 7-year-old child with rheumatic fever, which of the following would require contacting the primary care provider immediately? a) Heart rate of 150 beats/minute. b) Swollen and painful knee joints. c) Twitching in the extremities. d) Red rash on the trunk

a) Heart rate of 150 beats/minute. Reason: A heart rate of 150 beats/minute is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 beats/minute. Swollen and painful joints such as the knee are characteristic findings in the child with rheumatic fever and do not require immediate physician notification. Twitching in the extremities, known as chorea, is a characteristic finding in a child with rheumatic fever and does not require immediate physician notification. A red rash on the trunk typically indicates rheumatic fever and does not require immediate physician notification.

Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea? a) Moist mucous membranes. b) Passage of a soft, formed stool. c) Absence of diarrhea for a 4-hour period. d) Ability to tolerate intravenous fluids well

a) Moist mucous membranes. Reason: The outcome of moist mucous membranes indicates adequate hydration and fluid balance, showing that the problem of fluid volume deficit has been corrected. Although a normal bowel movement, ability to tolerate intravenous fluids, and an increasing time interval between bowel movements are all positive signs, they do not specifically address the problem of deficient fluid volume.

A nurse is facilitating mandated group therapy for clients who have sexually abused children. Children who are victims of sexual abuse are typically: a) from any segment of the population. b) of low socioeconomic background. c) strangers to the abuser. d) willing to engage in sexual acts with adults.

a) from any segment of the population. Reason: Victims of childhood sexual abuse come from all segments of the population and from all socioeconomic backgrounds. Most victims know their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full decision-making capacities.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next? a) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. b) Ask the client to assume a side-lying position with the knees flexed. c) Perform massage vigorously at the level of the umbilicus if the fundus feels boggy. d) Place the client on a bedpan in case the uterine palpation stimulates the client to void.

a) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Reason: The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.

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

a) Respiratory acidosis Reason: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.

Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? a) Rewarm the neonate gradually. b) Rewarm the neonate rapidly. c) Observe the neonate hourly. d) Notify the physician when the neonate's temperature is normal.

a) Rewarm the neonate gradually. Reason: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock? a) Tachycardia. b) Dry, flushed skin. c) Increased urine output. d) Loss of consciousness.

a) Tachycardia. Reason: In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. The skin becomes cool and clammy. Urine output in early shock may be normal or slightly decreased. The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.

A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? a) Taking vital signs every 4 hours and obtaining daily weight b) Obtaining a blood sample for electrolyte analysis every morning c) Checking every urine specimen for protein and specific gravity d) Ensuring that the child has accurate intake and output and eats a high-protein diet

a) Taking vital signs every 4 hours and obtaining daily weight Reason: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation.

A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the primary care provider, he utters a stream of profanities. Which of the following statements best describes the client's behavior? a) The client's anger is not intended personally. b) The client's anger is a reliable sign of serious pathology. c) The client's anger is an intended attack on the primary care provider's skills d) The client's anger is a sign that his condition is improving

a) The client's anger is not intended personally. Reason: Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal. Such behavior is not necessarily a sign of serious pathology but must be weighed in conjunction with other behaviors. An angry outburst is not an attack on a primary care provider's skills. While not necessarily pathologic, the client's behavior isn't a sign that his condition is improving.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved? a) The entry should include clearer descriptions of the client's mood and behavior. b) The entry should avoid mentioning cognitive or psychosocial issues. c) The entry should list the specific reasons that the client was upset. d) The entry should specify the subsequent interventions that were performed

a) The entry should include clearer descriptions of the client's mood and behavior. Reason: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

A nurse on a rehabilitation unit is caring for a client who sustained a head injury in a motor vehicle accident. She notes that the client has become restless and agitated during therapy; previous documentation described the client as cooperative during therapy sessions. The nurse's priority action should be to: a) gather assessment data and notify the physician of the change in the client's status. b) ask the physician to order an antipsychotic medication for the client. c) consult with the social worker about the possibility of discharging the client from the facility. d) tell the client that she'll punish him if he doesn't behave.

a) gather assessment data and notify the physician of the change in the client's status. Reason: A client with a head injury who experiences a change in cognition requires further assessment and evaluation, and the nurse should notify the physician of the change in the client's status. The physician should rule out all possible medical causes of the change in mental status before ordering antipsychotic medications or considering discharging the client from the facility. A nurse shouldn't threaten a client with punishment; doing so is a violation of the client's rights.

A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: a) help the family prepare for the infant's imminent death. b) implement measures to facilitate the attachment process. c) provide emotional support so the family can adjust to the birth of an infant with health problems. d) prepare the family for the extensive surgical procedures the infant will require.

a) help the family prepare for the infant's imminent death. Reason: Anencephaly is incompatible with life. The nurse should support family members as they prepare for the infant's imminent death. Facilitating the attachment process, helping the family to adjust to the infant's problems, and preparing the family for extensive surgical procedures are inappropriate because the infant can't survive.

A pregnant client in her third trimester is started on chlorpromazine (Thorazine) 25 mg four times daily. Which of the following instructions is most important for the nurse to include in the client's teaching plan? a) "Don't drive because there's a possibility of seizures occurring." b) "Avoid going out in the sun without a sunscreen with a sun protection factor of 25." c) "Stop the medication immediately if constipation occurs." d) "Tell your doctor if you experience an increase in blood pressure."

b) "Avoid going out in the sun without a sunscreen with a sun protection factor of 25." Reason: Chlorpromazine is a low-potency antipsychotic that is likely to cause sun-sensitive skin. Therefore the client needs instructions about using sunscreen with a sun protection factor of 25 or higher. Typically, chlorpromazine is not associated with an increased risk of seizures. Although constipation is a common adverse effect of this drug, it can be managed with diet, fluids, and exercise. The drug does not need to be discontinued. Chlorpromazine is associated with postural hypotension, not hypertension. Additionally, if postural hypotension occurs, safety measures, such as changing positions slowly and dangling the feet before arising, not stopping the drug, are instituted.

A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask: a) "Do you have the pain all the time?" b) "Can you describe the pain?" c) "Where does it hurt the most?" d) "Is the pain stabbing like a knife?"

b) "Can you describe the pain?" Reason: Asking an open-ended question such as "Can you describe the pain?" encourages the client to describe any and all aspects of the pain in his own words. The other options are likely to elicit less information because they're more specific and would limit the client's response.

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents: a) "Does water ever get into the baby's ears during shampooing?" b) "Do you give the baby a bottle to take to bed?" c) "Have you noticed a lot of wax in the baby's ears?" d) "Can the baby combine two words when speaking?"

b) "Do you give the baby a bottle to take to bed?" Reason: In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media. Asking if the parent noticed earwax, or cerumen, in the external ear canal is incorrect because wax doesn't promote the development of otitis media. During shampooing, water may become trapped in the external ear canal by large amounts of cerumen, possibly causing otitis external (external ear inflammation) as opposed to internal ear inflammation. Asking if the infant can combine two words is incorrect because a 10-month-old child isn't expected to do so.

The mother of a client with chronic undifferentiated schizophrenia calls the visiting nurse in the The mother of a client with chronic undifferentiated schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I don't know what's wrong. I'm worried." Which of the following responses by the nurse is most appropriate? a) "Maybe she's just mad at you. Did you have an argument?" b) "She may have stopped taking her medications. I'll check on her." c) "Don't worry about this. It happens sometimes." d) "Go over to her apartment and see what's going on."

b) "She may have stopped taking her medications. I'll check on her." Reason: Noncompliance with medications is common in the client with chronic undifferentiated schizophrenia. The nurse has the responsibility to assess this situation. Asking the mother if they've argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what's going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client's symptoms.

A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? a) 7 weeks' gestation b) 11 weeks' gestation c) 17 weeks' gestation d) 21 weeks' gestation

b) 11 weeks' gestation Reason: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? a) Trendelenburg's b) 30-degree head elevation c) Flat d) Side-lying

b) 30-degree head elevation Reason: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be: a) An isotonic dextrose solution. b) A hypertonic dextrose solution. c) A hypotonic dextrose solution. d) A colloidal dextrose solution.

b) A hypertonic dextrose solution. Reason: The TPN solution is usually a hypertonic dextrose solution. The greater the concentration of dextrose in solution, the greater the tonicity. Hypertonic dextrose solutions are used to meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system. An isotonic dextrose solution (e.g., 5% dextrose in water) or a hypotonic dextrose solution will not provide enough calories to meet metabolic needs. Colloids are plasma expanders and blood products and are not used in TPN.

A woman who has recently immigrated from Africa who delivered a term neonate a short time ago requests that a "special bracelet" be placed on the baby's wrist. The nurse should: a) Tell the mother that the bracelet is not recommended for cleanliness reasons. b) Apply the bracelet on the neonate's wrist as the mother requests. c) Place the bracelet on the neonate, limiting its use to when the neonate is with the mother. d) Recommend that the mother wait until she is discharged to apply the bracelet

b) Apply the bracelet on the neonate's wrist as the mother requests. Reason: The nurse should abide by the mother's request and place the bracelet on the neonate. In some cultures, amulets and other special objects are viewed as good luck symbols. By allowing the bracelet, the nurse demonstrates culturally sensitive care, promoting trust. The neonate can wear the bracelet while with the mother or in the nursery. The bracelet can be used while the neonate is being bathed, or if necessary and acceptable to the client removed and replaced afterward.

A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to: a) Call for emergency assistance. b) Attempt reinsertion of tracheostomy tube. c) Position the client in semi-Fowler's position with the neck hyperextended. d) Insert the obturator into the stoma to reestablish the airway.

b) Attempt reinsertion of tracheostomy tube. Reason: The nurse's first action should be to attempt to replace the tracheostomy tube immediately so that the client's airway is reestablished. Although the nurse may also call for assistance, there should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through the tube.

A nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect? a) Absent pedal pulses b) Bilateral dependent edema c) Sluggish capillary refill d) Unilateral calf enlargement

b) Bilateral dependent edema Reason: As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department? a) Bacterial vaginitis b) Gonorrhea c) Genital herpes d) Human papillomavirus (HPV)

b) Gonorrhea Reason: Gonorrhea must be reported to the public health department. Bacterial vaginitis, genital herpes, and HPV aren't reportable diseases.

A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying: a) Concreteness. b) Flight of ideas. c) Depersonalization. d) Use of neologisms.

b) Flight of ideas. Reason: The client is demonstrating flight of ideas, or the rapid, unconnected, and often illogical progression from one topic to another. Concreteness involves interpreting another person's words literally. Depersonalization refers to feelings of strangeness concerning the environment or the self. A neologism is a word made up by a client.

After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings should lead the nurse to believe the child is experiencing anxiety? a) Not able to get comfortable. b) Frequent requests for someone to stay in the room. c) Inability to remember her exact address. d) Verbalization of a feeling of tightness in her chest.

b) Frequent requests for someone to stay in the room. Reason: A 9-year-old child should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress that, at this age, suggests anxiety. The inability to get comfortable is more characteristic of a child in pain. Inability to answer questions correctly may reflect a state of anoxia or a lack of knowledge. Tightness in the chest occurs as a result of bronchial spasms.

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? a) G 4, P 1 client who is breastfeeding her infant. b) G 3, P 3 client who is breastfeeding her infant. c) G 2, P 2 cesarean client who is bottle-feeding her infant. d) G 3, P 3 client who is bottle-feeding her infant

b) G 3, P 3 client who is breastfeeding her infant. Reason: The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There is no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breast-feeding—places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has delivered several children, but her choice to bottle-feed reduces her risk of pain.

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should: a) Administer TPN through a nasogastric or gastrostomy tube. b) Handle TPN using strict aseptic technique. c) Auscultate for bowel sounds prior to administering TPN. d) Designate a peripheral intravenous (IV) site for TPN administration

b) Handle TPN using strict aseptic technique. Reason: TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract motility, to better meet their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.

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

b) Hypertensive crisis Reason: The most serious adverse reaction associated with high doses of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high doses. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.

A 7 year old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an intravenous (IV) line of D5 1/2 NS + 20 meq KCL/L running at 60 ml/hr. Vital signs are a temperature of 38 degrees C, heart rate of 120, respiratory rate of 28, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for: a) Rectal diazepam (Diastat). b) IV lorazepam (Ativan). c) Rectal acetaminophen (Tylenol). d) IV fosphenytoin.

b) IV lorazepam (Ativan). Reason: IV ativan is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter, stopping seizure activity. If an IV line is not available, rectal Diastat is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? a) Have the client wear eyeglasses at all times. b) Lightly tape the eyelid shut. c) Instill artificial tears once every shift. d) Clean the eyelid with a washcloth every shift.

b) Lightly tape the eyelid shut. Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.

A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately: a) Put the client to bed. b) Obtain the child's blood pressure. c) Notify the physician. d) Administer acetaminophen (Tylenol)

b) Obtain the child's blood pressure. Reason: Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before confirming the cause of the symptoms would not assist the physician in his treatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering Tylenol for high blood pressure is not recommended.

A client who took an overdose of Tylenol in a suicide attempt is transferred overnight to the psychiatric inpatient unit from the intensive care unit. The night shift nurse called the primary health care provider on call to obtain initial prescriptions. The primary health care provider prescribes the typical routine medications for clients on this unit: Milk of Magnesia, Maalox and Tylenol as needed. Prior to implementing the prescriptions, the nurse should? a) Ask the primary health care provider about holding all the client's PM prescriptions. b) Question the primary health care provider about the Tylenol prescription. c) Request a prescription for a medication to relieve agitation. d) Suggest the primary health care provider write a prescription for intravenous fluids.

b) Question the primary health care provider about the Tylenol prescription. Reason: The nurse should question the Tylenol order because the client overdosed on Tylenol, and that analgesic would be contraindicated as putting further stress on the liver. There is no need to hold the PM Milk of Magnesia or Maalox. There is no indication that the client is agitated or needs medication for agitation. There is little likelihood that the client needs an IV after being transferred out of an intensive care unit, as the client will be able to take oral fluids.

The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is: a) Relief from spasms of the diaphragm. b) Relaxation of smooth muscles in the bronchioles. c) Efficient pulmonary circulation. d) Stimulation of the medullary respiratory center.

b) Relaxation of smooth muscles in the bronchioles. Reason: Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in the treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does not have an effect on the diaphragm or the medullary respiratory center and does not promote pulmonary circulation.

A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely? a) Early deceleration pattern. b) Sinusoidal pattern. c) Variable deceleration pattern. d) Late deceleration pattern.

b) Sinusoidal pattern. Reason: The fetal heart rate of a multipara diagnosed with Rh sensitization and probable fetal hydrops and anemia will most likely demonstrate a sinusoidal pattern that resembles a sine wave. It has been hypothesized that this pattern reflects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. This client will most likely require a cesarean delivery to improve the fetal outcome. Early decelerations are associated with head compression; variable decelerations are associated with cord compression; and late decelerations are associated with poor placental perfusion.

The nurse is assessing the development of a 7-month-old. The child should be able to: a) Play pat-a-cake. b) Sit without support. c) Say two words. d) Wave bye-bye

b) Sit without support. Reason: The majority of infants (90%) can sit without support by 7 months of age. Approximately 75% of infants at 10 months of age are able to play pat-a-cake. The ability to say two words occurs in 90% of children by age 16 months. A child typically can wave bye-bye at about 14 months of age.

Which scenario complies with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations? a) Two nurses in the cafeteria are discussing a client's condition. b) The health care team is discussing a client's care during a formal care conference. c) A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor. d) A nurse talks with her spouse about a client's condition.

b) The health care team is discussing a client's care during a formal care conference. Reason: To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates HIPAA regulations. Looking up laboratory results for a neighbor is a HIPAA violation, as is discussing a client's condition with one's spouse.

Communicating with parents and children about health care has become increasingly significant because: a) Consumers of health care cannot keep up with rapid advances in science. b) The influence of the media and specialization have increased the complexity of managing health. c) Nurse educators have recognized the value of communication. d) Clients are more demanding that their rights be respected.

b) The influence of the media and specialization have increased the complexity of managing health. Reason: Today's health care network includes many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring, to name a few. Due to expanded media coverage of health care issues, parents are more aware of health care issues but cannot understand all the ramifications of possible health care decisions. Because of this expanded media coverage, health care consumers are more aware of advances in the science of health care. Nurses have always recognized the value of communication and that all nurses are teachers. Clients are more aware of their rights through media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well and communicating with parents and children should not be impacted by a client's knowledge or demand for those rights.

After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery? a) Peritonitis. b) Thrombophlebitis. c) Ascites. d) Inguinal hernia.

b) Thrombophlebitis. Reason: After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? a) Diaphragmatic breathing b) Use of accessory muscles c) Pursed-lip breathing d) Controlled breathing

b) Use of accessory muscles Reason: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

When assessing a client for early septic shock, the nurse should assess the client for which of the following? a) Cool, clammy skin. b) Warm, flushed skin. c) Increased blood pressure. d) Hemorrhage.

b) Warm, flushed skin. Reason: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

A primigravid client gives birth to a full-term girl. When teaching the client and her partner how to change their neonate's diaper, the nurse should instruct them to: a) fold a cloth diaper so that a double thickness covers the front. b) clean and dry the neonate's perineal area from front to back. c) place a disposable diaper over a cloth diaper to provide extra protection. d) position the neonate so that urine will fall to the back of the diaper.

b) clean and dry the neonate's perineal area from front to back. Reason: When changing a female neonate's diaper, the caregiver should clean the perineal area from front to back to prevent infection and then dry the area thoroughly to minimize skin breakdown. For a male, the caregiver should clean and dry under and around the scrotum. Because of anatomic factors, a female's diaper should have the double thickness toward the back. The diaper, not the neonate, should be positioned properly. Placing a disposable diaper over a cloth diaper isn't necessary. The direction of urine flow can't be ensured.

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that: a) the client requires an antiviral agent. b) enteric precautions must be continued. c) enteric precautions can be discontinued. d) the client's infection may be caused by droplet transmission.

b) enteric precautions must be continued. Reason: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease? a) "We try to keep him happy at all costs; otherwise, he has an asthma attack." b) "We keep our child away from other children to help cut down on infections." c) "Although our child's disease is serious, we try not to let it be the focus of our family." d) "I'm afraid that when my child gets older, he won't be able to care for himself like I do."

c) "Although our child's disease is serious, we try not to let it be the focus of our family." Reason: Positive adjustment to a chronic condition requires placing the child's illness in its proper perspective. Children with asthma need to be treated as normally as possible within the scope of the limitations imposed by the illness. They also need to learn how to manage exacerbations and then resume as normal a life as possible. Trying to keep the child happy at all costs is inappropriate and can lead to the child's never learning how to accept responsibility for behavior and get along with others. Although minimizing the child's risk for exposure to infections is important, the child needs to be with his or her peers to ensure appropriate growth and development. Children with a chronic illness need to be involved in their care so that they can learn to manage it. Some parents tend to overprotect their child with a chronic illness. This overprotectiveness may cause a child to have an exaggerated feeling of importance or later, as an adolescent, to rebel against the overprotectiveness and the parents.

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which of the following comments by the client supports the fact that the client may not need counseling? a) "My doctor just put me on an antidepressant, and I'll be fine in a week or so." b) "My daughter sent me here. She's mad because I don't have the energy to take care of my grandkids." c) "Since I've gotten over the death of my husband, I've had more energy and been more active than before he died." d) "My son got worried because I made this silly comment about wanting to be with my husband in heaven.

c) "Since I've gotten over the death of my husband, I've had more energy and been more active than before he died." Reason: Resolving grief and having increased energy and activity convey good mental health, indicating that counseling is not necessary at this time. Taking an antidepressant or having less energy and involvement with grandchildren reflects possible depression and the need for counseling. Wanting to be with her dead husband suggests possible suicidal ideation that warrants serious further assessment and counseling.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? a) Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician. b) Ask the nursing assistant to notify the physician of the low pulse oximetry level. c) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. d) Complete the assessment of the new client before attending to the client who underwent laminectomy.

c) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Reason: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

A nurse is developing a nursing diagnosis for a client. Which information should she include? a) Actions to achieve goals b) Expected outcomes c) Factors influencing the client's problem d) Nursing history

c) Factors influencing the client's problem Reason: A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.

A client with pneumonia has a temperature of 102.6° F (39.2° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? a) Position changes every 4 hours. b) Nasotracheal suctioning to clear secretions. c) Frequent linen changes. d) Frequent offering of a bedpan.

c) Frequent linen changes. Reason: Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet? a) Lean beef. b) Air-popped popcorn. c) Hot chocolate. d) Raw vegetables.

c) Hot chocolate. Reason: With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.

During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which of the following activities should the nurse perform after finishing the incident report? a) Attach a copy to the client's records. b) Highlight the mistake in the client's records. c) Include the time and date of the incident. d) Mention the name of the nursing assistant in the client records.

c) Include the time and date of the incident. Reason: The nurse should include the date and time of the incident in the incident report, the events leading up to it, the client's response, and a full nursing assessment. To prevent legal issues, the nurse should not attach the copy of the incident report to the client's records. Also to prevent litigation, the mistake should not be highlighted in the client's records. As the client report is a legal document, it should not contain the name of the nursing assistant.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Shock b) Encephalitis c) Increased intracranial pressure (ICP) d) Status epilepticus

c) Increased intracranial pressure (ICP) Reason: When ICP increases, Cushing's triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. (If the client doesn't maintain adequate hydration, hypotension may occur.) Status epilepticus causes unceasing seizures, not changes in vital signs.

Which of the following is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose? a) Educate regarding drug abuse. b) Minimize pain. c) Maintain intact skin. d) Increase caloric intake

c) Maintain intact skin. Reason: Maintaining intact skin is a priority for the unconscious client. Unconscious clients need to be turned every hour to prevent complications of immobility, which include pressure ulcers and stasis pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.

A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which emotional response is typical during early adolescence? a) Frequent anger b) Cooperativeness c) Moodiness d) Combativeness

c) Moodiness Reason: Moodiness may occur often during early adolescence. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.

An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and saying that she thinks she is pregnant but does not know what to do. Which of the following nursing interventions is most appropriate at this time? a) Ask the client about the type of things that she had thought of doing. b) Give the client some ideas about what to expect to happen next. c) Recommend a pregnancy test after acknowledging the client's distress. d) Question the client about her feelings and possible parental reactions.

c) Recommend a pregnancy test after acknowledging the client's distress. Reason: Before any interventions can occur, knowing whether the client is pregnant is crucial in formulating a plan of care. Asking the client about what things she had thought about doing, giving the client some ideas about what to expect next, and questioning the client about her feelings and possible parental reactions would be appropriate after it is determined that the client is pregnant.

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it: a) Purges evil spirits. b) Promotes tranquility. c) Restores the balance of energy. d) Blocks nerve pathways to the brain

c) Restores the balance of energy. Reason: Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? a) The client sees his physician for a check-up yearly. b) The client has never traveled outside of the country. c) The client had a liver transplant 2 years ago. d) The client works in a health care insurance office.

c) The client had a liver transplant 2 years ago. Reason: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse should make which judgment about the client? a) The client is decompensating and in need of being readmitted to the hospital. b) The client needs an adjustment or increase in his dose of antidepressant. c) The depression is improving and the suicidal ideation is lessening. d) The presence of suicidal ideation warrants a telephone call to the client's primary care provider.

c) The depression is improving and the suicidal ideation is lessening. Reason: The client's statements about being in control of his behavior and his or her plans to return to work indicate an improvement in depression and that suicidal ideation, although present, is decreasing. Nothing in his comments or behavior indicate he is decompensating. There is no evidence to support an increase or adjustment in the dose of Effexor or a call to the primary care provider. Typically, the cognitive components of depression are the last symptoms eliminated. For the client to be experiencing some suicidal ideation in the second week of psychopharmacologic treatment is not unusual.

Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area? a) The client will be maintained on bed rest for several days. b) Ambulation is restricted by the presence of drainage tubes. c) The operative incision is near the diaphragm. d) The presence of a nasogastric tube inhibits deep breathing.

c) The operative incision is near the diaphragm. Reason: The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep breathing and coughing.

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? a) Total iron-binding capacity b) Hemoglobin (Hb) c) Total protein d) Sweat test

c) Total protein Reason: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: a) deeper sleep than CNS depressants. b) greater sedation than CNS depressants. c) a calming effect from which the client is easily aroused. d) more prolonged sedative effects, making the client more difficult to arouse

c) a calming effect from which the client is easily aroused. Reason: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.

A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. He admits drinking excessively over the previous 48 hours. This behavior is an example of: a) alcoholism. b) a manic episode. c) situational crisis. d) depression.

c) situational crisis. Reason: A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks.

A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should: a) place the client in a supine position and prepare to perform cardiopulmonary resuscitation. b) place the client in high-Fowler's position and administer supplemental oxygen. c) turn the client on his left side and place the bed in Trendelenburg's position. d) position the client in the shock position with his legs elevated.

c) turn the client on his left side and place the bed in Trendelenburg's position. Reason: A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.

A 16-year-old academically gifted boy is about to graduate from high school early, because he has completed all courses needed to earn a diploma. Within the last 3 months, he has experienced panic attacks that have forced him to leave classes early and occasionally miss a day of school. He is concerned that these attacks may hinder his ability to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks? a) "It is natural to be worried about going into a new environment. I am sure with your abilities you will do well once you get settled." b) "You are putting too much pressure on yourself. You just need to relax more and things will be alright." c) "It might be best for you to postpone going to college. You need to get these panic attacks controlled first." d) "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."

d) "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." Reason: The client's concerns are real and serious enough to warrant assessment by a physician rather than being dismissed as trivial. Though he is very intelligent, his intelligence cannot overcome his anxiety. In fact, his anxiety is likely to interfere with his ability to perform in college if no assessment and treatment are received. Just postponing college is likely to increase rather than lower the client's anxiety, because it does not address the panic he is experiencing.

A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following should the nurse do upon the client's arrival? a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital signs every 4 hours. d) Admit the client to a quiet, darkened room

d) Admit the client to a quiet, darkened room. Reason: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible. Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.

Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct? a) An infant should ride in a front-facing car seat until he weighs 20 lb (9.1 kg) and is 1 year old. b) An infant should ride in a rear-facing car seat until he weighs 25 lb (11.3 kg) or is 1 year old. c) An infant should ride in a front-facing car seat until he weighs 30 lb (13.6 kg) or is 2 years old. d) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old.

d) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old. Reason: Until the infant weighs 20 lb and is 1 year old, he should ride in a rear-facing car seat.

The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective? a) Abnormal thought form. b) Hallucinations and delusions. c) Bizarre behavior. d) Asocial behavior and anergia

d) Asocial behavior and anergia. Reason: Asocial behavior, anergia, alogia, and affective flattening are some of the negative symptoms of schizophrenia that may improve with risperidone therapy. Abnormal thought form is a positive symptom of schizophrenia. Hallucinations and delusions are positive symptoms of schizophrenia. Bizarre behavior is a positive symptom of schizophrenia.

A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? a) Sit with the client for a few minutes. b) Administer an analgesic. c) Inform the nurse manager. d) Call the physician immediately

d) Call the physician immediately. Reason: The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. Which of the following should the nurse do first? a) Start mouth-to-mouth resuscitation. b) Contact the neonatal resuscitation team. c) Raise the neonate's head and pat the back gently. d) Clear the neonate's airway with suction or gravity.

d) Clear the neonate's airway with suction or gravity. Reason: If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction. Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic and lowering his head or suctioning doesn't clear his airway. Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway. Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties.

A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy? a) Decrease in appetite. b) Drowsiness. c) Spasms of the diaphragm. d) Cough and shortness of breath.

d) Cough and shortness of breath. Reason: Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.

Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use? a) Verbalizing an understanding of blood glucose meter use b) Documenting a normal blood glucose level c) Providing documentation of previous certification d) Demonstrating correct technique

d) Demonstrating correct technique Reason: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? a) Phimosis. b) Hydrocele. c) Epispadias. d) Hypospadias

d) Hypospadias. Reason: The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

Which of the following is an early symptom of glaucoma? a) Hazy vision. b) Loss of central vision. c) Blurred or "sooty" vision. d) Impaired peripheral vision.

d) Impaired peripheral vision. Reason: In glaucoma, peripheral vision is impaired long before central vision is impaired. Hazy, blurred, or distorted vision is consistent with a diagnosis of cataracts. Loss of central vision is consistent with senile macular degeneration but it occurs late in glaucoma. Blurred or "sooty" vision is consistent with a diagnosis of detached retina.

A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do? a) Ask the client's daughter to serve as an interpreter. b) Ask one of the Hispanic nursing assistants to serve as an interpreter. c) Use the limited Spanish she remembers from high school along with nonverbal communication. d) Obtain a trained medical interpreter.

d) Obtain a trained medical interpreter. Reason: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the patient's confidentiality. Using the nursing assistant or limited Spanish and nonverbal communication do not ensure accuracy of interpretation and back-translation into English.

A client was talking with her husband by telephone, and then she began swearing at him. The nurse interrupts the call and offers to talk with the client. She says, "I can't talk about that bastard right now. I just need to destroy something." Which of the following should the nurse do next? a) Tell her to write her feelings in her journal. b) Urge her to talk with the nurse now. c) Ask her to calm down or she will be restrained. d) Offer her a phone book to "destroy" while staying with her.

d) Offer her a phone book to "destroy" while staying with her. Reason: At this level of aggression, the client needs an appropriate physical outlet for the anger. She is beyond writing in a journal. Urging the client to talk to the nurse now or making threats, such as telling her that she will be restrained, is inappropriate and could lead to an escalation of her anger.

A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision? a) Inserting an indwelling urinary catheter b) Fundal massage c) Administration of oxytocics d) Pad count

d) Pad count Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.

A client diagnosed with pain disorder is talking with the nurse about fishing when he suddenly reverts to talking about the pain in his arm. Which of the following should the nurse do next? a) Allow the client to talk about his pain. b) Ask the client if he needs more pain medication. c) Get up and leave the client. d) Redirect the interaction back to fishing.

d) Redirect the interaction back to fishing. Reason: The nurse should redirect the interaction back to fishing or another focus whenever the client begins to ruminate about physical symptoms or impairment. Doing so helps the client talk about topics that are more therapeutic and beneficial to recovery. Allowing the client to talk about his pain or asking if he needs additional pain medication is not therapeutic because it reinforces the client's need for the symptom. Getting up and leaving the client is not appropriate unless the nurse has set limits previously by saying, "I will get up and leave if you continue to talk about your pain."

A nurse is caring for a client with a diagnosis of Impaired gas exchange. Based upon this nursing diagnosis, which outcome is most appropriate? a) The client maintains a reduced cough effort to lessen fatigue. b) The client restricts fluid intake to prevent overhydration. c) The client reduces daily activities to a minimum. d) The client has normal breath sounds in all lung fields.

d) The client has normal breath sounds in all lung fields. Reason: If the interventions are effective, the client's breath sounds should return to normal. The client should be able to cough effectively and should be encouraged to increase activity, as tolerated. Fluids should help thin secretions, so fluid intake should be encouraged.

Based on a client's history of violence toward others and her inability to cope with anger, which of the following should the nurse use as the most important indicator of goal achievement before discharge? a) Acknowledgment of her angry feelings. b) Ability to describe situations that provoke angry feelings. c) Development of a list of how she has handled her anger in the past. d) Verbalization of her feelings in an appropriate manner

d) Verbalization of her feelings in an appropriate manner. Reason: Verbalizing feelings, especially feelings of anger, in an appropriate manner is an adaptive method of coping that reduces the chance that the client will act out these feelings toward others. The client's ability to verbalize her feelings indicates a change in behavior, a crucial indicator of goal achievement. Although acknowledging feelings of anger and describing situations that precipitate angry feelings are important in helping the client reach her goal, they are not appropriate indicators that she has changed her behavior. Asking the client to list how she has handled anger in the past is helpful if the nurse discusses coping methods with the client. However, based on this client's history, this would not be helpful because the nurse and client are already aware of the client's aggression toward others.

On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for: a) endometritis. b) postpartum hemorrhage. c) subinvolution. d) afterpains

d) afterpains. Reason: In a multiparous client, decreased uterine muscle tone causes alternating relaxation and contraction during uterine involution, which leads to afterpains. The client's symptoms don't suggest endometritis, hemorrhage, or subinvolution.

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to: a) remove the raised skin because the blister has already broken. b) wash the area with soap and water to disinfect it. c) apply a weakened alcohol solution to clean the area. d) clean the area with normal saline solution and cover it with a protective dressing.

d) clean the area with normal saline solution and cover it with a protective dressing. Reason: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include: a) increased coronary artery blood flow. b) decreased posterior thoracic curve. c) decreased peripheral resistance. d) delayed gastric emptying.

d) delayed gastric emptying. Reason: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

A client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of: a) delusion. b) looseness of association. c) illusion. d) hallucination

d) hallucination. Reason: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.