nclex saunders pt. 7

A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. To meet these goals, which action should the nurse take when working with the child? 1. Place the child on a wheeled scooter board. 2. Remove ankle-foot orthoses and braces once the child arrives at school. 3. Keep the child in a special education classroom with other children with similar disabilities. 4.Lay the child in the supine position with a 30-degree elevation of the head to facilitate feeding.

1. Place the child on a wheeled scooter board. Option 1 provides the child with maximum potential in locomotion, self-care, and socialization. The child can move around independently on the abdomen anywhere the child wants to go and can interact with others as desired. Orthoses must be used all the time to aid locomotion (option 2). Option 3 does not provide for maximum socialization and normalization; rather, children with CP need to be mainstreamed as much as cognitively able. Not all children with CP are intellectually challenged. Option 4 does not provide for normalization in self-care. Just as children without CP sit up and use assistive devices when eating, so should children with CP.

The nurse is assisting in working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are examples of which type of prevention? 1. Aggregate care prevention 2. The tertiary level of prevention 3. The primary level of prevention 4. The secondary level of prevention

2. The tertiary level of prevention Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on seeking to detect existing health problems or trends and reducing the intensity and duration of the crisis during the crisis itself. There is no known aggregate care prevention level.

The unlicensed assistive personnel (UAP) who has been employed in a long-term care facility for 8 weeks is consistently 10 to 20 minutes late for work. The UAPs lateness has caused unrest with other staff members in the nursing unit. The UAP is due to receive a 3-month probation evaluation in 1 month. Which is the most appropriate action by the nurse in charge of the nursing unit when dealing with this situation? 1. Telling the other staff members to cover for the UAP until she arrives 2. Telling the UAP that she will be fired if the behavior does not change 3. Addressing the lateness with the UAP at the 3-month probation evaluation 4. Confronting the UAP to discuss the lateness and initiate problem-solving measures

4. Confronting the UAP to discuss the lateness and initiate problem-solving measures Arriving late to work is an unacceptable behavior. Although the UAPs behavior has caused unrest with other staff members, the primary concern is that this behavior affects client care. The nurse in charge needs to confront the UAP and discuss the lateness and initiate problem-solving measures that ensure that the behavior does not continue. It is not appropriate to wait 1 month to address the behavior (option 3). It is also inappropriate to expect other staff members to cover for the UAP until she arrives. In addition, this action will increase the unrest with the staff members. Telling the UAP that she will be fired if the behavior does not change does not provide confrontation or address problem solving. However, firing may be an outcome if adequate warning has been issued and a change in behavior does not occur.

A woman at 20 weeks of gestation calls the health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client? 1. "Drink three glasses of water and lie on your left side for 1 hour." 2. "This is an emergency; you should come to the clinic within the hour." 3. "Tell me about your activity, food, fluid, and medication intake for the past 24 hours." 4. "Palpate for contractions and if four or more are felt within 1 hour, you need to be seen by the health care provider."

"This is an emergency; you should come to the clinic within the hour." The woman should be instructed to lie on her side, drink fluids, and keep her bladder empty. This will decrease uterine activity and prevent uterine hypoxia. If the woman continues to have persistent uterine activity after 1 hour or counts four or more contractions in less than an hour, she should be seen for further evaluation. Option 3 addresses the process of data collection and is an important initial component of care.

what is subinvolution of the uterus?

- a delay of the uterus returning to normal after birth -should be 1 cm/day

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which fibrinogen level? 1. 90 mg/dL 2. 190 mg/dL 3. 290 mg/dL 4. 390 mg/dL

1. 90 mg/dL The normal fibrinogen level is 180 to 340 mg/dL for men and 190 to 420 mg/dL for women. A critical value is less than 100 mg/dL. With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. For these reasons, the nurse should become most concerned with the level of 90 mg/dL.

The nurse is caring for a hospitalized client with a mechanical heart valve who is receiving maintenance therapy of warfarin sodium (Coumadin). The client's international normalized ratio (INR) is 3. The nurse anticipates which prescription? 1. Adding a dose of heparin 2. Holding the next dose of warfarin sodium 3.Increasing the next dose of warfarin sodium 4.Administering the next dose of warfarin sodium

4.Administering the next dose of warfarin sodium A client's INR of 2 to 3 is appropriate for most clients. An client's INR of 3 to 4.5 is recommended for clients with mechanical heart valves. If the client's INR is below the recommended range, the warfarin sodium dose is increased. If the client's INR is above the recommended range, the warfarin sodium dose is decreased. Because the value identified in this question is within the therapeutic range, the nurse would administer the next dose of warfarin.

The nurse is preparing to reinforce instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which diet should be prescribed for this client? 1. Low-sodium, low-protein diet 2. Low-protein, high-carbohydrate diet 3. Low-carbohydrate, low-protein diet 4.High-sodium, high-carbohydrate diet

4.High-sodium, high-carbohydrate diet A high-sodium, high-complex carbohydrate, and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain an adequate salt intake of up to 8 g of sodium daily and to increase salt intake during hot weather; before strenuous exercise; and in response to fever, vomiting, or diarrhea.

A client calls the health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which in the urine? 1. Estrogen 2.Progesterone 3.Follicle-stimulating hormone (FSH) 4.Human chorionic gonadotropin (hCG)

4.Human chorionic gonadotropin (hCG) In early pregnancy, hCG is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for positive pregnancy tests. Options 1, 2, and 3 are incorrect

What is encopresis?

A condition in which a child resists having bowel movements, causing impacted stool to collect in the colon and rectum and lead to leakage.

A health care provider has prescribed a liquid oral suspension of amoxicillin (Amoxil). The prescription reads 0.25 gram (g) orally 3 times daily. How many milliliters (mL) should the nurse administer to the client per dose? Refer to the figure. Fill in the blank. prescription: 125mg/5mL

Rationale: Convert grams to milligrams first before using the formula. To convert larger to smaller, move the decimal point three places to the right. Therefore, 0.25 gram = 250 mg. Formula: Desired --------- × Quantity = mL per doseAvailable 250 mg ------ × 5 mL = 10 mL125 mg

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which? 1. Uterine atony 2. Bladder distention 3. Endometrial infection 4. Retained placental fragments

Bladder distention Immediately following expulsion of the placenta, the fundus is firmly contracted, midline, and located one half to two thirds of the way between the symphysis pubis and the umbilicus. Because the uterine ligaments are still stretched, a full bladder can move the uterus upward and to the side. Options 1, 3, and 4 are complications not usually indicated by a firm and displaced uterus.

What is uterine atony?

Failure of the uterus to "cramp down" and tighten after delivery and it can lead to a potentially life-threatening condition known as postpartum hemorrhage

The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication? 1. Fever and pruritic urticaria 2. Bradycardia and chest pain 3. Hypothermia and muscle weakness 4. Hypertension and decreased urine output

Fever and pruritic urticaria Signs and symptoms of fat overload include fever, leukocytosis, hyperlipidemia, pruritic urticaria, and possibly focal seizures. Hepatosplenomegaly may also be present. Options 2, 3, and 4 are not signs of this complication.

A client has a chest tube that is attached to a chest drainage system. The client asks the nurse, "Can the tube come out faster if you turn the wall suction up higher?" The nurse's response is based on which fact with regard to turning up the wall suction? 1. It would increase the actual suction in the system and is a good idea. 2. It would increase the actual suction in the system but could damage lung tissue. 3. It would not increase the actual suction in the system but could cause the client to suffer injury. 4. It would not increase the actual suction in the system but would cause more air to be pulled through the air vent and suction chamber to the suction source.

It would not increase the actual suction in the system but would cause more air to be pulled through the air vent and suction chamber to the suction source. The amount of suction in the chest drainage system is controlled by the amount of sterile water that is poured into the suction control chamber. In a dry suction system, this is accomplished by regulating the suction dial on the chest drainage device. Increasing the wall suction will only cause vigorous bubbling in the suction chamber, as more air is pulled through the air vent and suction control chamber to the suction source. The only effect this would have is to increase the rate of water evaporation from the suction control chamber, so sterile water would have to be added to the system more frequently.

A client with lung cancer receiving chemotherapy tells the nurse that the food on the meal tray tastes "funny." Which is the appropriate nursing intervention? 1. Keep the client NPO. 2 .Provide oral hygiene care frequently. 3.Administer an antiemetic as prescribed. 4.Consult with other health care providers regarding a prescription for parenteral nutrition.

Provide oral hygiene care frequently. Chemotherapy may cause distortion of taste. Frequent oral hygiene aids in preserving taste function. Keeping a client NPO increases nutritional risks. Antiemetics are used when nausea and vomiting are a problem. Parenteral nutrition is used when oral intake is not possible.

What does myoglobin in the urine mean?

Sometimes, a urine test is used to evaluate myoglobin levels in people who have had extensive damage to their skeletal muscles (rhabdomyolysis). Urine myoglobin levels reflect the degree of muscle injury and, since myoglobin is toxic to the kidneys, reflect the risk of kidney damage.

In providing initial care to the newborn following delivery, what is the nurse's priority action? 1. Identify gestational age. 2. Identify the infant and mother. 3. Turn the infant's head to the side. 4. Record the number of umbilical vessels.

Turn the infant's head to the side. The priority is to maintain an open airway. Turning the infant's head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later.

What is imperforate anus?

birth defect that happens while your baby is still growing in the womb. this defect means that your baby has an improperly developed anus, and therefore can't pass stool normally from their rectum out of their body.

The nurse is caring for a client who has been taking diuretics on a long-term basis. The nurse reviews the medication record, knowing that which medications, if prescribed for this client, would place the client at risk for hypokalemia? 1. Bumetanide 2. Triamterene (Dyrenium) 3. Spironolactone (Aldactone) 4.Amiloride hydrochloride (Midamor)

1. Bumetanide Bumetanide is a potassium-losing loop diuretic. The client on this medication would be at risk for hypokalemia. Spironolactone, triamterene, and amiloride hydrochloride are potassium-retaining diuretics.

The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement? 1. "I'm having bloody show." 2."The contractions are intense." 3."My cervix is completely dilated." 4."My membranes are now ruptured."

3."My cervix is completely dilated." The second stage of labor begins when the cervix is completely dilated and ends with the birth of the infant. Options 1, 2, and 4 can occur any time in labor.

The nurse has reinforced discharge instructions regarding home care to a client following a prostatectomy for cancer of the prostate. Which statement by the client indicates an understanding of the instructions? 1. "I can begin to drive my car in 1 week." 2. "I should not lift anything over 20 pounds." 3. "To prevent dribbling of urine, I need to limit my fluid intake to four glasses daily." 4."If I see any clots in my urine, I need to call the health care provider immediately."

2. "I should not lift anything over 20 pounds." The client needs to be instructed to avoid lifting objects heavier than 20 pounds for at least 6 weeks. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and do not necessitate the need to notify the health care provider. Driving a car and sitting for long periods are restricted for at least 3 weeks. A high daily fluid intake of 2 to 2.5 L/day should be maintained to limit clot formation and prevent infection.

Which individuals is least likely at risk for the development of psoriasis? 1. A client with a systemic illness 2. A 32-year-old African American 3.A woman experiencing menopause 4.An individual with emotional distress

2. A 32-year-old African American Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races. The disorder may begin at any time throughout the life span but most commonly affects persons ages 10 to 40. Emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbations.

The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching? 1. "If I develop a fever, I will call my doctor." 2. "I will lift nothing heavier than the baby for 2 weeks." 3. "I can start doing abdominal exercises as soon as I get home." 4. "When getting out of bed, I will turn on my side and push up with my arms."

3. "I can start doing abdominal exercises as soon as I get home." Abdominal exercises should not start following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. Options 1, 2, and 4 reflect proper understanding of self-care after discharge.

A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which? 1. Fear 2.Pain 3.Hypoxia 4.Anxiety

3.Hypoxia After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury. The data in the question is not specifically related to options 1, 2, or 4.

The nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate. The nurse determines the medication is effective when the client makes which statement? 1. "I feel less nauseated." 2. "The pain is less intense." 3. "At least now I can sleep." 4. "My afterpains are really strong."

4."My afterpains are really strong." Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used postpartally to stimulate the uterus to contract and control excessive blood loss. The client statements in options 1, 2, and 3 are not related to this medication.

what is direct coombs test used for?

The direct Coombs test finds antibodies attached to your red blood cells. The antibodies may be those your body made because of disease or those you get in a blood transfusion. The direct Coombs test also may be done on a newborn baby with Rh-positive blood whose mother has Rh-negative blood. An abnormal (positive) direct Coombs test means you have antibodies that act against your red blood cells

A client is seen in the health care clinic with a diagnosis of mild anemia. The anemia is believed to be a result of the menstrual period. The woman asks the nurse how much blood is lost during a menstrual period. Which is a normal amount of blood loss during a menstrual period that the nurse should compare with the client's loss? 1. 40 mL 2. 60 mL 3. 80 mL 4. 100 mL

1. 40 mL During a menstrual period, a woman loses about 40 mL of blood. Because of the recurrent loss of blood, many women are mildly anemic during their reproductive years, especially if their diets are low in iron. Options 2, 3, and 4 are incorrect

An oral powder form of nelfinavir (Viracept) is prescribed for a client with human immunodeficiency virus (HIV). The nurse reinforces instructions regarding the preparation of the medication and tells the client to mix the powder with which substance? 1. Milk 2. Applesauce 3. Orange juice 4. Grapefruit juice

1. Milk Nelfinavir is an antiviral medication used in the treatment of HIV infection when antiretroviral therapy is warranted. It is available in tablet and powder form. The powder form is prepared by mixing the dose with a small amount of water, milk, formula, soy milk, or dietary supplements. The powder is not mixed with acidic foods or juices such as apple juice or applesauce, orange juice, or grapefruit juice.

A client is brought to the ambulatory care department by the spouse one day following a cataract extraction procedure. A diagnosis of hyphema is made, which occurred as a result of the surgical procedure. The nurse reinforces instructions to the client and spouse regarding the treatment for the complication and makes which statement? 1. "Ambulate as necessary." 2. "Maintain bed rest and patching of both eyes." 3. "Resume normal activities because the hyphema will resolve on its own." 4. "Return to the outpatient department for removal of the intraocular lens implant."

2. "Maintain bed rest and patching of both eyes." Hyphema is bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery. Treatment includes bed rest and bilateral eye patching for 2 to 5 days, during which absorption occurs. The client should be instructed to monitor for signs of increased intraocular pressure, which commonly causes sudden ocular pain. Miotics and cycloplegics may be prescribed. Occasionally, irrigation of the anterior chamber may be done to remove the blood.

Which measure should the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease? 1. A high-fiber diet 2. A restful environment 3. Three small meals per day 4. Providing the client with extra blankets

2. A restful environment Because of the hypermetabolic state, the client with Graves' disease needs to be provided with an environment that is restful both physically and mentally. Six full meals a day that are well balanced and high in calories are required because of the accelerated metabolic rate. Foods that increase peristalsis (e.g., high-fiber foods) need to be avoided. These clients suffer from heat intolerance and require a cool environment.

The nurse is assisting in planning client assignments. Which is the least appropriate assignment for the unlicensed assistive personnel (UAP)? 1. Obtaining frequent oral temperatures on a client 2. Assisting a profoundly developmentally disabled child to eat lunch 3. Collecting a urine specimen from a 70-year-old woman admitted 3 days ago 4. Accompanying a 51-year-old man, being discharged to home following a bowel resection 8 days ago, to his transportation

2. Assisting a profoundly developmentally disabled child to eat lunch The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating, and therefore a higher potential for complications such as choking and aspiration exists. The three remaining options include no data that indicate that these tasks carry any unforeseen risk.

Potassium iodide (Lugol's solution) is prescribed for a client. The client calls the nurse at the clinic and complains of a brassy taste and burning sensations in the mouth. How should the nurse respond? 1. Continue with the medication. 2. Contact the health care provider. 3. Take half of the prescribed dose for the next 24 hours. 4. Stop the medication for the next 24 hours and then continue as prescribed.

2. Contact the health care provider. Chronic ingestion of iodide can produce iodism. The client needs to be instructed about the symptoms of iodism, which include a brassy taste, burning sensations in the mouth, soreness of gums and teeth, frontal headache, coryza, salivation, and skin eruptions. The client needs to be instructed to notify the health care provider if these symptoms occur.

The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern? 1. Ignore the racial comments. 2. Discourage the racial comments. 3. Leave articles about racial prejudice in the nurse's lounge. 4. Report the racial comments to the grievance committee.

2. Discourage the racial comments. Prejudice reduction is a method of managing or discouraging racial comments made by others. When racial comments are discouraged, fewer comments will be made. Ignoring the racial comments is an inappropriate option because the concern will not be addressed. Leaving articles about racial prejudice in the nurse's lounge indirectly addresses the issue. In addition, the nurse cannot ensure that the staff will read the articles. Likewise, reporting the racial comments to the grievance committee does not directly address the issue. The best approach that the nurse could take would be to directly discuss the concern with the staff members. This action is not identified in the options. Therefore, from the options presented, option 4 would most appropriately manage this concern.

The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom? 1. Each employee 2. All members of the organization 3. A few individuals such as the board of directors 4. Many individuals filtering down to the individual employee

3. A few individuals such as the board of directors With regard to the decision-making process, organizations may be described as having a centralized or decentralized structure. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals. Conversely, when the decision making involves a number of individuals and filters down to the individual employee, the organization is said to operate in a decentralized fashion.

A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and asks the child about a history of an allergy to which product? 1. Eggs 2. Penicillin 3. Baker's yeast 4. Sulfonamides

3. Baker's yeast A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to common baker's yeast. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.

An adult client with suspected meningitis has undergone lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis of a bacterial infection. The nurse checks for which value indicating a bacterial infection of the CSF? 1. Red blood cells 2. Decreased protein level 3. Decreased glucose level 4. Decreased white blood cells

3. Decreased glucose level Findings that indicate a bacterial infection of the cerebrospinal fluid include presence of a bacterial organism, elevated WBC count, elevated protein level, and decreased glucose level. Red blood cells should not be present in CSF.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which? 1. Encourage immediate breast-feeding. 2. Complete routine newborn care measures quickly. 3. Determine the parents' desires for contact with the newborn. 4. Suggest the mother hold the newborn after the placenta is delivered.

3. Determine the parents' desires for contact with the newborn. Although immediate contact may be important for attachment or breast-feeding, the parents' wishes concerning contact with their newborn must be supported and determined first. The remaining options would follow the initial intervention.

A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands what is necessary in this situation and prepares the client for which treatment? 1. Fundal massage 2. A blood transfusion 3. Emergency surgery 4. An infusion of oxytocin (Pitocin)

3. Emergency surgery Options 1, 2, and 4 identify interventions to reverse uterine atony. When uterine atony cannot be reversed, surgery is required.

A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation? 1. The client is unable to nurse the baby. 2. The client is an older first-time mother. 3.The client is required to stay on bed rest. 4.The client is considering giving the baby up for adoption.

3. The client is required to stay on bed rest. Clients with thrombophlebitis may be placed on bed rest with elevation of the affected extremity. Bed rest restricts normal newborn care, feeding, and parenting and will require interventions that promote attachment. Options 1, 2, and 4 are unrelated to the subject of the question.

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective? 1. "I'll eat until I don't feel hungry." 2. "I no longer have a weight problem." 3. "I don't want to starve myself anymore." 4. "My friends and I went out to lunch today."

4. "My friends and I went out to lunch today." In anorexia nervosa the client tries to establish identity and control by self-imposed starvation. Options 1, 2, and 3 are verbalizations of the client's intentions. Option 4 is a measurable action that can be verified.

A client who suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse plans to monitor this particular client carefully for signs of which complication? 1. Respiratory failure 2. Brain attack (stroke) 3. Myocardial infarction 4. Acute tubular necrosis

4. Acute tubular necrosis The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream, where it is cleared from the body by the kidneys. When a large amount of myoglobin is being cleared from the body, the renal tubules may become clogged with myoglobin, which causes acute tubular necrosis. This is one form of acute kidney injury.

A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? 1. Maternal hypertension and infection 2. Afterpain and increased estrogen levels 3. Increased estrogen and progesterone levels 4. Retained placental fragments and infections

4. Retained placental fragments and infections Retained placental fragments and infections are the primary causes of subinvolution. When either of these factors is present, the uterus has difficulty contracting. The conditions in the remaining options are not associated causes of subinvolution.

Metformin (Glucophage) is prescribed for a client with type 2 diabetes mellitus. Which should the nurse tell the client is a common side effect of the medication? 1. Weight gain 2. Hypoglycemia 3. Flushing and palpitations 4. Gastrointestinal (GI) disturbances

4. Gastrointestinal (GI) disturbances The most common side effect of metformin is GI disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; in fact, clients lose an average of 7 to 8 pounds because the medication causes decreased appetite. Hypoglycemia may be an adverse effect. Option 3 is not related to the use of this medication.

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response? 1. Exhaustion 2. Fear of losing control 3. Involuntary grunting 4. Valsalva's maneuver

2. Fear of losing control Pains, helplessness, and fear of losing control are possible client responses in the transition stage of labor. Whimpering, high-pitched cries, and crying out in pain are indicative of losing control, and low-pitched grunting sounds usually indicate a woman is working effectively with contractions. The Valsalva maneuver is performed by attempting to forcibly exhale while keeping the mouth and nose closed. This maneuver is used to evaluate the condition of the heart and is sometimes done as a treatment to correct abnormal heart rhythms or relieve chest pain.

The nurse is collecting data regarding the motor development of a 24-month-old child. Based on the age of the child, the nurse expects to note which highest level of developmental milestone? 1. The child snaps large snaps. 2. The child builds a tower of two blocks. 3. The child uses a doorknob to open a door. 4. The child puts on simple clothes independently.

3. The child uses a doorknob to open a door. A 24-month-old would be able to use a doorknob to open a door. At age 15 months, the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently.

The nurse is reviewing the health record of a child with a diagnosis of celiac disease. Which clinical manifestation should the nurse expect to note documented in the health record? 1. Frothy diarrhea 2. Foul-smelling ribbon stools 3. Profuse watery diarrhea and vomiting 4. Diffuse abdominal pain unrelated to meals or activity

4. Diffuse abdominal pain unrelated to meals or activity Celiac disease causes profuse watery diarrhea and vomiting. Option 1 is a symptom of lactose intolerance. Option 2 is a symptom of Hirschsprung's disease. Option 4 is a symptom of irritable bowel syndrome.

The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which disorder? 1. Myxedema 2. Graves' disease 3.Addison's disease 4.Cushing's syndrome

2. Graves' disease PTU inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function.

A hospitalized client with severe seborrheic dermatitis is receiving treatments of topical glucocorticoid applications followed by the application of an occlusive dressing. The nurse monitors the client for which systemic effect that can occur as a result of this treatment? 1. Local infection 2. Thinning of the skin 3. Adrenal suppression 4. Adrenal hyperactivity

3. Adrenal suppression Topical glucocorticoids can be absorbed in sufficient amounts to produce systemic toxicity. Primary concerns are growth retardation (in children) and adrenal suppression in all age groups. Systemic toxicity is more likely under extreme conditions, such as with prolonged therapy, in which extensive surfaces are treated with high doses of high-potency agents in conjunction with occlusive dressings

A normal saline 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which is a characteristic of this type of solution? 1. Affects the plasma osmolarity 2. Is the same solution as sodium chloride 0.9% 3. Is hypertonic with the plasma and other body fluids 4. Is hypotonic with the plasma and other body fluids

2. Is the same solution as sodium chloride 0.9% Sodium chloride 0.9% is the same solution as normal saline 0.9%. This solution is isotonic, and isotonic solutions frequently are used for intravenous infusion because they do not affect the plasma osmolarity.

A nursing student is asked to describe the corpus of the uterus. Which response by the student indicates an understanding of the anatomy of the uterus? 1. "It is the lower portion of the uterus." 2."It is the uppermost part of the uterus." 3."It is the area where the vagina meets the uterus." 4."It is the area where the cervix meets the external os."

2."It is the uppermost part of the uterus." The uterus has three divisions, the corpus, isthmus, and the cervix. The upper division is the corpus or the body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus.

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which? 1. Iron 2. Folic acid 3.Thiamine 4.Vitamin B12

4. Vitamin B12 Pernicious anemia is caused by a deficiency of vitamin B12. Treatment consists of monthly injections of vitamin B12. Thiamine is most often prescribed for the client with alcoholism. Iron is administered for iron deficiency anemia, and folic acid is prescribed for folic acid deficiency.

The health care provider (HCP) prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention? 1. The medication is administered within 60 minutes before the morning and evening meal. 2. The medication is withheld and the HCP is called to question the prescription for the client. 3. The client is monitored for gastrointestinal side effects after administration of the medication. 4. The insulin is withdrawn from the Penlet into an insulin syringe to prepare for administration.

The medication is withheld and the HCP is called to question the prescription for the client. Exenatide (Byetta) is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the HCP regarding this prescription. Although options 1 and 3 are correct statements about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. The nurse understands that this characterizes which type of presentation? 1. An abnormal presentation 2. The least favorable presentation 3. The most common presentation 4. A presentation associated with prolonged labor

3. The most common presentation The cephalic presentation (head-first presentation) is more favorable than others and is the most common. Abnormal presentations result in prolonged labor and are likely to necessitate a cesarean birth.

fter surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the motherneeds further discharge instructions if the new mother makes which statement? 1. "I will probably need my mother to help me with housekeeping." 2."Because I am so sore, I will nurse the baby while lying on my side." 3."My husband and I will not have intercourse until the stitches are healed." 4."The only medications that I will take are prenatal vitamins and stool softeners."

4."The only medications that I will take are prenatal vitamins and stool softeners." After surgical evacuation and repair of a vaginal hematoma, the client will need an antibiotic because she is at increased risk for infection because of the break in skin integrity and collection of blood at the hematoma site. The client statements in options 1, 2, and 3 indicate that the client understands the necessary home care measures.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)? 1. Length 19 inches 2. Birth weight 6 pounds 14 ounces 3. Microcephaly and increased respiratory effort 4. Head circumference appropriate for gestational age

3. Microcephaly and increased respiratory effort Features associated with FAS include craniofacial abnormalities, cleft lip or palate, abnormal palmar creases, and irregular hair distribution. Microcephaly, limb anomalies, and increased respiratory effort during the transition to extrauterine life also are noted frequently in the neonate with FAS.

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. The instructor asks a nursing student to identify when this substance begins to be produced. The nursing student responds correctly by stating that this substance is produced at approximately which gestational week? 1. Week 12 2. Week 18 3. Week 28 4. Week 32

3. Week 28 Surfactant, a substance needed to facilitate neonatal breathing, begins to be produced at approximately week 28. Therefore, the remaining options are incorrect.

A client reports to the health care clinic for an eye examination, and a diagnosis of primary open-angle glaucoma is suspected. Which question will elicit information regarding the signs/symptoms associated with this disorder? 1. "Do bright lights cause glare?" 2. "Is your central vision blurred?" 3. "Do you have any pain in your eyes?" 4. "Have you had difficulty with peripheral vision?"

4. "Have you had difficulty with peripheral vision?" Because glaucoma is usually symptom free, the client may first note changes in peripheral visual acuity. If pain occurs with glaucoma, it is usually late in the course of structural changes with an intraocular pressure of 40 to 50 mm Hg or higher. More severe pain is characteristic of absolute glaucoma (total vision loss). Glare from bright lights is a complaint of a client with a cataract. Blurred central vision occurs with macular degeneration.

The nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse should take which action? 1. Apply a tourniquet. 2. Apply ice to the site of the bite. 3. Elevate the leg above the level of the heart. 4. Ensure that the victim is lying down, and remove restrictive items.

4. Ensure that the victim is lying down, and remove restrictive items. Initial first aid at the site of a snakebite includes having the victim lie down, removing constrictive items such as clothing or rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Ice or a tourniquet is not applied during the acute stage.

The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure? 1. "I cannot eat on the day of the test." 2. "The test takes about 1 hour and is painless." 3."I will need to wear a sports bra for the procedure." 4."I should not wear deodorant on the day of the test."

4."I should not wear deodorant on the day of the test." Mammography takes about 15 to 30 minutes to complete. Some discomfort may be experienced because of the breast compression required to obtain a clear image. Maintaining a nothing-by-mouth (NPO) status before the procedure is not necessary. A sports bra is not required; the test is performed without clothing. Deodorants, powders, and lotions should not be worn on the day of the test because it will affect the testing process and affect the imaging of the breasts.

The nurse is providing dietary instructions to a client with a diagnosis of ulcerative colitis. Which food should the nurse instruct the client to avoid? 1. Whole-grain cereals 2. Fresh corn on the cob 3.Broiled chicken breast 4.Bagels with cream cheese

2. Fresh corn on the cob A low-residue (low-fiber) diet places less strain on the intestines because this type of diet is easier to digest. This diet is used for ulcerative colitis, diverticulitis, and irritable bowel syndrome. The item that contains high residue and thus would place strain on the intestines is the fresh corn on the cob.

A client received a dose of regular insulin (Humulin R) this morning at 7:00 am. At which time should the nurse likely anticipate the potential for a hypoglycemic reaction to occur? 1. 8:00 am 2.10:00 am 3.12:00 noon 4.2:00 pm

2.10:00 am Humulin R is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. During the peak action of insulin is when hypoglycemic reactions are most likely to occur. This makes option 2 correct.

The nurse is caring for a client who is receiving intramuscular antibiotics. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want the medication to be given. The nurse tells the client that the medication is necessary and administers the medication. With which crime can the client legally charge the nurse as a result of the nursing action? 1. Assault 2.Battery 3.Negligence 4.Invasion of privacy

2.Battery An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. Invasion of privacy occurs when the individual's private affairs are unreasonably intruded. In this situation, the nurse can be charged with battery because the nurse administered a medication that the client refused.

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) has been on oral glucocorticoids and is being weaned to triamcinolone (Azmacort) by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change when the client states to monitor for which? 1. Chills, fever, generalized rash 2. Blurred vision, headache, and insomnia 3. Anorexia, nausea, weakness, and fatigue 4. Vomiting and diarrhea and increased thirst

3. Anorexia, nausea, weakness, and fatigue The client being changed from oral to inhalation glucocorticoids could experience signs of adrenal insufficiency. The nurse teaches the client to report anorexia, nausea, weakness, and fatigue. Other objective signs that can be detected include hypotension and hypoglycemia.

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care? 1. Set up a phototherapy unit. 2. Prepare for an exchange transfusion. 3.Ask about the newborn's blood type and direct Coombs. 4.Administer an injection of vitamin K to prevent isoimmunization.

3.Ask about the newborn's blood type and direct Coombs. To further assess and plan for the newborn's care, the newborn's blood type and direct Coombs must be known. If the newborn's blood type is Rh negative, or if the newborn's blood type is Rh positive with a negative direct Coombs' test, then there is no concern for Rh incompatibility. If the newborn's blood type is Rh positive and the direct Coombs is positive, then Rh incompatibility exists. Options 1 and 2 are inappropriate at this time because additional data are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease in the newborn.

The nurse is giving a bed bath to an assigned client. An unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The nurse should do which? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. The nurse is responsible for the care provided to the assigned clients. The appropriate action is to provide safety to the client that is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP.

The nurse is preparing a client for an intravesical instillation of an alkylating chemotherapeutic agent into the bladder for the treatment of bladder cancer. The nurse provides instructions to the client regarding the procedure. Which client statement indicates an understanding of this procedure? "I need to stay on bed rest after the procedure is completed." 2."I will need to immediately urinate after the instillation is done." 3."After the instillation is done, I will need to retain the fluid for 30 minutes." 4."After the instillation is done, I will need to change position every 15 minutes from side to side."

4."After the instillation is done, I will need to change position every 15 minutes from side to side." Focus on the subject, intravesical instillation of an alkylating chemotherapeutic agent into the bladder. Knowledge regarding this procedure and posttreatment care is required to answer this question. Remember that after the instillation, the client needs to change position every 15 minutes from side to side.

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept? 1. "It is managing client care by managing the client care environment." 2."It represents a primary health prevention focus managed by a single case manager." 3."It maximizes hospital revenues while providing for optimal outcome of client care." 4."It is designed to promote appropriate use of hospital personnel and material resources."

2."It represents a primary health prevention focus managed by a single case manager." Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. Options 1, 3, and 4 identify the components of managed care.

Prescriptive glasses are prescribed for a client with bilateral aphakia, and the nurse reinforces instructions to the client regarding the use of the glasses. Which statement by the client indicates the need for further teaching? 1. "Objects that I look at may be distorted." 2. "It may be difficult to judge distances when I drive a car." 3. "The prescriptive glasses will correct my visual field of sight." 4."The prescriptive glasses will magnify my central vision by 30%."

3. "The prescriptive glasses will correct my visual field of sight." Aphakia (absence of the lens of the eye) can be corrected by prescriptive glasses, contact lenses, or intraocular lenses. Only central vision is corrected with these prescriptive glasses, and the peripheral vision is distorted. Prescriptive glasses provide approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted, and it is difficult to judge distances such as when driving a car.

The nurse discovers that one of her assigned clients is bleeding excessively from an abdominal incision. The nurse gives specific prescriptions to an unlicensed assistive personnel (UAP) to attend to the other clients and tells another nurse to call the health care provider immediately. In this situation, the nurse is implementing which leadership style? 1. Democratic 2. Situational 3. Autocratic 4. Laissez-faire

3. Autocratic Autocratic leadership, also called "directive leadership," involves the leader in assuming complete control over the decisions and activities of the group. In this situation, the nurse assumed the autocratic style of leadership so that all necessary tasks would be accomplished immediately. Democratic leadership, also called "participative leadership," is characterized by a sense of equality among the leader and other participants. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Laissez-faire is a permissive style of leadership in which the leader gives up control and delegates all decision making to the work group.

A student nurse has received the client assignment for the day and is organizing the required tasks. The nursing instructor reviews the plan for time management with the student and determines that the student needs assistance with the plan if the student indicated that which activity should be part of it? 1. Providing time for unexpected tasks 2. Prioritizing client needs and daily tasks 3. Gathering supplies before beginning a task 4.Documenting task completion at the end of the day

4. Documenting task completion at the end of the day The nurse should document task completion continually throughout the day. Options 1, 2, and 3 identify accurate components of time management.

A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record? 1. Positive Babinski's sign 2. The presence of blast cells in the bone marrow 3. Projectile vomiting occurring often in the morning 4. Elevated vanillylmandelic acid (VMA) levels in the urine

4. Elevated vanillylmandelic acid (VMA) levels in the urine Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated VMA levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinski's sign are signs/symptoms of a brain tumor.

A pregnant client is positive for the human immunodeficiency virus (HIV). Based on this information, the nurse makes which determination? 1. The client has the herpes simplex virus. 2. This client has contracted an airborne disease. 3. The newborn infant will have this disease at birth. 4. HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test.

4. HIV antibodies are detected on the enzyme-linked immunosorbent assay (ELISA) test. Diagnosis depends on serological studies to detect human immunodeficiency virus antibodies. The most commonly used test is the ELISA test. Options 1 and 2 are incorrect because HIV is contracted primarily through the exchange of body fluids. Option 3 is incorrect. A neonate born to an HIV-positive mother is at risk of developing this infection.

The nurse is assigned to assist in working with food services in a rural, poor school setting. A goal for the school dietary program is to avoid nutritional deficiencies and enhance the children's nutritional status through healthy dietary practices. In implementing interventions by levels of prevention, which primary prevention intervention should the nurse suggest to use? 1. Case finding in the school to identify dietary practices 2. School screening programs for early detection of children with poor eating habits 3. Conducting a community-wide dietary screening activity to detect community dietary trends 4. Providing educational programs, literature, and posters to promote awareness of healthy eating

4. Providing educational programs, literature, and posters to promote awareness of healthy eating Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring. Options 1, 2, and 3 are secondary prevention measures that seek to detect existing health problems or trends.

The nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. Which supplement should the nurse give the child to treat the reaction? 1. One sugar cube 2. 1 teaspoon of sugar 3. ½ cup of diet cola 4. ½ cup of fruit juice

4. ½ cup of fruit juice Hypoglycemia is immediately treated with 10 to 15 g of carbohydrate. Glucose tablets or glucose gel may be administered. Other items used to treat hypoglycemia include ½ cup of fruit juice, ½ cup of regular (nondiet) soft drink, 8 ounces of skim milk, 6 to 10 hard candies, 4 cubes of sugar or 4 teaspoons of sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup. The items in options 1, 2, and 3 would not adequately treat hypoglycemia.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids? 1. Fever, yawning, irritability, diaphoresis, and diarrhea 2. Increased appetite, irritability, anxiety, and restlessness 3. Depressed feelings, high drug craving, fatigue, agitation, and disorientation 4.Tachycardia, mild hypertension, fever, sweating, nausea, vomiting, and marked tremors

1. Fever, yawning, irritability, diaphoresis, and diarrhea Opioids are central nervous system (CNS) depressants. Option 1 identifies some of the signs/symptoms associated with withdrawal from opioids. Option 2 describes withdrawal from nicotine. Option 3 describes withdrawal from cocaine. Option 4 describes withdrawal from alcohol.

The nurse overhears a client ask the health care provider if the results of a biopsy indicated cancer. The health care provider tells the client that the results have not returned, when in fact, the health care provider is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the health care provider has not shared the results with the client and tells another nurse that the health care provider has lied to the client and that this health care provider probably lies to all of the clients. Which legal tort has the nurse violated by this statement? 1. Libel 2.Slander 3.Assault 4.Negligence

2.Slander Defamation takes place when something untrue is said (slander) or written (libel) about a person resulting in injury to that person's good name and reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Although the health care provider may be aware of the biopsy results, the health care provider decides when it is best to share such a diagnosis with the client.

The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is important for the nurse to take at this time? 1. Assist the client to breast-feed. 2. Encourage food and fluid intake. 3. Check the uterine fundus and lochia. 4. Provide privacy for the parents and their newborn.

3. Check the uterine fundus and lochia. A potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted, and vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours. Options 1, 2, and 4 are nursing actions that would follow

The nurse in the outpatient unit is preparing a client who is scheduled for a laser trabeculoplasty for the treatment of primary open-angle glaucoma. Which instructions should the nurse reinforce to the client? 1. "The procedure takes about 2 hours." 2. "Your vision loss will be restored following the procedure." 3. "You may return to work 1 or 2 days following the procedure." 4. "Activities can be resumed immediately following the procedure."

3. "You may return to work 1 or 2 days following the procedure." Laser trabeculoplasty is performed in the outpatient setting and requires about 30 minutes. The client will experience little discomfort and may resume all normal activities including returning to work within 1 or 2 days. The treatment prevents further visual loss, but the lost vision cannot be restored.

The nurse is caring for a client with pheochromocytoma. Which data are indicative of a potential complication associated with this disorder? 1. A urinary output of 50 mL/hr 2. A coagulation time of 5 minutes 3. Congestion heard on auscultation of the lungs 4. A blood urea nitrogen (BUN) level of 20 mg/dL

3. Congestion heard on auscultation of the lungs The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, heart failure (HF), increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. Congestion heard on auscultation of the lungs is indicative of heart failure (HF). A urinary output of 50 mL/hr is an appropriate output; the nurse would become concerned if the output were less than 30 mL/hr. A coagulation time of 5 minutes is normal. A BUN level of 20 mg/dL is a normal finding.

The nurse is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. What does the nurse determine is a characteristic of this type of nursing model practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used in providing client care. 3. Nursing personnel are led by an RN leader in providing care to a group of clients. 4. A single registered nurse (RN) is responsible for providing nursing care to a group of clients.

3. Nursing personnel are led by an RN leader in providing care to a group of clients. In team nursing, nursing personnel are led by an RN leader to provide care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

A 2-year-old child is diagnosed with constipation due to encopresis. Which description is a characteristic of this disorder? 1. Anorexia in the evening 2. Incomplete development of the anus 3. The infrequent and difficult passage of dry stools 4. Invagination of a section of the intestine into the distal bowel

3. The infrequent and difficult passage of dry stools Constipation can affect any child at any time, although its incidence peaks at ages 2 to 3 years. Option 3 describes encopresis, which can develop as a result of constipation and is one of the major concerns regarding constipation. Encopresis generally affects preschool and school-age children. Option 1 is not associated with encopresis. Option 2 describes imperforate anus, which is diagnosed in the neonatal period. Option 4 describes intussusception, which is the most common cause of bowel obstruction in children ages 3 months to 6 years.

The nurse is caring for a client with chronic heart failure who is taking digoxin (Lanoxin) 0.125 mg daily. Before administering the medication, the nurse reviews the serum digoxin level that was drawn earlier in the day. The result is 1 ng/mL. Which action should the nurse take based on this laboratory result? 1. Notify the health care provider. 2. Check the client's last pulse rate. 3.Administer the dose of the medication as scheduled. 4.Obtain another serum digoxin level to verify the results.

3.Administer the dose of the medication as scheduled. The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 1 is within therapeutic range, and the nurse should administer the next dose as scheduled. Options 1 and 4 are unnecessary. An apical pulse must be obtained before each dose of digoxin is administered. It is incorrect to administer the digoxin based on the client's last pulse rate, although a comparison of pulse rates may be appropriate.

The nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. Which would be the initial action by the nurse who observed the error? 1. Contact the supervisor. 2. Complete an incident report. 3. Document the error in the client's record. 4. Ask the nurse if he or she intends to report the error.

4. Ask the nurse if he or she intends to report the error. The initial action by the nurse who observed the error would be to ask the nurse if he or she intends to report the error. To ensure client safety, all errors need to be reported. The client also needs to be assessed immediately. An incident report needs to be completed by the nurse who administered the incorrect medication. The appropriate documentation also needs to be made in the client's record by the nurse who administered the incorrect medication. If the nurse who made the error indicates that the error will not be reported, then it may be necessary to contact the supervisor.

The nurse is caring for a client with kidney failure. The serum phosphate level is reported as 7 mg/dL. Which medication should the nurse plan to administer as prescribed to the client? 1. Calcium gluconate 2. Calcium chloride 3. Calcitonin (Calcimar) 4. Aluminum hydroxide gel

4. Aluminum hydroxide gel The normal serum phosphate level is 3 to 4.5 mg/dL. The client in this question is experiencing hyperphosphatemia. Certain medications can be given to increase fecal excretion of phosphorus by binding phosphorus from the food in the gastrointestinal tract. Aluminum hydroxide gel is one such medication. Calcium gluconate and calcium chloride are medications used in the treatment of tetany that occurs from acute hypocalcemia. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum.

Which statement indicates that a client with Addison's disease knows how to safely manage a medication regimen that consists of daily doses of glucocorticoids? 1. "The medication I am taking is very safe and does not cause side effects." 2. "I should stop my medication if I begin to experience any unpleasant side effects." 3."If I'm nauseated and can't take my medicine for a few days, I can do without them." 4."I will need to call my doctor for an increase in medication dose when I'm experiencing a lot of stress.

4."I will need to call my doctor for an increase in medication dose when I'm experiencing a lot of stress. The client with Addison's disease will require lifelong replacement of adrenal hormones. The medications must be taken daily, and an alternate route of administration must be used if the client cannot take oral medications for any reason, such as nausea and vomiting. Additional doses of glucocorticoids will be needed during times of acute stress. The nurse must emphasize to the client that the health care provider must be called to obtain a dosage increase when experiencing stressful situations. Abrupt withdrawal of this medication can result in Addisonian crisis. Although side effects are not severe at lower doses, side effects may be experienced with glucocorticoid administration. It is very unsafe to stop taking the medication without first consulting the health care provider.

The nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed? 1. Use the assistance of four nurses to reposition the client. 2.Place a draw sheet under the client for pulling the client up in bed. 3.Encourage the client to pull up by pushing with the unaffected leg on the bed mattress. 4.Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.

4.Place a trapeze on the bed to provide a means for the client to lift the hips off the bed. The nurse can best assist the client in skeletal traction with positioning in bed by providing a trapeze on the bed for the client's use. Encouraging the client to pull up by pushing with the unaffected leg on the bed mattress may cause skin breakdown on the unaffected heel area. Although a draw sheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote the means of positioning by the client.

The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder? 1. Stenosis of the anorectal canal 2.Failure to pass meconium stool 3.The presence of stool in the vagina 4.The passage of bloody mucous stool

4.The passage of bloody mucous stool Signs/symptoms of an imperforate anus include failure to pass meconium stool within 24 hours following birth, absence or stenosis of the anorectal canal, an anal membrane, and an external fistula to the perineum. During neonatal assessment, the defect should be identified easily on sight. However, a rectal thermometer may be necessary to determine patency if meconium stool is not passed. The presence of stool in the urine, the vagina, or a skin dimple should be reported immediately as an indication of abnormal anorectal development. Option 4 is a clinical manifestation of intussusception.

What are the uses of direct and indirect Coombs test?

The direct Coombs' test, also known as the direct antiglobulin test, is the test usually used to identify hemolytic anemia. [The indirect Coombs' test is used only in prenatal testing of pregnant women and in testing blood prior to a transfusion.]

The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? 1. Dysuria, headache, and epistaxis 2. Epistaxis, hematuria, and dysuria 3. Hematuria, ecchymosis, and epistaxis 4. Hematuria, ecchymosis, and dysuria

3. Hematuria (blood in urine), ecchymosis (bruising), and epistaxis (nose bleed). The treatment for thrombophlebitis is anticoagulant therapy. Adverse effects of anticoagulants include bleeding and would be recognized by the presence of hematuria, ecchymosis, and epistaxis. Dysuria (painful or difficulty urinating) may indicate a bladder infection. Headache is not an adverse effect of an anticoagulant. Focus on the subject, adverse effect of an anticoagulant. Recall that bleeding is the major concern with the use of anticoagulants. Note that option 3 is the only option that addresses bleeding in all of its components.

A child is diagnosed with lactose intolerance. The child's mother asks the nurse about the disease. Which statement is the appropriate nursing response? 1. "It is the inability to tolerate sugar found in dairy products." 2."It results from the absence of ganglion cells in the rectum." 3."It results from increased bowel motility that leads to spasm and pain." 4."It is the inability to fully digest the protein part of wheat, barley, rye, and oats."

1. "It is the inability to tolerate sugar found in dairy products." Lactose intolerance is the inability to tolerate lactose, the sugar found in dairy products. It results from absence or deficiency of lactase, an enzyme found in the secretions of the small intestine required for the digestion of lactose. Option 2 describes Hirschsprung's disease. Option 3 describes irritable bowel syndrome. Option 4 describes celiac disease.

A new mother is attempting to breast-feed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breast-feeding the newborn? 1. Massage the breast, applying gentle pressure on the areola. 2. Have the mother grasp the nipples between the thumb and forefinger and tug firmly to get the nipple to protrude. 3. Have the mother take a cool shower, allowing the water to run over the breasts because this will encourage the nipples to protrude. 4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.

4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp. Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn to grasp the nipple. True inverted nipples will retract if the areola is pressed between the thumb and forefinger, making option 2 incorrect. Option 1 is appropriate advice for mothers experiencing inverted nipples. Option 3 will only make the mother cold and has no effect on inverted nipples.

A nursing instructor asks a nursing student to describe the standards of care formulated by the American Nurses Association. Which statement by the student indicates an inaccurate description of these statements? 1. They are specific guidelines." 2. "They define professional practice." 3."They have some similarity to policies and procedures." 4."They are authoritative statements that describe a common or acceptable level of client care or performance."

1. They are specific guidelines." Focus on the subject, standards, noting the word inaccurate in the question. This word indicates that you need to select an option that is an incorrect statement. Noting the standards of care are formulated by the American Nurses Association will direct you to option 1. In addition, noting that these guidelines are generalized will direct you to this option.

The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and the family? 1. The nurse encourages the client and family to openly identify and discuss feelings. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 3. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. 4. The nurse makes decisions for the client and family in order to relieve them of unnecessary demands.

The nurse makes decisions for the client and family in order to relieve them of unnecessary demands. Option 4 describes the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention that can further impair communication. Option 1 describes encouraging discussion of feelings and is likely to enhance communication. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an effect on how people react to crisis. Option 3 is also an effective intervention because the client and family need to know that someone will be supportive and nonjudgmental.