NCLEX Study

The health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication will be administered intrathecally. Which medication should the nurse expect to be prescribed and administered by this route? 1. Baclofen 2. Chlorzoxazone 3. Dantrolene sodium 4. Cyclobenzaprine hydrochloride

1 Baclofen is the skeletal muscle relaxant that can be administered intrathecally, which means within the spinal column. Therefore, the remaining options are incorrect.

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance? 1. Hypokalemia 2. Hypercalcemia 3. Hypochloremia 4. Hypernatremia

1 Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding? 1. Presence of fasciculations 2. Muscle strength of normal power 3. Symmetrical movements bilaterally 4. Hypertrophy of right upper arm of 1 cm

1 Fasciculations are fine-muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding.

A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which item in the preoperative period? 1. Vital signs 2. Fluid balance 3. Anxiety level 4. Creatinine levels

1 Hypertension is the hallmark symptom of pheochromocytoma. Severe hypertension can precipitate a stroke (brain attack) or sudden blindness. Although all of the items are appropriate nursing assessments for the client with pheochromocytoma, the priority is to monitor the vital signs, especially the blood pressure.

A nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. The nurse should ask the client if which measure is taken? 1. Rotating sites for injection 2. Administering the insulin at a 45-degree angle 3. Cleaning the skin with alcohol before each injection 4. Aspirating for blood before injection into the subcutaneous tissue

1 Lipodystrophy (hypertrophy of subcutaneous tissue at the injection site) occurs in some clients with diabetes mellitus when injection sites are used for a prolonged period. Therefore, clients are instructed to adhere to a plan of rotating injection sites to avoid tissue changes. Angle of insulin administration, cleansing with alcohol, and aspiration do not produce this complication.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1. Observe the client demonstrating the transfer technique. 2. Start a restorative nursing program before an injury occurs. 3. Seize the opportunity to discuss potential nursing home placement. 4. Determine the number of falls that the client has had in recent weeks.

1 Observation of the client's transfer technique is the initial intervention. Starting a restorative program is important but not unless an assessment has been completed first. Discussing nursing home placement would be inappropriate in view of the information provided in the question. Determining the number of falls is another important intervention, but observing the transfer technique should be done first.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum

1 fter birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

1 2 3 5 Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of GERD and therefore should be avoided. Aggravating substances include coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages, and alcohol. Options 4 and 6 do not promote this effect.

The nurse is reviewing the white blood cell (WBC) count and differential on a client and notes that the results indicate a left shift. What are the possible indications for these laboratory results? Select all that apply. 1. The total number of WBCs 2. An increased number of bands 3. The presence of an acute infectious process 4. An increased number of mature neutrophils 5. An increased number of immature neutrophils

1 2 3 5 The differential count reflects the percentage of the total number of WBCs. A left shift indicates an increased number of immature neutrophils, or an increased number of bands. This signals the presence of an acute infectious process. A right shift represents an increased number of mature neutrophils.

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse should ask the client about which manifestations of the disorder? Select all that apply. 1. Fatigue 2. Malaise 3. Anorexia 4. Weight gain 5. Dyspnea at rest

1, 2, 3 Silicosis is a chronic lung fibrosis that results from the long-term inhalation of silica dust. It is characterized by nodule formation between alveoli leading to fibrosis. Malaise, extreme fatigue, anorexia, weight loss, and dyspnea on exertion (not at rest) would occur in a client with silicosis. Additional manifestations include reduced lung volume and upper lobe fibrosis.

A new mother reports that her niece was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's mother asks the nurse if her newborn also has this diagnosis. Which findings should the nurse identify as potential indicators of GER? Select all that apply. 1. Irritability 2. Failure to thrive 3. Choking with feeding 4. Excessive weight gain 5. Spitting up and regurgitation

1, 2, 3, 5 GER assessment findings include irritability, failure to thrive, choking with feeding, weight loss, and spitting up and regurgitation. Weight loss, not weight gain, is typical of this condition due to frequent refusal to eat.

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. 1. Hemodialysis 2. Peritoneal dialysis 3. Kidney transplant 4. Bilateral nephrectomy 5. Intense immunosuppression therapy

1,3,4 Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys. Peritoneal dialysis is not a treatment option due to the infected cysts. The condition does not respond to immunosuppression.

What is the priority nursing action when admitting a client who has just attempted suicide? 1. Ensure constant observation of the client at all times. 2. Conduct a thorough mental health assessment of the client. 3. Determine whether the client has ever attempted suicide previously. 4. Remove all potentially dangerous articles from among the client's belongings.

1. Ensure constant observation of the client at all times The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one-on-one by the nurse) and never being less than an arm's length away are the best interventions. While the remaining options are appropriate, none have the priority at the time of admission.

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action? 1. Identify an object placed in the client's hand. 2. Identify 3 numbers or letters traced in the client's palm. 3. State whether 1 or 2 pinpricks are felt when the skin is pricked bilaterally in the same place. 4. Identify the smallest distance between 2 detectable pinpricks, made with 2 pins held at various distances.

1Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Agraphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and 2-point stimulation, respectively.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

2

Home History Help Calculator Review ModeQuestion 71 of 75QN: 4047 | ID: 4424 | file: Funds_4 Previous Go Next Stop Bookmark Rationale Strategy Reference(s) Submit The nurse is preparing to apply a mitten restraint to the client's hand. The nurse should take which action to ensure that the restraint is applied correctly? Click on the Question Video button to view a video showing preparation procedures. 1. Applies the restraint loosely 2. Makes sure that two fingers can be inserted under the restraint 3. Secures the restraint straps to the side rail using a quick-release tie 4. Makes sure that the sheepskin is on the outside rather than against the client's skin

2

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1. Anterior chest pain 2. Pericardial friction rub 3. Weakness and irritability 4. Chest pain that worsens on inspiration

2 A pericardial friction rub is heard when inflammation of the pericardial sac is present during the inflammatory phase of pericarditis. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints and could accompany a variety of disorders. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy.

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

2 An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question.

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux

2 Bethanechol chloride can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could damage or rupture the bladder in clients with these conditions.

The nurse reviews the health record of a 2-year-old child. The health care provider has documented that the results of a tuberculin skin test have indicated an area of induration measuring 5 mm. How should the nurse interpret these results? 1. Positive 2. Negative 3. Inconclusive 4. Requires a repeat test

2 Induration measuring 10 mm or greater is considered to be a positive result in children younger than 4 years. A reaction of 5 mm or greater is considered to be a positive result for the highest risk groups

The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client? 1. The client is drowsy. 2. Bowel sounds are absent. 3. The abdomen is slightly distended. 4. NG tube drainage is Hematest negative.

2 The NG tube should remain in place until the client has bowel sounds. If NG suction is being used, the nurse should turn off the suction before listening to bowel sounds to prevent mistaking the sound of the suction for bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is likely that the client may be drowsy after experiencing a stressor such as cardiac surgery. The abdomen is likely to be slightly distended after surgery, and it is normal for NG tube drainage to be Hematest negative.

The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse should inquire about the last time the client had which done? 1. Tuberculin test 2. Tetanus vaccine 3. Chest radiograph 4. Physical examination

2 With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. The remaining options are unrelated to the current situation identified in the question.

A client taking albuterol by inhalation cannot cough up secretions. What should the nurse suggest that the client do to assist in expectoration of secretions? 1. Get more exercise each day. 2. Use a dehumidifier in the home. 3. Drink increased amounts of fluids every day. 4. Take an extra dose of albuterol before bedtime.

3

A client with tuberculosis (TB) has a prescription for rifampin. What instruction should the nurse include in the client's teaching plan? 1. Yellow-colored skin is common with this medication. 2. The medication must always be taken on an empty stomach. 3. Wearing glasses instead of soft contact lenses will be necessary. 4. As soon as the cultures come back negative, the medication may be stopped.

3

The pediatric nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia and suspected central nervous system metastasis. The nurse should place the child in which position for this procedure? 1. Lithotomy position 2. Modified Sims' position 3. Lateral recumbent, knees flexed to the abdomen and the head bent, chin down 4. Prone, with the knees flexed to the abdomen and the head bent, the chin resting on the chest

3 A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. The remaining options are incorrect positions.

The nurse is preparing to care for a client in labor. The health care provider (HCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse should ensure that which is implemented before the beginning of the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedsid

3 Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. There are no data in the question that indicate the need for antibiotics or complete bed rest. It is not necessary to place a code cart at the bedside of a client receiving an oxytocin infusion.

The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood? 1. Phlebotomist 2. Medical student 3. Registered nurse (RN) 4. Blood bank technician

3 Depending on agency policy, two RNs or one RN and one licensed practical nurse (LPN) must check the label on the blood product together against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. A blood bank technician verifies data with the nurse when the blood is obtained from the blood bank but does not verify information on the nursing unit or at the client's bedside. The other options are also incorrect.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? 1. Hematuria 2. Proteinuria 3. Bacteriuria 4. Glucosuria

3 Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. Hematuria, proteinuria and glucosuria are not characteristically noted in this condition.

The health care provider has prescribed regular insulin 6 units and NPH insulin 20 units subcutaneously to be administered every morning. How should the nurse prepare to administer insulin? 1. Shake the NPH insulin vial to distribute the suspension. 2. Administer regular insulin and NPH insulin in separate syringes. 3. Draw up the regular insulin first and then the NPH insulin in the same syringe. 4. Draw up the NPH insulin first and then the regular insulin in the same syringe.

3 Regular insulin is always drawn up before NPH insulin, and NPH insulin can be drawn into the same syringe as the regular insulin. Insulins usually are administered 15 to 30 minutes before a meal. To mix the NPH insulin suspension, the vial should be rotated gently. Shaking introduces air bubbles into the solution.

The nurse has completed teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. The nurse should determine that education was effective if the client states to record which parameters daily? 1. Pulse and respiratory rate 2. Amount of activity and sleep 3. Intake and output (I&O) and weight 4. Blood urea nitrogen (BUN) and creatinine levels

3 The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording I&O and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day. It is not necessary to record the pulse and respiratory rate or the amount of activity and sleep; these parameters are not specifically related to hemodialysis. BUN and creatinine levels are not measured on a daily basis.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply. 1. Oranges 2. Broccoli 3. Margarine 4. Cream cheese 5. Luncheon meats 6. Broiled haddock

3, 4, 5

Mineral oil has been prescribed for constipation, and the nurse teaches about administration of the mineral oil. Which statement by the mother indicates that teaching was effective? 1. "I will administer the mineral oil before each meal." 2. "I will administer the mineral oil followed by a glass of warm water." 3. "I will mix the mineral oil with a chilled drink before administration." 4. "I will mix the mineral oil with 8 ounces of warm juice before administration."

3. I will mix the mineral oil with a chilled drink before administration Mineral oil is best tolerated when it is given chilled or mixed with cold drinks. Mixing the oil with chocolate milk, blending it with ice cubes and fruit juice, or chilling it helps to disguise the taste. Administering mineral oil before meals would affect appetite

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage him or her to remain still

4

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action? 1. Agree to act as a witness. 2. Call the health care provider (HCP). 3. Ask another nurse to serve as a witness. 4. Ask the client who might be available to serve as a witness

4 A living will addresses the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the client who will make care decisions if the client is unable to take action. It is witnessed and signed by 2 people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the HCP.

The health care provider (HCP) writes a prescription for capecitabine for a client who was admitted to the hospital. The nurse should contact the HCP to verify the prescription if which condition is noted in the assessment data? 1. Myalgia 2. Psoriasis 3. Rheumatoid arthritis 4. Chronic kidney disease

4 Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. A contraindication to the use of this medication is severe renal impairment such as that which occurs in chronic kidney disease. Myalgia, psoriasis, and rheumatoid arthritis are not contraindications to this medication.

The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest in Williams' position to minimize the pain. The nurse should put the bed in what position? 1. Flat with the knees raised 2. In high Fowler's position, with the foot of the bed flat 3. In semi Fowler's position, with the foot of the bed flat 4. In semi Fowler's position, with the knees slightly flexed

4 Clients with low back pain often are more comfortable when placed in Williams' position. The bed is placed in semi Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. The remaining positions will not minimize the pain and may make the pain worse.

The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn? 1. Fear and anxiety 2. Complaints of pain 3. Clear breath sounds 4. Use of accessory muscles for breathing

4 Clinical indicators of respiratory injury in a burn-injured client include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would be more likely to indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values also would be noted.

An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information? 1. "I should not wear my contact lenses." 2. "New contact lenses should be obtained." 3. "My old contact lenses should be discarded." 4. "My contact lenses can be worn if they are cleaned properly."

4 If the adolescent wears contact lenses, he should be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.

A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder? 1. "It is an acute bowel obstruction." 2. "It is a condition that causes an acute inflammatory process in the bowel." 3. "It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel." 4. "It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel."

4 Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is not an acute bowel obstruction, but it is a common cause of bowel obstruction in infants and young children. It is not an inflammatory process.

The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. Which statement by the nursing student indicates a need for further research? 1. "It also is called inherited immunity." 2. "It is the immunity with which a person is born." 3. "It does not require previous exposure to the antigen." 4. "It includes all antigen-specific immunities a person develops during a lifetime."

4 Natural resistance, also called innate inherited or innate-native immunity, is the immunity with which a person is born. It does not require previous exposure to the antigen. Acquired immunity includes all antigen-specific immunities that a person develops during a lifetime.

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4 Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

The nurse in the recovery room is caring for a client who underwent neurosurgery. Sequential compression devices (SCDs) have been applied to prevent venous stasis. While awaiting client transfer to the intensive care unit, the recovery room nurse should perform which critical assessment? 1. Assess radial pulses. 2. Log roll client to check skin integrity. 3. Monitor hemoglobin and hematocrit levels. 4. Monitor vascular status of the lower extremities.

4 SCDs may be useful to provide circulatory assistance after surgery. The critical nursing assessment includes monitoring the vascular status of the lower extremities. The remaining options may be components of the nursing assessment, but these actions are not part of the critical assessment required with use of SCDs.

A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery? 1. 50 J 2 120 J 3. 200 J 4. 360 J

4 The energy level used for all defibrillation attempts with a monophasic defibrillator is 360 joules.

patient is admitted to the emergency department (ED) after ingesting MDMA (ecstasy). Which of the following symptoms would the healthcare provider anticipate? Choose all answers that apply: A Chest pain B Flaccid extremities C Hypertension D Seizures E Hypothermia F Agitation

A, C, D, F

A patient is brought to the emergency department by a family member. The patient has been agitated for the past several hours and has alternated between grandiosity and expressing a desire to commit suicide. Upon examination, the patient is diaphoretic, hypertensive, and tachycardic. Intoxication with which of the following substances would contribute to these symptoms? Choose 1 answer: A Benzodiazepine B Alcohol C Methamphetamine D Marijuana

C

Emergency medical personnel bring an unconscious patient to the emergency department. The patient's pupils are pinpoint and respirations are depressed. Intoxication of which of the following substances could contribute to these clinical signs? Choose 1 answer: A Ecstasy B Cocaine C Methadone D Methamphetamine

C

A patient is brought to the emergency department (ED) by a friend. The patient is unresponsive and respirations are slow and shallow. Which of the following is the priority intervention? Choose 1 answer: A Check the patient's blood glucose level B Ask the friend if they were using illicit drugs C Administer naloxone, per protocol D Administer 100% oxygen per nasal cannula

D

A patient reports smoking 10 cigarettes per day for 40 years. How will the healthcare provider document this patient's smoking habit in terms of pack years? Choose 1 answer: A 10 pack years B 5 pack years C 4 pack years D 20 pack years

D

A patient who overdosed on oxycodone is given naloxone. When assessing the patient, the healthcare provider would anticipate which of these clinical manifestations of opioid withdrawal? Choose 1 answer: A Depressed respirations and somnolence B Bradycardia and hyporthermia C Hyperthermia and euphoria D Irritability and nausea

D

A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath? 1. A gown and gloves 2. Gloves and goggles 3. A gown and goggles 4. Gloves and shoe protectors

1

A 15-year-old is injured and sustains a fractured jaw. The fractured jaw has been surgically wired, and the health care provider (HCP) has prescribed a full liquid diet. Which nursing action would best promote compliance and provide an adequate nutrient value with the full liquid diet for this teenager? 1. Offer chocolate milkshakes between meals. 2. Explain the importance of good nutrition to the teenager. 3. Offer commercial nutritional supplements 4 to 6 times per day. 4. Ask the teenager for food preferences and liquefy these foods using a blender.

4

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"

4

A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact? 1. The client has experienced more than one sexual assault. 2. The client routinely incorporates foreign objects into the sex act. 3. The client actively initiating situations in which sex is forced is common. 4. The client regularly re-experiences the events associated with the assault.

4

A client is prescribed a liquid iron preparation that has the potential to stain the teeth. The nurse should instruct the client to take which action to prevent staining of the teeth? 1. Brush the teeth before drinking the iron. 2. Drink the iron undiluted for maximal effect. 3. Dilute more than the amount prescribed to obtain the correct dosage. 4. Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward.

4

A client who has undergone creation of a colostomy has a concern about body image. What action by the client indicates the most significant progress toward identified goals? 1. Looking at the ostomy site 2. Reading the ostomy product literature 3. Watching the nurse empty the ostomy bag 4. Practicing proper cutting of the ostomy appliance

4

A clinic nurse is assessing a client who has been on isoniazid for 6 months. Which client complaint should most concern the nurse? 1. Dry mouth 2. Cramping diarrhea 3. Frequent headaches 4. Difficulty tying shoes

4

A registered nurse (RN) is orienting a new RN on the use of atorvastatin. Which statement by the new RN indicates that the teaching has been effective? 1. "It is used in heart failure." 2. "It helps to control hypertension." 3. "It helps to reduce episodes of angina pectoris." 4. "It is given to clients with hypercholesterolemia."

4

A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do? 1. Eat twice the amount normally eaten at lunchtime. 2. Take half the amount of prescribed insulin on practice days. 3. Take the prescribed insulin at noontime rather than in the morning. 4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4

An older client is brought to the hospital emergency department by a neighbor who heard the client talking and found him wandering in the street at 3 a.m. The nurse should first determine which data about the client? 1. His insurance status 2. Blood toxicology levels 3. Whether he ate his evening meal 4. Whether this is a change in usual level of orientation

4

The nurse is preparing to teach a client with a new colostomy about how to perform a colostomy irrigation. Which information should the nurse include in the teaching plan? 1. Use 500 to 1000 mL of warm tap water. 2. Suspend the irrigant 36 inches above the stoma. 3. Insert the irrigation cone ½ inch into the stoma. 4. If cramping occurs, open the irrigation clamp farther.

1

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1. The client's noncompliance with medication therapy 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care

1

he nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? 1. After a shower or bath 2. While standing to void 3. After having a bowel movement 4. While lying in bed before arising

1

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1. Monitor for fetal movement. 2. Monitor the maternal blood glucose. 3. Instruct the client to maintain complete bed rest. 4. Instruct the client to restrict dietary sodium and any food items that contain sodium.

1 A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is not necessary. Urine should be checked for protein. Sodium restriction is not necessary.

What is the appropriate nursing intervention in dealing with a suicidal client? 1. Provide authority, action, and participation. 2. Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Promote hope and reassurance that the problems will resolve themselves.

1 A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A client who is suicidal is in a state of crisis and temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. When the nurse intervenes in this situation, the nurse "takes over" for the client who is not in control and devises a plan (action) to secure and maintain the client's safety. Once this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies. Therefore, the remaining options are not appropriate for this client.

A client has a risk for infection following radical vulvectomy. Therefore, the nurse should avoid which action when giving perineal care to this client? 1. Cleansing with warm tap water 2. Intermittently exposing the wound to air 3. Providing prescribed sitz baths after the sutures are removed 4. Providing perineal care after each voiding and bowel movement

1 A sterile solution such as normal saline should be used for perineal care using an aseptic syringe. This should be done regularly at least twice a day and after each voiding and bowel movement. The wound is intermittently exposed to air to permit drying and to prevent maceration. Once sutures are removed, sitz baths may be prescribed to stimulate healing and for the soothing effect.

The nurse gives a dose of diazepam to an assigned client. What is the most important action to be taken by the nurse before leaving the room? 1. Instituting safety measures 2. Closing the curtains in the room 3. Lowering the volume on the television set 4. Giving the client the remote control for the television set

1 Diazepam is a sedative hypnotic that also has anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to prevent injury as a result of medication side effects, which include dizziness, drowsiness, and lethargy. The other options listed are useful but not essential to the client's safety in this situation.

The nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do first? 1. Review intake and output records for the last 2 days. 2. Prescribe daily weights starting on the following morning. 3. Change the time of diuretic administration from morning to evening. 4. Request a sodium restriction of 1 g/day from the health care provider (HCP).

1 Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Therefore, the nurse should review intake and output records for the last 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs? 1. Flashbacks 2. Amotivational syndrome 3. Enhanced physical strength 4. Absence of pain perception

1 Flashbacks, the recurrence of perceptual distortions, are unique to the use of hallucinogenic drugs. Enhanced physical strength and the inability to feel pain are indicative of phencyclidine use, whereas marijuana abuse can result in amotivational syndrome

An older client with rheumatoid arthritis has been instructed by the health care provider to take ibuprofen 400 mg orally (PO) three times daily. The home care nurse reading the medication prescription knows that the instruction has been effective when the client states the instructed dose is which? 1. The normal adult dose 2. Higher than the normal adult dose 3. An unusual dosage for this diagnosis 4. Two times higher than the normal adult dose

1 For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose for an older client is 400 to 800 mg three or four times daily. The other options are incorrect.

The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? 1. Dark red drainage 2. Dark brown drainage 3. Green-tinged drainage 4. Light yellowish-brown drainage

1 For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.

The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant."

1 HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control.

A client is admitted to the nursing unit after undergoing radical prostatectomy for cancer. The nurse anticipates that which problem would be of most concern to the client in the immediate postoperative period? 1. Concern about the outcome of surgery 2. Continuous pain because of the effects of cancer 3. Appearance disturbance as a result of the presence of a suprapubic catheter 4. Concern about caring for self at home because of insufficient help after discharge

1 In the immediate postoperative period, the client who has had surgery for cancer may experience fear or concern related to the uncertain outcome of surgery. Postoperative pain is classified as acute, not continuous. The client may experience an alteration in appearance, but this is more likely to be related to the anticipated change in sexual function than the presence of the suprapubic catheter. The priority focus in the immediate postoperative period is not on concerns that apply to hospital discharge.

A child is suspected of suffering from intussusception. The nurse should be alert to which clinical manifestation of this condition? 1. Tender, distended abdomen 2. Presence of fecal incontinence 3. Incomplete development of the anus 4. Infrequent and difficult passage of dry stools

1 Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children aged 3 months to 6 years. A tender, distended abdomen is a clinical manifestation of intussusception. The presence of fecal incontinence describes encopresis. Encopresis generally affects preschool and school-aged children. Incomplete development of the anus describes imperforate anus, and this disorder is diagnosed in the neonatal period. The infrequent and difficult passage of dry stools describes constipation. Constipation can affect any child at any time, although the incidence peaks at age 2 to 3 years.

A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider? 1. Naloxone 2. Betamethasone 3. Morphine sulfate 4. Meperidine hydrochloride

1 Opioids are used for epidural analgesia, which can lead to delayed respiratory depression. For this reason, respirations are monitored for 24 hours after administration of epidural analgesia. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given if the respiratory rate falls below 8 breaths per minute. Betamethasone is a corticosteroid administered to enhance fetal lung maturity. Morphine sulfate and meperidine hydrochloride are opioids and would further compromise the respiratory rate.

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Gastrointestinal function

1 Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to this medication.

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? 1. Mitral area 2. Right atrium 3. Right ventricle 4. Pulmonic valve

1 The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apical pulse. S1 ("lub") and S2 ("dub") should be distinguished. The pulse should be counted for a full minute. The right atrium, right ventricle, and pulmonic valve areas will not provide clear auscultation of the apical pulse.

The nurse is reviewing the health care provider's prescriptions for an adult client who has been admitted to the hospital after a back injury. Carisoprodol is prescribed for the client to relieve the muscle spasms. The health care provider has prescribed 350 mg to be administered four times a day. What should the nurse conclude? 1. The prescription is the normal adult dosage. 2. The prescription is lower than normal dosage. 3. The prescription is higher than normal dosage. 4. The dosage prescribed requires further clarification with the health care provider.

1 The normal adult dosage for carisoprodol is 350 mg orally three to four times daily

Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? 1. "I feel like I need to push." 2. "My contractions seem to be getting stronger." 3. "I am glad that I have several minutes to rest between contractions." 4. "Warm fluid is running down my legs each time I have a contraction."

1 The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. At this time, the laboring woman typically experiences the desire to push. Contractions becoming stronger are experienced throughout labor and do not indicate that she has reached stage 2. Having several minutes to rest between contractions does not describe the end of transition.Leaking of amniotic fluid does not mean that she is completely dilated.

A client is prescribed tranylcypromine. The nurse educating a client about tranylcypromine should instruct the client to avoid which activity? 1. Drinking any amount of wine 2. Consuming any fresh dairy products 3. Exposing the skin of the face to sunlight 4. Eating either fresh or frozen green leafy vegetables

1 Tranylcypromine is a monoamine oxidase inhibitor (MAOI) that is used to treat depression. Food and fluids containing tyramine, such as aged cheese, smoked or pickled meats or poultry, fermented meat, beer, wine, and liqueurs, should not be used concurrently with MAOIs because they can cause sudden and severe hypertensive reactions. The remaining options are not contraindicated with the use of this medication.

The nurse is caring for a 1-day postoperative client who is complaining of urinary retention. What are some of the initial assessment techniques or interventions the nurse should employ? Select all that apply. 1. Palpation 2. Inspection 3. Percussion 4. Auscultation 5. Bladder scanner 6. Insertion of Foley catheter

1 2 3 5 Control of urination may return immediately after surgery or may not return for hours after general or regional anesthesia. The effects of preoperative medications (especially atropine), anesthetic agents, or manipulation during surgery can cause urine retention. Assessment may be difficult to perform after lower abdominal surgery. Assess for urinary retention by inspection, palpation, and percussion of the lower abdomen for bladder distention or by the use of a bladder scanner. Auscultation and inserting a Foley catheter are not interventions for initial postoperative urinary problems.

client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

1 2 5 6 Cancer is a common cause of SIADH. In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.

The health care provider (HCP) prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1. Encourage coughing with deep breathing. 2. Place in high Fowler's position for eating. 3. Encourage increased oral intake of water daily. 4. Place thigh-length elastic stockings on the client. 5. Place sequential compression boots on the client. 6. Encourage the intake of dark green, leafy vegetables.

1 3 4 The client with DVT may require bed rest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bed rest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with high Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.

The nurse is caring for a client with an intracranial aneurysm who has been alert. Which signs and symptoms are an early indication that the level of consciousness (LOC) is deteriorating? Select all that apply. 1. Mild drowsiness 2. Drooping eyelids 3. Ptosis of the left eyelid 4. Slight slurring of speech 5. Less frequent spontaneous speech

1 4 5 Early changes in LOC relate to orientation, alertness, and verbal responsiveness. Mild drowsiness, slight slurring of speech, and less frequent spontaneous speech are early signs of decreasing LOC. Ptosis (drooping) of the eyelid is caused by pressure on and dysfunction of cranial nerve III. Once ptosis occurs, it is ongoing; it does not relate to LOC.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply. 1. Elevated lipase level 2. Elevated lactase level 3. Elevated trypsin level 4. Elevated amylase level 5. Elevated sucrase level

1, 3, 4 Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively. Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Sucrase is produced in the small intestine and converts sucrose into glucose and fructose.

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply. 1. Fever 2. Positive Cullen's sign 3. Complaints of indigestion 4. Palpable mass in the left upper quadrant 5. Pain in the upper right quadrant after a fatty meal 6. Vague lower right quadrant abdominal discomfort

1, 3, 5 During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula or shoulder or experience epigastric pain after a fatty or high-volume meal. Fever and signs of dehydration would also be expected, as well as complaints of indigestion, belching, flatulence, nausea, and vomiting. Options 4 and 6 are incorrect because they are inconsistent with the anatomical location of the gallbladder. Option 2 (Cullen's sign) is associated with pancreatitis.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1, 4, 5 Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels

The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor for changes in mentation. 2. Encourage an intake of low-protein foods. 3. Encourage an intake of low-sodium foods. 4. Encourage fluid intake of at least 3000 mL per day. 5. Monitor vital signs, skin turgor, and intake and output.

1, 4, 5 The client at risk for deficient fluid volume should be encouraged to eat regular meals and snacks and to increase intake of sodium, protein, and complex carbohydrates and fluids. Oral replacement of sodium losses is necessary, and maintenance of adequate blood glucose levels is required. Mentation, vital signs, skin turgor and intake and output should be monitored for signs of fluid volume deficit.

client is undergoing a 2-hour glucose tolerance test. The nurse assesses for which client factors that can interfere with the test period results? Select all that apply. 1. Experiencing stress 2. Fasting before the test period 3. Voiding during the test period 4. Eating a small snack or candy during the test period 5. Having an episode of diarrhea before the test period 6. Being unable to eat the entire test meal or vomiting some or all of the meal

1, 4, 6

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2

A client has been taking glucocorticoids to control rheumatoid arthritis. Which laboratory abnormality is the client at risk for as a result of taking this medication? 1. Increased serum glucose 2. Decreased serum sodium 3. Elevated serum potassium 4. Increased white blood cells

1. Increased serum glucose Glucocorticoids have 3 primary uses: replacement therapy for adrenal insufficiency, immunosuppressive therapy, and antiinflammatory therapy. Exogenous glucocorticoids cause the same effects on cellular activity as those of the naturally produced glucocorticoids; however, exogenous glucocorticoids also may have undesired effects. The glucocorticoids stimulate appetite and increase caloric intake. They also increase the availability of glucose for energy. These combined effects cause the blood glucose levels to rise, making the client prone to hyperglycemia. Glucocorticoids can also lead to hypokalemia. The remaining options are not expected effects of the use of glucocorticoids.

The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels. Which statement by one of the new RNs indicates that teaching has been effective? 1. "Calcium has no effect on the risk for stroke." 2. "Low calcium levels can lead to cardiac arrest." 3. "Low calcium levels cause high blood pressure." 4. "Calcium has no effect on urinary stone formation."

2

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 1. Obtain a new IV bag. 2. Obtain new IV tubing. 3. Wipe the spike end of the tubing with povidone iodine. 4. Scrub the spike end of the tubing with an alcohol swab.

2

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2

The nurse providing instructions to a client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching? 1. "It will open up the major airways." 2. "It will keep the small airways open." 3. "It will increase lubrication for the lungs." 4. "The lungs can better rid themselves of secretions."

2

When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question? 1. "Are you drinking more than you did 5 years ago?" 2. "How do you feel when you haven't had a drink all day?" 3. "Does your drinking ever cause you problems with your family?" 4. "Do you ever feel that you really need a drink to calm your nerves?"

2

When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration? 1. Encouraging social interactions 2. Assessing all activities for safety risks 3. Focus upon providing verbal stimulation 4. Providing detailed instructions to ensure success

2

The nurse is preparing to care for a client with a diagnosis of metastatic cancer. The nurse notes documentation in the client's chart that the client is experiencing cachexia. Which should the nurse expect to note on assessment of the client? 1. Elevated blood pressure and ascites 2. Sunken eyes and a hollow cheek appearance 3. Periorbital edema and swelling around the ears 4. Generalized edema and the presence of weight gain

2 Cachexia accompanies chronic wasting diseases and conditions such as cancer, dehydration, and starvation. Assessment findings in a client with cachexia include sunken eyes; hollow cheeks; and an exhausted, defeated expression. Options 1, 3, and 4 are not characteristic of a cachectic appearance.

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position? 1. Supine 2. Side-lying 3. High Fowler's 4. Trendelenburg's

2 A tonsillectomy is the surgical removal of the tonsils. The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage. Options 1, 3, and 4 would not achieve this goal

The nurse has a prescription to administer acetylcysteine to a client admitted to the emergency department with acetaminophen overdose. Before giving this medication, what is the nurse's best action? 1. Administer the full-strength solution. 2. Empty the stomach by emesis or lavage. 3. Check that the antidote is readily available. 4. Ensure that the client knows how to use a nebulizer.

2 Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. Before giving the medication as an antidote to acetaminophen, the nurse ensures that the client's stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make it more palatable. It is then administered orally or by nasogastric tube. Acetylcysteine is the antidote to acetaminophen.

A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor? 1. Development of tolerance for the drug 2. Lack of naturally occurring endorphins 3. Client's psychological dependency on opiates 4. Typical abuse pattern for central nervous system depressants

2 Craving opiates is a result of the diminished production of endorphins that occurs with long-term abuse of the drug. Tolerance is the need for increased amounts of the drug to achieve the desired effects. Psychological dependency is the emotional need for the drug. Cravings are not typical of all central nervous system depressant abuse.

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action? 1. Take the medication with food. 2. Increase fluid intake to 2000 to 3000 mL daily. 3. Decrease sodium intake while taking the medication. 4. Increase potassium intake while taking the medication.

2 Hemorrhagic cystitis is an adverse effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be told to increase potassium intake. The client would not be instructed to alter sodium intake.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1. Therapeutic abortion is required. 2. Isoniazid plus rifampin will be required for 9 months. 3. She will have to stay at home until treatment is completed. 4. Medication will not be started until after delivery of the fetus.

2 More than 1 medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition? 1. Bleeding 2. Heart failure 3. Failure to thrive 4. Decreased tolerance to stimulation

2 Nursing care initially centers on observing for signs of heart failure. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distension. The remaining options are not conditions directly associated with this disorder.

client is experiencing blockage of the eustachian tubes. The nurse educates the client on how the client may forcibly open the eustachian tube. Which statement by the client indicates that the teaching has been effective? 1. "I should tap the side of the head lightly." 2. "I should perform the Valsalva maneuver." 3. "I should use cotton-tipped applicators in the ears." 4. "I should chew food using exaggerated mouth movements."

2 Performing the Valsalva maneuver increases pressure in the nasopharynx and may help open a blocked eustachian tube. The actions described in the other options will not accomplish this.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida. 2. The client has a history of cardiac disease. 3. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4. The client is a 20-year-old primigravida of average weight and height.

2 Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.

The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? 1. The client who lacks knowledge regarding postoperative home care 2. The client with problems clearing the airway related to abdominal incision pain 3. The client with tissue perfusion alterations related to postoperative venous stasis 4. The client who is at risk for infection related to a history of smoking for 20 years

2 Priority care is focused on the client who has an ineffective airway. Although postoperative home care teaching is essential before discharge, there is no indication that the client is ready for discharge. The client with venous stasis has a circulatory issue related to immobility but no indication of an absence of arterial circulation. The potential for infection as a result of long-term smoking is a risk but not the most immediate concern. All 3 problems are important, but the client in the correct option has an airway concern, which supersedes the other clients' immediate needs.

he nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who has undergone lumbar puncture. The nurse determines that which is an abnormal finding? 1. Red blood cells (negative) 2. Protein 100 mg/dL (1 g/L) 3. Glucose 52 mg/dL (2.9 mmol/L) 4. White blood cells 3 cells/mcL (3 × 106/L)

2 Protein (15 to 45 mg/dL [0.15 to 0.45 g/L]) and glucose (50 to 75 mg/dL [2.8 to 4.2 mmol/L]) normally are present in CSF; however, the protein level for this client is above the expected range. The adult with normal CSF has no red blood cells in the CSF. The client may have small numbers of white blood cells (0 to 5 cells/mcL [0 to 5 × 106/L]).

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.

2 Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.

The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? 1. "Flames should be doused with water." 2. "The client should be maintained in a standing position." 3. "Flames may be extinguished by rolling the client on the ground." 4. "Flames may be smothered by the use of a blanket or another cover."

2 The client should be placed or maintained in a supine position; otherwise, flames may spread to other parts of the body, causing more extensive injury. Flame burns may be extinguished by rolling the client on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water.

Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? 1. Taking off the gloves first before removing the gown 2. Removing the gown without rolling it from inside out 3. Washing the hands after the entire procedure has been completed 4. Removing the gloves and then removing the gown using the neck ties

2 The gown must be rolled from inside out to prevent the organisms on the outside of the gown from contaminating other areas. Gloves are considered the dirtiest piece of equipment and therefore must be removed first. Hands must be washed after removal of the protective garb to remove any unwanted germs still present. Ungloved hands should be used to remove the gown to prevent contaminating the back of the gown with germs from the gloves.

Home History Help Calculator Review ModeQuestion 18 of 75QN: 4904 | ID: 3541 | file: Pediatric_Part_1 Previous Go Next Stop Bookmark Rationale Strategy Reference(s) Submit The nurse is providing home care instructions to the parents of a child with a seizure disorder. Which statement indicates to the nurse that the teaching regarding seizure disorders has been effective? 1. "We're glad we only have to give our child the medication for 30 days." 2. "We will make appointments for follow-up blood work and care as directed." 3. "We're glad there are no side effects from taking the antiseizure medications." 4. "After our child has been seizure free for 1 month, we can discontinue the medication."

2 Antiseizure medications are continued for a prolonged time even if seizures are controlled. Periodic reevaluation of the child is important to assess the continued effectiveness of the medication, to check serum medication levels, and to determine the need to alter the dosage if indicated. Antiseizure medications have potential side effects, and parents should be informed of such effects specific to the medication the child will be taking. Withdrawal of medication follows a predesigned protocol, usually begun when the child has been seizure free for at least 2 years. When a medication is discontinued, the dosage should be reduced gradually over 1 to 2 weeks.

The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? Select all that apply. 1. Secure the drain to the sheet. 2. Make sure suction is maintained. 3. Check that the drains are sutured in place. 4. Use clean technique to empty the reservoir. 5. Compress the reservoir to restore suction after emptying. 6. Record the amount and color of drainage according to agency protocol or health care provider's orders.

2 3 5 6 Interventions include making sure suction is maintained, checking that the drains are sutured in place, compressing the reservoir to restore suction after emptying, and recording the amount and color of drainage according to agency protocol or health care provider's orders. The other interventions are not appropriate.

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4400 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. 1. Retinopathy 2. Hypoglycemia 3. Fractured clavicle 4. Hyperbilirubinemia 5. Congenital heart defect 6. Necrotizing enterocolitis

2, 3, 5 Any newborn weighing more than 4000 g at birth is defined as being large for gestational age (LGA). Because of their size, LGA infants are at risk for hypoglycemia. LGA infants also have a higher incidence of birth injuries (fractured clavicle), asphyxia, and congenital anomalies (heart defect). Retinopathy is a disorder that affects the developing vessels of preterm infants. Hyperbilirubinemia is not an immediate risk related to LGA infants. Preterm birth is the most prominent risk factor in the development of necrotizing enterocolitis.

A nursing instructor asks a nursing student to describe the process of quickening. Which statements by the student indicate an understanding of this term? Select all that apply. 1. "It is the thinning of the lower uterine segment." 2. "It is the fetal movement that is felt by the mother." 3. "It is irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated." 5. "It is a process that occurs in the pregnant woman as early as 16 weeks but definitely by week 20."

2, 5 Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements that gradually increase in intensity. A thinning of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, known as uterine souffle. This sound is caused by the blood circulation to the placenta and corresponds to the maternal pulse.

The nurse manager meets with the staff nurses and announces that management has developed a new policy and procedure that is significantly different from old practices. Which statement by the nurse manager reflects the manager's use of legitimate power? 1. "The health care system services a client population that presents particular challenges. The changes made will enhance client safety and reduce errors." 2. "If you don't follow the new policy and procedure, I'll have no choice but to give you a notice about poor performance, which could lead to termination of your employment." 3. "Every manager has the responsibility to see that these new policies and procedures are followed 100% of the time. Please join me in this organization's effort to continue to improve quality care." 4. "You're just going to have to trust me on this one. I was a member of the committee that wrote the policy and procedure, and there are good reasons why the specific nursing actions need to be done this new way."

3

The ambulatory care nurse is preparing to assist the health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse should assist the client into which position for this test to be performed? 1. Right lateral side-lying 2. Flat with the head elevated 3. Supine with the right hand under the head 4. Prone with the hands crossed under the head

3 A client undergoing liver biopsy with the use of a local anesthetic will be positioned supine with the client's right hand placed under the head. An alternative position is the left lateral side-lying position. The client also will be asked to remain as still as possible during the test. The remaining options are inappropriate positions for this procedure.

The nurse is preparing to care for a client after a lumbar puncture. The nurse should plan to place the client in which best position following the procedure? 1. Prone in semi Fowler's position 2. Supine in semi Fowler's position 3. Prone with a small pillow under the abdomen 4. Lateral with the head slightly lower than the rest of the body

3 After the procedure, the client assumes a flat position. If the client is able, a prone position with a pillow under the abdomen is the best position. This position helps reduce cerebrospinal fluid leakage and decreases the likelihood of post-lumbar puncture headache. The remaining options are incorrect.

The nurse is preparing a subcutaneous dose of bethanechol prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart for use if needed? 1. Vitamin K 2. Mucomyst 3. Atropine sulfate 4. Protamine sulfate

3 Bethanechol is a cholinergic medication. Administration of bethanechol could result in cholinergic overdose. The antidote is atropine (an anticholinergic), which should be readily available for use if overdose occurs. Mucomyst is the antidote for acetaminophen overdose. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin.

A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother as to how to obtain a cellophane tape rectal specimen. Which statement by the mother indicates an understanding of the correct procedure to obtain the specimen? 1. "I need to collect the specimen after I give my child a bath." 2. "I need to collect the first bowel movement of the day and place it in a sealed container." 3. "I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination." 4. "I need to place a piece of transparent cellophane tape lightly over the anal area after my child has a bowel movement and bring it to the clinic for examination."

3 Diagnosis of pinworm is confirmed by direct visualization of the worms. Parents can view the sleeping child's anus with a flashlight. The worm is white, thin, and about ½ to1 inch (1.3 to 2.5 cm) long, and it moves. A simple technique, the cellophane tape slide method, is used to capture worms and eggs. Transparent tape is lightly touched to the anus and then applied to a slide for examination. The best specimens are obtained as the child awakens, before toileting or bathing.

The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism? 1. A normal T4 level 2. An elevated T4 level 3. An elevated TSH level 4. A decreased TSH level

3 Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. The remaining options are not diagnostic findings of this condition.

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response? 1. "I don't believe that." 2. "Everything will be all right." 3. "I'm not sure that I understand. Would you please explain?" 4. "I think you should talk more with the health care provider about this."

3 Explaining what is vague or clarifying the meaning of what has been said increases understanding for both the client and the nurse. Refusing to consider the client's ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. False reassurance devalues the client's feelings. Placing the client's feelings on hold by referring him or her to the health care provider for further information is a block to communication.

he nurse is providing education to a client with type 2 diabetes about starting insulin glargine to help with improved glycemic control. Which statement made by the client indicates understanding? 1. "It has a distinct peak." 2. "It can be given intravenously." 3. "It has a decreased risk for hypoglycemia." 4. "I don't have to perform fingerstick glucose monitoring."

3 In contrast to other long-acting insulins, insulin glargine achieves blood levels that are relatively steady over 24 hours. As a result, there is less risk of hypoglycemia or hyperglycemia. The only insulins that can be administered intravenously are the short-acting insulins. All medications used to treat diabetes mellitus require fingerstick monitoring.

The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which position? 1. Prone position 2. Supine position 3. Semi Fowler's position 4. Dorsal recumbent positio

3 In supratentorial surgery (surgery above the brain's tentorium), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins. The client's head or the head of the bed is not lowered in the acute phase of care after supratentorial surgery. An exception to this is the client who has undergone evacuation of a chronic subdural hematoma, but a health care provider's (HCP's) prescription is required for positions other than those involving head elevation. In addition, the HCP's prescription regarding positioning is always checked and agency procedures are always followed.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Notify the health care provider. 4. Cover the ears with gauze pads.

3 Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.

The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? 1. Run a dehumidifier in the home. 2. Apply astringents to the skin twice daily. 3. Apply emollients to the skin after bathing. 4. Take baths twice daily using a dilute solution of alcohol and water.

3 One bath or one shower per day for 15 to 20 minutes with warm water and a mild soap should be followed immediately by the application of an emollient to prevent evaporation of water from the hydrated epidermis. The client should avoid using a dehumidifier because this will further dry room air. The client should be instructed to avoid applying rubbing alcohol, astringents, or other drying agents to the skin. A bath using a dilute alcohol solution will cause further drying of the skin.

The nurse should determine that tracheal suctioning is needed if which is noted? 1. Arterial oxygen level of 90 mm Hg 2. 2 hours elapsed since the last suctioning 3. Congested breath sounds in the lung fields 4. Respiratory rate of 18 breaths/min, up from 16 breaths/min

3 Suctioning is indicated only when the client has adventitious breath sounds or has accumulation of secretions. It is not performed routinely according to time elapsed since the last suctioning (2 hours elapsed since the last suctioning). Arterial blood gas results and respiratory rate (arterial oxygen level of 90 mm Hg and respiratory rate of 18 breaths/min, up from 16 breaths/min) are not good indicators of the need for suctioning because they may be influenced by a number of other factors in addition to the need for suctioning.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the health care provider (HCP). 4. Tell the client that the fetal heart rate is normal.

3 The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.

A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority? 1. Administer oxygen and protamine sulfate. 2. Cut the infusion rate in half and sit the client up in bed. 3. Stop the infusion and call for the Rapid Response Team (RRT). 4. Administer diphenhydramine and epinephrine and continue the infusion.

3 The client is experiencing an anaphylactic reaction. Therefore, the priority action is to stop the infusion and notify the RRT. The health care provider should be contacted once the client has been stabilized. The client may be treated with epinephrine, antihistamines, and corticosteroids as prescribed, but the infusion should not be continued.

The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure? 1. Turning the head to one side 2. Using oral suction equipment 3. Rinsing with a large volume of fluid 4. Using a bite stick or padded tongue blade

3 The client who is unconscious is at great risk of aspiration. The nurse assesses the client for the presence of a gag reflex. The nurse turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or padded tongue blade is used to open the mouth; use of the nurse's gloved fingers is avoided to prevent injury to the nurse. Small volumes of fluid are used in rinsing the mouth, and oral suctioning is used to prevent aspiration.

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? 1. Client in heart failure 2. Client in acute kidney injury 3. Client with diabetes insipidus 4. Client with controlled hypertension

3 The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 1. Fractured tibia 2. Penetrating abdominal injury 3. Bright red bleeding from a neck wound 4. Open massive head injury in deep coma

3 The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last.

The nurse is delegating the morning hygienic care of a man to the unlicensed assistive personnel (UAP). In reviewing the assigned tasks, the nurse should instruct the UAP to use an electric razor for which client? 1. The client with severe pain related to osteoporosis 2. The client with hypokalemia related to diuretic therapy 3. The client with thrombocytopenia related to chemotherapy 4. The client with an elevated white blood cell count related to infection

3 The client with thrombocytopenia has a low platelet count. Using a straight razor increases the risk of abrasion and bleeding caused by ineffective clotting capability. The client with hypokalemia has a low potassium level. Shaving the client has no relationship to the client's potassium level. The client with severe pain is not affected by the different choices in shaving tools. Likewise, the client with an elevated white blood cell count will not be affected by the different choices in shaving tools.

The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the health care provider (HCP)? 1. Serum electrolytes 2. Urine specific gravity 3. 24-hour fluid intake and output without restricting food or fluid intake 4. Postoperative magnetic resonance imaging to detect any damage to the hypothalamus or pituitary gland

3 The first step in diagnosing DI is to measure a 24-hour fluid intake and output without restricting food or fluid intake. All of the other options may be done but would not be as definitive as a 24-hour fluid intake and output test.

The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell count is 2000 mm3 (2 × 109/L) and that the platelet count is 150,000 mm3 (150 × 109/L). Which intervention should the nurse incorporate into the plan of care? 1. Avoid unnecessary injections. 2. Encourage quiet play activities. 3. Maintain strict neutropenic precautions. 4. Encourage the child to use a soft toothbrush.

3 The normal white blood cell (WBC) count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L) and the normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). Strict neutropenic procedures would be required if the WBC count were low to protect the child from infection. Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury.

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1. "Autonomy is the fundamental right of each and every client." 2. "A client's rights are guaranteed by both state and federal laws." 3. "Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4. "Regardless of the client's condition, all nurses have the duty to value client rights."

3 The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights. While it is true that autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for the concept.

The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution? 1. Urine test strips 2. Blood glucose meter 3. Electronic infusion pump 4. Noninvasive blood pressure monitor

3 The nurse obtains an electronic infusion pump before hanging a PN solution. Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Because the client's blood glucose level is monitored every 4 to 6 hours during administration of PN, a blood glucose meter also will be needed, but this is not the most essential item needed before hanging the solution because it is not directly related to administering the PN. Urine test strips (to measure glucose) rarely are used because of the advent of blood glucose monitoring. Although the blood pressure will be monitored, a noninvasive blood pressure monitor is not the most essential piece of equipment needed for this procedure.

What action should the nurse take as a priority after administering an opioid analgesic to a client experiencing pain? 1. Dim the lights in the room. 2. Take the client to the bathroom to void. 3. Provide safety measures per agency protocol. 4. Perform range-of-motion exercises to the injection site to promote medication absorption.

3 The nurse should ensure client safety after administering an opioid analgesic to prevent injury once the medication has taken effect. The nurse should provide safety measures per agency protocol, such as raising side rails, ensuring that the client understands the use of the call bell, and ensuring that the nurse should be called before the client gets out of bed. Dimming the light in the room is the next most helpful action. The client should have been asked about the need to urinate before the medication was administered. It is unnecessary to do range-of-motion exercises to the injection site.

The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? 1. Adjust the infusion rate to catch up over the next hour. 2. Increase the infusion rate to catch up over the next 2 hours. 3. Ensure that the fat emulsion infusion rate is infusing at the prescribed rate. 4. Adjust the infusion rate to run wide open until the solution is back on time.

3 The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. In addition, increasing the rate suddenly can cause fluid overload. The same principle (not increasing the rate) applies to parenteral nutrition or any intravenous infusion. Therefore, the remaining options are incorrect.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next? 1. Check the client's temperature. 2. Contact the health care provider. 3. Isolate the client in a private room. 4. Check a complete set of vital signs.

3 The nurse should suspect the potential for Ebola virus disease (EVD) because of the client's recent travel to Liberia. The nurse needs to consider the symptoms that the client is reporting, and clients who meet the exposure criteria should be isolated in a private room before other treatment measures are taken. Exposure criteria include a fever reported at home or in the ED of 38.0°C (100.4°F) or headache, fatigue, weakness, muscle pain, vomiting, diarrhea, abdominal pain, or signs of bleeding. This client is reporting a fever and is showing other signs of EVD, and therefore should be isolated. After isolating the client, it would be acceptable to then collect further data and notify the health care provider and other state and local authorities of the client's signs and symptoms.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

3 The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS.

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria." 2. "These medications are only taken when I have pain from my ulcer." 3. "The medications will kill the bacteria and decrease the acid production." 4. "These medications will coat the ulcer and decrease the acid production in my stomach."

3 Triple therapy for H. pylori infection usually includes 2 antibacterial medications and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer an antibiotic per HCP prescription and per agency protocol.

3 Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? 1. Fleet enema 2. Fecal disimpaction 3. Glycerin suppository 4. Soap solution enema (SSE)

3 he least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Fecal disimpaction is done only when the client's rectum has become impacted from constipation as a result of inattention or failure of other measures. Stool softeners may be prescribed on a regular schedule for some clients to avoid hard, dry stools, but oral medication is not administered to an unconscious client.

The nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction? 1. "I should avoid sexual activity for 4 to 6 weeks." 2. "I should wash the perineum after each voiding." 3. "It is all right to ride in a car as much as I want, as long as I am not driving the car." 4. "I need to report any redness, swelling, or drainage to the health care provider."

3 The client should avoid activities such as sitting for long periods of time and doing heavy housework until approved by the health care provider (HCP) because of pressure and trauma at the surgical site. The client should be instructed to avoid sexual activity for 4 to 6 weeks or as indicated by the HCP. The client should keep the perineal area as clean and dry as possible and should wash the perineum with solutions such as peroxide and water or as prescribed after each urination or defecation to prevent infection. The client should be instructed to report any redness, swelling, drainage, odor, or increased soreness along the suture line because these are signs of infection.

The nurse is reviewing the medication list for a client seen in the health care clinic. The nurse determines that which medications will increase the sodium level? Select all that apply. 1. Laxatives 2. Stool softeners 3. Anabolic steroids 4. Oral contraceptives 5. Nonsteroidal antiinflammatory drugs

3, 4, 5 The normal sodium level for an adult client is 135 to 145 mEq/L. Some medications are known to increase sodium levels, and these medications include anabolic steroids, oral contraceptives, and nonsteroidal antiinflammatory drugs.

The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. How should the nurse respond? Select all that apply. 1. "It causes the cessation of menstruation." 2. "It is pain that occurs during ovulation." 3. "It is the presence of tissue outside the uterus that resembles the endometrium." 4. "It is also known as primary dysmenorrhea and causes lower abdominal discomfort." 5. "Major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia."

3, 5

The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses should the nurse give the client about the role of estrogen? Select all that apply. 1. It maintains and relaxes the uterine lining for implantation. 2. It stimulates metabolism of glucose and converts the glucose to fat. 3. It increases the blood flow to mucous membranes and causes them to swell and soften. 4. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. 5. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

3, 5 Estrogen is a very important hormone of pregnancy. It is responsible for vasocongestion of the mucous membranes. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat; it is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? 1. "What makes you think that I am a vampire?" 2. "I'll leave and come back later for the specimen." 3. "Do you remember discussing the lab work earlier?" 4. "It must be frightening to think that others want to hurt you."

4

The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? 1. Increased systolic blood pressure 2. Abnormal posturing of extremities 3. Significant widening pulse pressure 4. Changes in level of consciousness

4

The nurse has a prescription to infuse 1000 mL of 5% dextrose in lactated Ringer's solution at 80 mL per hour. The nurse time-tapes the intravenous (IV) bag with a start time of 0900. After making hourly marks on the time-tape, the nurse should note which completion time for the bag? 1. 1530 2. 1730 3. 1930 4. 2130

4

The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which action to maintain the infant's safety? 1. Covering the back dressing with a binder 2. Placing the infant in a head-down position 3. Strapping the infant in a baby seat sitting up 4. Elevating the head with the infant in the prone position

4

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? 1. Total loss of vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4 A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Options 1 and 3 are not characteristics of this disorder. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count

4 A client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication.

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the mother's reflexes 2. Taking the mother's temperature 3. Taking the mother's apical pulse 4. Monitoring the mother's blood pressure

4 A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

The nurse is monitoring a client who is receiving intravenous (IV) acyclovir. The nurse would monitor the client closely for which primary toxic effect of the medication? 1. Ototoxicity 2. Neurotoxicity 3. Cardiotoxicity 4. Nephrotoxicity

4 Acyclovir is an antiviral medication. Although the most common side and adverse reactions with this medication are phlebitis and inflammation at the IV site, reversible nephrotoxicity, evidenced by elevated serum creatinine and BUN levels, can occur in some clients. The cause of nephrotoxicity is deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and the use of other nephrotoxic medications. Ototoxicity, neurotoxicity, and cardiotoxicity are not specific to this medication.

Laptop computers have been purchased by a community hospital to be used in the nursing units for documentation. The nurse educator at the hospital plans in-service educational sessions regarding the use of the computers and the new documentation system. The nurse educator anticipates some resistance to the use of the computers and should plan to best deal with this difficulty by doing what? 1. Ignoring the resistance 2. Discarding all paper-type documentation forms 3. Demanding that the nurses use the new computer system 4. Allowing the nurses extra time to work with the new computer system

4 Allowing the nurses extra time to work with the new computer system will alleviate anxiety. Ignoring the issue will not address the problem. Discarding all paper-type documentation forms may cause anxiety in the nurses, particularly if the nurses are uncomfortable with the computer system. Demanding that the nurses use the new computer system may cause resentment and resistance.

A client diagnosed with peptic ulcer disease is prescribed an over-the counter antacid suspension containing aluminum hydroxide, magnesium hydroxide, and simethicone. What should the nurse include in the client instructions for time of administration of this medication? 1. Just before each meal 2. An hour before breakfast 3. Immediately after each meal 4. 1 and 3 hours after meals

4 Antacids are alkaline compounds that neutralize stomach acid. The objective of peptic ulcer therapy is to promote healing in addition to relieving pain. Consequently, antacids should be taken on a regular schedule, not just in response to discomfort. In the usual dosing schedule, antacids are administered 7 times a day: 1 and 3 hours after each meal and at bedtime. Thus, option 4 is the correct option. Options 1, 2, and 3 are incorrect because they are either not the correct timing or not often enough as recommended.

The nurse is caring for an Appalachian client. The nurse makes sure to have frequent contact with the client and to initiate many different conversations. What is the best reason why the nurse uses this approach? 1. The Appalachian client expects an impersonal relationship with the nurse. 2. The Appalachian client will not want to make any decisions regarding health care. 3. The Appalachian client is most comfortable with impersonal relationships with health care providers. 4. The Appalachian client may prefer personal relationships with health care providers and a desire for frequent communication.

4 Appalachian clients traditionally have close family interaction patterns that often lead them to desire close personal relationships with health care providers, frequent communication, and participation in health care decisions. Appalachian clients are likely to be uncomfortable with any impersonal, bureaucratic orientation of health care institutions.

The client has an impairment of cranial nerve II. Specific to this impairment, what should the nurse plan to do to ensure client safety? 1. Speak loudly to the client. 2. Test the temperature of the shower water. 3. Check the temperature of the food on the dietary tray. 4. Provide a clear path for ambulation without obstacles.

4 Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Testing the shower water temperature would be useful if there was an impairment of peripheral nerves. Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively.

A hospitalized client has a prescription for dextroamphetamine daily. The unit nurse collaborates with the dietitian to limit the amount of which item on the client's dietary trays? 1. Fat 2. Starch 3. Protein 4. Caffeine

4 Dextroamphetamine is a central nervous system (CNS) stimulant. Caffeine is a stimulant also, so caffeine intake should be limited in the client taking this medication. The client should be taught to limit his or her own caffeine intake as well. It is not necessary to limit fat, starch, or protein while taking this medication.

A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information? 1. The woman has the herpes simplex virus (HSV). 2. The woman has contracted an airborne viral disease. 3. The neonate will definitely develop this disease after birth. 4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test.

4 Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA. HIV and herpes simplex virus are different types of infections. HIV infection occurs primarily through the exchange of body fluids, not via airborne disease. A neonate born to an HIV-positive mother is at risk for developing the virus, but it is not an absolute

Daily administration of dipyridamole has been prescribed for the client, and the nurse teaches the client about the medication. Which client statement indicates an understanding of the instructions? 1. "This medication will prevent a stroke." 2. "This medication will prevent a heart attack." 3. "This medication will help keep my blood pressure down." 4. "If I take this medicine with my warfarin, it will protect my artificial heart valve."

4 Dipyridamole combined with warfarin sodium is prescribed to protect the client's artificial heart valves. Dipyridamole does not prevent strokes, heart attacks, or hypertension.

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother on measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instruction? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4 Foods and fluids that acidify, not alkalinize, the urine should be encouraged. The woman should be encouraged to urinate frequently throughout the day, instructed to take the medication for the entire time it is prescribed, and encouraged to drink at least 3000 mL of fluid each day to flush the infection from the bladder.

A client who is taking phenytoin for a seizure disorder is being admitted to the hospital because of an increase in seizure activity. The client reports severe vomiting for the last 24 hours and an inability to take phenytoin during that time. The nurse anticipates that the health care provider will most likely prescribe which medication? 1. Clonazepam 2. Phenobarbital 3. Carbamazepine 4. Fosphenytoin sodium

4 Fosphenytoin sodium is used for short-term parenteral (intravenous) infusion. A client who is not tolerating medications orally and has a seizure disorder would need an anticonvulsant administered by the parenteral route. Phenobarbital is an antiseizure medication that is given orally or parenterally. However, the medication of choice in this case would be fosphenytoin since its use is short term. Carbamazepine and clonazepam usually are administered orally.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1. Incessant talking and sexual innuendoes 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake

4 Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

The nurse provides home care instructions to the parents of a child hospitalized with pertussis who is in the convalescent stage and is being prepared for discharge. Which statement by a parent indicates a need for further instruction? 1. "We need to encourage our child to drink fluids." 2. "Coughing spells may be triggered by dust or smoke." 3. "Vomiting may occur when our child has coughing episodes." 4. "We need to maintain droplet precautions and a quiet environment for at least 2 weeks."

4 Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 3 are accurate components of home care instructions.

The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? 1 "I need to eat foods high in potassium." 2. "I need to drink at least 2 to 3 L of fluid daily." 3. "I need to eat small, frequent meals and snacks if nauseated." 4. "I need to increase my intake of dietary items that are high in calcium."

4 The aim of treatment in the client with hyperparathyroidism is to increase the renal excretion of calcium and decrease gastrointestinal absorption and bone resorption of calcium. Dietary restriction of calcium may be used as a component of therapy. The client should eat foods high in potassium, especially if the client is taking furosemide. Drinking 2 to 3 L of fluid daily and eating small, frequent meals and snacks if nauseated are appropriate instructions for the client.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction? 1. "I need to take the antibiotics as prescribed." 2. "I need to take warm sitz baths to promote healing." 3. "I need to apply warm compresses to provide comfort." 4. "I need to isolate the infant for 48 hours after beginning the antibiotics."

4 The infant is not isolated routinely from the mother with a wound infection, but the mother must be taught good hand-washing techniques and how to protect the infant from contact with contaminated articles. If the mother has a wound infection, broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and sitz baths or warm compresses may be used to provide comfort in the area. There is no need to isolate the infant.

The nurse is assessing a child with increased intracranial pressure. On assessment, the nurse notes that the child is now exhibiting decerebrate posturing. The nurse should modify the client's plan of care based on which interpretation of the client's change? 1. An insignificant finding 2. An improvement in condition 3. Decreasing intracranial pressure 4. Deteriorating neurological function

4 The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants health care provider notification. The remaining options are inaccurate interpretations.

The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? 1. Victim with an open fracture of the left lower extremity 2. Victim who is crying hysterically and complaining of pain in the right ankle 3. Victim who is unresponsive and not breathing and whose left pupil is fixed and dilated 4. Victim with an apparent chest wall defect and asymmetrical chest wall movement

4 The victim in option 4 will continue to have a decline in respiratory status and imminent threat to life unless immediate intervention is instituted. The victims in options 1 and 2 have conditions that can wait to be treated. The victim in option 3 is dead.

A client is scheduled to take ticlopidine. The nurse plans to take which action before implementing this medication therapy? 1. Take the client's blood pressure. 2. Obtain a prothrombin time (PT). 3. Take the client's apical heart rate. 4. Review the results of the complete blood cell (CBC) count.

4 Ticlopidine is an antiplatelet agent that is used for the prevention of thrombotic stroke. Ticlopidine's effects last for the life of the platelet, 7 to 10 days. Ticlopidine also can cause neutropenia, which is an abnormally small number of mature white blood cells (WBCs). Baseline data from a CBC count are necessary before implementation of therapy, and the nurse should monitor for neutropenia during this medication therapy. If this adverse effect does occur, the health care provider is notified and therapy should be stopped. The effects of neutropenia are reversible within 1 to 3 weeks. Options 1, 2, and 3 are actions that are not specific to this medication therapy.

A client is prescribed trimethoprim-sulfamethoxazole for a recurrent urinary tract infection (UTI). The nurse should give the client which instruction regarding this medication? 1. Expect rashes or skin changes as a result of therapy. 2. Discontinue the medication when symptoms subside. 3. Take most doses early in the day when fluid intake is greatest. 4. Take each dose with 8 oz (235 mL) of water, and drink extra water each day.

4 Trimethoprim-sulfamethoxazole is a combination medication. The client takes each dose with 8 oz (235 mL) of water and drinks several extra glasses of water each day. The client should space doses evenly around the clock for stable blood levels and should take the medication for the full course of therapy. The client should report rashes or other skin changes, which could indicate an allergy to sulfa.

A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 1. Pain medication 2. Endotracheal intubation 3. Oxygen via nasal cannula 4. 100% humidified oxygen by face mask

4 With a smoke inhalation injury, the client is immediately treated with 100% humidified oxygen delivered by face mask. This method provides a greater concentration of oxygen than oxygen delivered via nasal cannula. Endotracheal intubation is needed if the client exhibits respiratory stridor, which indicates airway obstruction. Pain medication may be needed but would not be the initial intervention.

The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply. 1. Keep leads on the child at all times. 2. Place the monitor inside the child's crib. 3. Adjust the monitor to eliminate false alarms. 4. Sleep in the same bed as the monitored infant. 5. Keep pets and children away from the monitor. 6. Keep emergency rescue numbers near the telephone.

5, 6 An apnea monitor should not be adjusted to eliminate false alarms; adjustments could compromise the monitor's effectiveness. The monitor should be placed on a firm surface away from the crib and drapes. The caregiver should not sleep in the same bed as a monitored infant. Pets and children should be kept away from the monitor and infant. Emergency rescue numbers should be kept near phones in the home. Leads should be removed when the infant is not attached to the monitor.