NCLEX study

A client has been taking prescribed dose of propranolol hydrochloride daily. The nurse enters the room to administer todays 0900 dose and finds the client wheezing with a nonproductive cough and SOB. Initially what does the nurse do? 1. hold med and count RR 2. hold med and call HCP 3. takes apical pulse and gives med 4. gives med as prescribed

1 - Correct Adverse effects of medication include increased airway resistance. The client is experiencing bronchospasm. The nurse will count RR and notify HCP with assessment data

The nurse provides cares for a client with a sodium level of 156 mEq/L (156 mmol/L). Which health care provider prescription does the nurse anticipate? 1.A 3% saline solution. 2.A 5% dextrose solution. 3.A 0.9% saline solution 4.A lactated ringer solution.

1) A 3% saline solution contains sodium; therefore, not indicated for a client experiencing hypernatremia. 2) CORRECT — This client is experiencing hypernatremia. The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The nurse anticipates a prescription for a sodium-free intravenous fluid such as D5W, which dilutes excess serum sodium. 3) A 0.9% saline solution contains sodium; therefore, not indicated for a client experiencing hypernatremia. 4) A lactated ringer solution contains sodium; therefore, not indicated for a client experiencing hypernatremia.

The nurse provides care for a client experiencing a sickle cell crisis. Which nursing diagnosis is the priority for the nurse to include in the plan of care? 1.Risk for infection. 2.Risk for ineffective cerebral tissue perfusion. 3.Activity intolerance. 4.Ineffective peripheral tissue perfusion.

1) A client is at risk for infection but it is not highest priority. 2) Risk for ineffective cerebral tissue perfusion is a concern but not the highest priority. 3) Activity intolerance related to fatigue is a problem but not as high of a priority as ineffective peripheral tissue perfusion. 4) CORRECT - Due to infarction, ineffective peripheral tissue perfusion is the highest priority for a client with a sickle cell crisis.

The visiting nurse notes that a client diagnosed with asthma is in the "red zone" of the peak flow meter system. Which action does the nurse take first? 1.Take a detailed medical history. 2.Call the health care provider. 3.Do a medication reconciliation. 4.Repeat the peak flow meter test.

1) A detailed history is not the priority. 2) CORRECT— The red zone (50% or below peak flow) of the peak flow meter system signals an emergent situation. 3) Medication reconciliation is not the priority. 4) If done correctly, the peak flow meter reading is accurate. Repeating it will waste time in an emergent situation.

The nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care? 1.Risk for impaired cognition. 2.Risk for cardiac dysrhythmia. 3.Risk for acid-base imbalance. 4.Risk for shivering and spasm.

1) A low body temperature will probably impair cognition; however, this is not a priority. 2) CORRECT - Severe hypothermia can lead to cardiac arrest. 3) Acid-base imbalance will most likely occur; however, this is not a priority. 4) The client will most likely shiver and experience spasms; however, this is not a priority.

The nurse evaluates care provided to a client diagnosed with anorexia nervosa. Which laboratory result indicates to the nurse that further treatment is needed? 1.Arterial pH 7.37. 2.Arterial pH 7.48. 3.Arterial bicarbonate 24 mEq/L. 4.Arterial bicarbonate 19 mEq/L.

1) A pH of 7.37 is within normal limits. 2) A pH of 7.48 is elevated and indicates alkalosis. 3) A bicarbonate of 24 mEq/L is within normal limits. 4) CORRECT — A bicarbonate level of 19 mEq/L is low and indicates metabolic acidosis that, in this client's case, is caused by starvation.

The nurse provides care to a client with severe anemia related to peptic ulcer disease. Which intervention is most appropriate for the nurse to include in the client's plan of care? (Select all that apply.) 1.Administering vitamin B12 injections. 2.Monitoring stools for guaiac. 3.Measuring vital signs every 4 hours. 4.Instructing about a high-iron diet. 5.Teaching self-injection of erythropoietin.

1) A vitamin B12 (cobalamin) deficiency is a common cause of macrocytic or pernicious anemia. It is much less common in anemia related to recurrent peptic ulcer disease. 2) CORRECT - This test measures loss of blood in stools, which occurs in peptic ulcer disease. 3) CORRECT - Assessing vital signs every 4 hours provides indicators of the severity of anemia, such as tachycardia and hypotension. 4) CORRECT - The client with severe anemia related to peptic ulcer disease requires increased dietary iron to replace red blood cells, which carry oxygen to all parts of the body. 5) Erythropoietin is used for the maintenance of hemoglobin levels in anemia of chronic renal failure.

The nurse develops a teaching plan for a client diagnosed with heart failure. Which information does the nurse include? 1.Tell the client to notify the health care provider of a weight gain of 1 pound a week. 2.Teach the client to monitor urine output for changes in color. 3.Encourage the client to check blood pressure every 4 hours. 4.Advise the client to have flu and pneumococcal immunizations.

1) A weight gain of a pound a week is not clinically significant. A weight gain of 2 or more pounds per day is reportable. 2) Changes in urine color are not a reliable indicator of relevant clinical changes. 3) Self-monitoring of blood pressure every 4 hours is not evidence-based practice. 4) CORRECT — Flu and pneumonia create a greater hemodynamic burden and lead to higher mortality. The Centers for Disease Control and Prevention (CDC) recommends flu and pneumonia immunizations for clients with heart failure and all chronic diseases.

The nurse cares for a group of assigned clients. Which action constitutes negligence? (Select all that apply.) 1.Administering furosemide 40 mg orally followed by potassium chloride 20 mEq orally. 2.Transcribing a health care provider's telephone prescription for digoxin 0.5 mg to be given twice daily. 3.Using a nasogastric tube (NGT) to administer oral contrast dye prior to a computerized tomography scan. 4.Performing a baseline neurological assessment on a post-craniotomy client 4 hours after surgery. 5.Checking post-cardiac catheterization distal pulses on a client 2 hours after the procedure.

1) Administering a loop diuretic with potassium is an expected action. 2) CORRECT - Digoxin is normally prescribed only once a day. The normal dosage range is 0.125 mg to 0.5 mg daily. The nurse is expected to clarify the frequency of this maximum dose. The nurse also should not accept a telephone order except in the case of an emergency. And the nurse should ensure that a route of administration (e.g. orally) is specified for each medication order. 3) Using an NGT to administer a contrast dye for a client who cannot swallow or is nauseated is acceptable practice. 4) CORRECT - The nurse assesses the neurological status of a post-craniotomy client as soon as the client returns from surgery and at least every hour thereafter. 5) CORRECT - Pulses after a cardiac catheterization are checked every 15 minutes for the first hour, every 30 minutes for the second hour, and hourly for the next 4 hours.

The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication? 1."Take the medication at bedtime with a snack." 2."Take the medication in the morning after breakfast." 3."Lie down for 30 minutes after taking the medication." 4."Take the medication with a full glass of water."

1) Alendronate is to be taken on an empty stomach. 2) Alendronate can be taken anytime during the day with an empty stomach. 3) The client must remain upright 30 minutes after taking alendronate to prevent esophagitis. 4) CORRECT - Alendronate must be taken with a full glass of water to prevent acid reflux.

The nurse provides care for a client who reports fatigue, has dry skin, and a poorly healing wound. Which health problem will the nurse consider the client to be experiencing? 1.Anemia. 2.Malnutrition. 3.Activity intolerance. 4.Peripheral vascular disease.

1) Although fatigue is a manifestation of anemia, dry skin and poor wound healing are not. 2) CORRECT - Manifestations of malnutrition include fatigue from a lack of adequate caloric intake, dry skin from a deficiency in protein and vitamins, and poor wound healing from a lack of adequate protein and vitamins needed for skin repair. 3) Activity intolerance is an assessment finding that could indicate another health problem. 4) Poor wound healing can occur in peripheral vascular disease, but fatigue and dry skin are not necessarily associated with this disease process.

The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care? 1.Client with a brain natriuretic peptide (BNP) level of 300 pg/mL. 2.Client with an erythrocyte sedimentation rate of 10 mm/h. 3.Client with a C-reactive protein (CRP) level of 4 mg/L. 4.Client with an international normalized ratio (INR) level of 8.0.

1) An elevated BNP level indicates congestive heart failure and requires observation by the nurse. The normal value is less than 100 pg/mL. This client requires frequent assessment of breathing and circulation. 2) CORRECT - An elevated sedimentation rate indicates an inflammatory process. The normal value for males under 50 years is less than 15 mm/h. For males over 50 years, it is less than 20 mm/h. For females under 50 years, it is less than 25 mm/h. For females over 50 years, it is less than 30 mm/h. This client can be delegated to the LPN/LVN. 3) An elevated CRP indicates inflammation, tissue injury, infection, or atherosclerosis and follow up by the nurse. The normal CRP level is less than 1 mg/L. 4) The INR level monitors the effectiveness of warfarin. The therapeutic range is 2 to 3.5, based on the diagnosis and the reasons for taking warfarin. An elevated INR indicates that the warfarin dose is not therapeutic. The client is at high risk for bleeding and should be monitored by the nurse.

The nurse plans for the discharge of a client with Parkinson disease. Which outcome is appropriate for collaboration between the nurse and the physical therapist? (Select all that apply.) 1.Maintain physical strength and mobility. 2.Bladder training to increase bladder capacity. 3.Optimal use of extremities in performing activities. 4.Proper use of ambulatory assistive devices. 5.Monitor skin for alterations in integrity.

1) CORRECT - A physical therapist can design a personal exercise program to strengthen and stretch specific muscles. 2) Bladder training does not increase bladder capacity. 3) CORRECT - A physical therapist can help optimize independence with activities. 4) CORRECT - A physical therapist can provide expert advice on the proper use of ambulatory assistive devices. 5) Monitoring for skin breakdown is a nursing assessment.

The nurse is providing care to a client diagnosed with measles. Which transmission-based precaution does the nurse implement when caring for this client? 1.Airborne. 2.Droplet. 3.Contact. 4.Neutropenic.

1) CORRECT - Airborne precautions are implemented when providing care for clients with measles for up to 4 days after the onset of rash. 2) Droplet precautions are used for clients with diphtheria, rubella, streptococcal pharyngitis, pertussis, and mumps, among other conditions. 3) Contact precautions are used for clients diagnosed with multidrug resistant infections and Clostridium difficile. 4) Neutropenic precautions are used specifically for clients with very low white blood cell counts.

Prior to the beginning of a site survey, the charge nurse advises the nurse to deny any knowledge of a recent sentinel event if asked by the surveyor. Which action will the nurse take? 1.Notify the unit manager. 2.Notify the medical director. 3.Tell the charge nurse about being uncomfortable lying to the surveyor. 4.Tell the surveyor the nurse is not allowed to talk to them.

1) CORRECT - Always follow the direct chain of command. If asked about the event by the surveyor prior to speaking with the unit manager, do not lie. Nurses have a professional and ethical responsibility to tell the truth in all situations. 2) The medical director is not the nurse's direct supervisor. 3) Confronting the charge nurse will not resolve the issue and will likely increase the tension of an already stressful situation. 4) If asked about the event by the surveyor prior to speaking with the unit manager, do not lie. Nurses have a professional and ethical responsibility to tell the truth in all situations.

The health care provider prescribes a unit of packed red blood cells for a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.) 1.Ensure adequate infusion access is present before obtaining the blood from the blood bank. 2.Initiate the transfusion within 1 hour of removing the blood from the blood bank refrigerator. 3.Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4.Monitor the client closely during the first 15 to 30 minutes of administration. 5.Ensure the administration time does not exceed 6 hours.

1) CORRECT - An adequate intravenous catheter should be inserted prior to obtaining the blood from the blood bank. 2) The infusion should be started within 30 minutes of removing the blood from the blood bank refrigerator. 3) CORRECT - Two-person verification in the presence of the client is done to make sure that the blood product matches the health care provider's prescription and the blood product is properly identified to the client to prevent a blood incompatibility error. 4) CORRECT - The client should be closely monitored for the first 15 to 30 minutes of the transfusion. Most transfusion reactions occur within this time. 5) The blood administration time should not exceed 3 to 4 hours to reduce the risk for bacterial growth.

The nurse provides care to a client who experienced prolonged cold exposure. For which complication does the nurse closely monitor this client? 1.Ventricular fibrillation. 2.Hypertension. 3.Metabolic alkalosis. 4.Shivering.

1) CORRECT - Cold-induced myocardial irritability may cause cardiac arrhythmias, especially ventricular fibrillation. 2) Hypotension, and not hypertension, is an adverse effect of hypothermia. 3) Metabolic acidosis, and not metabolic alkalosis, occurs with hypothermia as blood flow to the extremities becomes compromised. 4) Shivering, the body's self-warming mechanism, may be suppressed with hypothermia.

The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication? 1.Twice a day within 1 hour before morning and evening meals. 2.Once a day before bedtime. 3.Twice a day within 2 hours before morning and evening meals. 4.Twice a day within 1 hour after morning and evening meals.

1) CORRECT - Exenatide stimulates the pancreas to secrete insulin when blood sugar levels are high. It should be administered twice a day within 1 hour before the morning and evening meals. 2) Exenatide should be administered twice a day within 1 hour before the morning and evening meals, not once a day before bedtime. 3) Exenatide should be administered twice a day within 1 hour before the morning and evening meals, not twice a day within 2 hours before morning and evening meals. 4) Exenatide should be administered twice a day within 1 hour before morning and evening meals, not after the morning and evening meals.

The nurse provides care to a client with an epidural catheter for pain control with fentanyl after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client? (Select all that apply.) 1.Perform peripheral neurovascular checks every 2 hours 2.Ambulate the client around the hallway. 3.Assess for bowel and bladder distention. 4.Keep the client at nothing by mouth status. 5.Monitor client for nausea and vomiting.

1) CORRECT - Frequent neurovascular assessment is essential for clients with an epidural catheter, as it allows for early detection of sensory-motor impairment. 2) Ambulation is inappropriate for a client with an epidural catheter because of a risk for catheter displacement. 3) CORRECT - Assessment of bowel and bladder function is part of best practice guidelines for clients with epidural catheters. 4) It is not necessary to keep the client at nothing by mouth status because of an epidural catheter. 5) CORRECT - Nausea and vomiting are common side effects of opioids such as fentanyl.

The nurse provides care to an older client whose spouse died 6 months ago. Which behavior indicates to the nurse that the client is coping effectively? (Select all that apply.) 1.Shows the nurse family photographs. 2.Keeps bi-weekly haircut appointments. 3.Visits the spouse's grave every 2 weeks. 4.Attends church every week. 5.Watches television constantly.

1) CORRECT - Sharing photographs indicates normal grieving behavior. 2) CORRECT - Keeping appointments indicates normal progression through the grieving process. 3) CORRECT - Visiting the grave of the deceased spouse is normal behavior after the death of a loved one. 4) CORRECT - Attending religious services indicates normal grieving behavior. 5) Watching television constantly indicates extreme behavior rather than normal grieving.

The nurse provides care to a client with pneumonia, anorexia, and chronic pain. Which laboratory result does the nurse report to the health care provider immediately? 1.PaCO2 of 50 mm Hg. 2.pH of 7.33. 3.PaO2 of 86 mm Hg. 4.HCO3 of 23 mEq/L.

1) CORRECT - The PaC02 is significantly higher than the normal range of 35 to 45 mm Hg. This finding suggests compromised alveolar exchange with a potential for respiratory acidosis. 2) This pH is slightly below the normal range of 7.35 to 7.45. 3) The PaO2 is within the normal range of 85 to 95 mm Hg. 4) The HCO3 is within the normal range of 22 to 26 mEq/L.

The nurse provides care for a client in bilateral limb restraints. Which action does the nurse take to ensure proper use? (Select all that apply.) 1.Provide education to the client before applying the restraints. 2.Obtain an as-needed prescription from the health care provider. 3.Assess for skin breakdown under the restraints every shift. 4.Tie a quick release knot to the fixed portion of the bed frame. 5.Remove restraints every 2 hours or as needed.

1) CORRECT - The nurse needs to provide education to both the client and client's family before applying restraints. They need to understand why restraints are being used and for how long they may be used for. 2) When writing an order for restraints, the health care provider must identify specifically why the restraint is being used, along with a specific time frame. Writing an as-needed order for restraints is prohibited. 3) The nurse needs to assess for skin breakdown under restraints at least every 2 hours. 4) Restraints should be tied using a quick-release knot. However, the knot should never be tied to a fixed portion of the bed frame. 5) CORRECT - Restraints should be removed every 2 hours to assess for skin breakdown and to allow the client to eat and/or drink.

The nurse teaches a class on suicide prevention to high school students. Which risk factor is accurate with regard to suicide in adolescent clients? (Select all that apply.) 1.Possessions that are given to friends. 2.A low grade point average. 3.Statements like, "I may not be around anymore." 4.Access to a gun at home. 5.Frequent thoughts of suicide.

1) CORRECT - There is a correlation between this action and a high risk of suicidal tendencies or thoughts. 2) There is no specific correlation between a low grade point average and an increased risk for suicide. 3) CORRECT - There is a correlation between these types of statements and a high risk of suicidal tendencies or thoughts. 4) CORRECT - There is a correlation between easy access to a gun and an increased risk for suicide. 5) CORRECT - There is a correlation between frequent thoughts of suicide and an increased risk for suicide.

The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client's plan of care? 1.Client will verbalize a plan to implement a sleep promoting program within the next week. 2.Client will fall asleep with less difficulty over the next 2 weeks. 3.Client will achieve a more normal sleep pattern within 2 to 4 weeks. 4.Client will achieve an improved sense of adequate sleep over the next 4 weeks.

1) CORRECT - This measurable outcome requires the client to make specific adjustments more quickly to deal with the stress that is causing the disturbed sleep patterns. The client needs a shorter deadline to make the changes. 2) This outcome is not measurable because it does not provide a specific plan for the client to follow over the 2 weeks. Because the insomnia resulted in a car accident, a more aggressive approach is needed. 3) This outcome is not measurable because it does not provide a specific plan for the client to follow over the 2 to 4 weeks. Because the insomnia resulted in a car accident, a more aggressive approach is needed. 4) This outcome is not measurable because it does not provide a specific plan for the client to follow over the 4 weeks. Because the insomnia resulted in a car accident, a more aggressive approach is needed.

The nurse provides care to a client receiving lactulose as treatment for hepatic encephalopathy. For which reason will the nurse withhold the next scheduled dose of the medication? 1.Experienced five watery stools today. 2.Increased confusion. 3.Serum potassium level 4.0 mEq/L (4.0 mmol/L). 4.Reported intestinal cramping.

1) CORRECT - Two to three soft bowel movements is desirable when taking lactulose. Watery stools indicate lactulose overdose. 2) Lactulose is used to improve mental status. 3) The serum potassium level is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). 4) Intestinal cramping is a side effect, but not an adverse effect.

home health nurse documents that the client with osteoarthritis understands proper inclusion of assistive devices when the client makes which statement? (Select all that apply.) 1."I started using an electric can and jar opener." 2."There is a counter near the tub that I grab for balance." 3."I just bought the television remote with large keys." 4."I purchased a pair of shoes with larger laces." 5."We converted the doorknobs in the house to levers."

1) CORRECT - Use of an electric can and jar opener saves the joints from excessive force caused by a regular can opener or opening a jar by hand. 2) The client needs to install a bathtub grab bar for stability. A counter top cannot be fully grasped and may be a slick surface. 3) CORRECT - A remote with larger keys is good for those with diminished eyesight, but is also great for people with difficulty with fine motor movements of the hands and fingers. 4) Shoes with larger laces still require the fine motor movements of tying, which can be difficult with osteoarthritis. A better choice would be shoes with velcro or shoes that slip on. 5) CORRECT - Changing the door knobs to levers allows the client to push the handle up or down without having to grab and twist a knob.

The nurse works with an LPN/LVN on a team nursing unit. Which task is most appropriate for the nurse to delegate to the LPN/LVN? (Select all that apply.) 1.Administering an intramuscular injection. 2.Administering a blood pressure medication intravenously. 3.Administering oral medications. .Referring a client to a long-term care facility. 5.Obtaining a capillary blood glucose.

1) CORRECT — An LPN/LVN can administer an intramuscular injection. 2) The nurse will need to administer an intravenous blood pressure medication because these drugs require close monitoring after administration. 3) CORRECT — An LPN/LVN can administer oral medications. This is an appropriate task for the LPN/LVN. 4) The nurse oversees the client's care and should be making the referral to the long-term care facility. 5) CORRECT— An LPN/LVN can obtain a capillary blood glucose.

The nurse provides care for a client receiving chemotherapy and radiation who has several bruises. Which nursing intervention will be part of the care plan to prevent further injury? (Select all that apply.) 1.Shave with an electric razor. 2.Allow the client to be up without supervision as tolerated. 3.Avoid enemas and suppositories. 4.Administer stool softeners. 5.Place an indwelling catheter.

1) CORRECT — An electric razor reduces the risk of being cut. 2) Supervise out of bed activity to prevent injury. 3) CORRECT — Avoid inserting objects into body to reduce the risk of trauma to rectal mucosa. 4) CORRECT — Stool softeners reduce the risk of trauma to rectal mucosa and anal tears from hard stool. 5) Avoid inserting objects into the body. If catheterization is essential, use the smallest catheter possible.

The nurse notes that a client diagnosed with Parkinson disease moves slowly, has difficulty dressing, and experiences bowel and urinary incontinence. Which intervention is appropriate for this client? (Select all that apply.) 1.Provide an elevated toilet seat. 2.Make modified clothing without buttons available. 3.Transfer to a skilled nursing facility. 4.Arrange for gait training. 5.Lower the dose of Parkinson medications.

1) CORRECT — An elevated toilet seat makes it easier to get on and off the toilet. 2) CORRECT — Modified clothing that does not use buttons helps facilitate timely toileting. 3) There is no indication that a transfer to a skilled nursing facility is needed at this time. 4) CORRECT — Gait training assists with mobility and may help the client reach the bathroom on time. 5) It is not within the scope of practice for a nurse to change the dose of a client's medication.

The nurse receives a report of an elevated vancomycin trough level. The client has a glomerular filtration rate (GFR) of 58 mL per minute. Which action does the nurse take? 1.Inform the health care provider (HCP). 2.Check the client's urine output. 3.Request a renal consultation. 4.Assess for red man syndrome.

1) CORRECT — An elevated vancomycin trough level with an inadequate GFR requires immediate attention by HCP. The client's antibiotic level is toxic and the kidneys are not filtering correctly. 2) It is irrelevant whether the client is currently making urine because the drug's nephrotoxic effects are evident and must be reversed. Oliguria would be a late sign and result in a negative outcome. 3) The HCP requests a renal consult. 4) Red man syndrome is due to rapid infusion of vancomycin.

The nurse provides care for a postoperative client. The nurse notes that the client's wound is red around the margins. Which additional assessment data indicates the need to update the nursing plan of care to address a client infection? (Select all that apply.) 1.Pain. 2.Bruising. 3.Swelling. 4.Foul odor. 5.Drainage.

1) CORRECT — An infected wound is painful. The tissues are engorged with blood, white blood cells, and body fluids in an attempt to fight the infection. 2) Bruising is not an indication of an infected wound. 3) CORRECT — Swelling of the wound area is associated with a wound infection. Blood, white blood cells, and body fluids accumulate in the wound to help fight the infection. 4) CORRECT — An infected wound can produce a foul odor caused by the offending microorganism. 5) CORRECT — Drainage, particularly if purulent, occurs from the influx of white blood cells to the area to help fight the infection.

The nurse provides care to a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation will the nurse implement for this client? 1.Contact. 2.Droplet. 3.Airborne 4.Reverse.

1) CORRECT — Contact isolation involves the use of barrier protection (such as gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. 2) Hands of personnel continue to be the principal mode of transmission for MRSA. The organism is limited to the sputum in this example. Precautions are taken if contact with the patient's sputum is expected. 3) Hands of personnel continue to be the principal mode of transmission for MRSA. If the organism is limited to the sputum, precautions are taken if contact with the client's sputum is expected. 4) Reverse isolation is used to protect an immune-compromised client. The client in this example requires isolation to protect others.

The nurse uses a paper-based documentation system to write a client care note. The previous nurse's documentation appears incomplete. Which action should the nurse take next? 1.Draw a line through any empty space and continue documenting. 2.Mark out the previous nurse's entry, initial, and continue documenting. 3.Complete an incident report for the nurse manager to review. 4.Call the previous nurse at home and ask if the documented entry is complete.

1) CORRECT — Empty spaces should not be left because it allows others to document in that space in an incorrect manner. 2) The nurse has no reason to delete the other nurse's documentation. 3) Incomplete documentation does not require an incident report. 4) The nurse who did the documenting should come in to complete it as soon as possible, but calling the nurse to ask if the documentation is complete does not solve the issue.

After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and toes. Which electrolyte imbalance does the nurse suspect the client is experiencing? 1.Hypocalcemia. 2.Hypercalcemia. 3.Hyponatremia. 4.Hypernatremia.

1) CORRECT — Hypocalcemia results from blood transfusions containing citrate. Citrate causes increased cell membrane permeability, leading to increased neuromuscular excitability, which may result in numbness or tingling of the ears, nose, fingers, and toes. If severe, laryngospasm, seizures, and cardiac arrest may occur. 2) Hypercalcemia causes decreased neuromuscular excitability. Signs of this imbalance include fatigue, hypoactive deep tendon reflexes, decreased muscle tone and strength, bone pain, and decreased gastrointestinal motility. 3) Hyponatremia results in fluid shifts into the cerebral space causing cerebral edema. Seizures, coma, and respiratory arrest may occur. 4) With hypernatremia, water shifts out of the intracellular fluid resulting in cellular dehydration. Cerebral vessels shrink and tear, resulting in cerebral hemorrhage. Manifestations of this imbalance include lethargy, irritability on stimulation, and a high-pitched cry.

The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.) 1.Place respiratory equipment at the bedside. 2.Remove harmful objects from the client's reach. 3.Apply foam padding around the bed rails. 4.Time the duration of seizure activity. 5.Teach the client about antiseizure medications.

1) CORRECT — Settting up essential supplies and equipment at the bedside is within the scope of practice for NAPs. 2) CORRECT — Assisting the nurse in maintaining a safe care environment is within the scope of practice for NAPs. 3) CORRECT — Applying padding around the bedside is within the scope of practice for NAPs. 4) Only the nurse can do assessments such as timing the duration of a seizure activity. 5) Teaching about medication is the nurse's responsibility.

The nurse provides care to a client of Asian descent having surgery later in the day. Which action will be most appropriate for the nurse to take when assessing this client? 1.Observe the client's use of eye contact. 2.Look directly at the client when interacting. 3.Avoid eye contact with the client. 4.Ask a family member about the client's cultural beliefs.

1) CORRECT— Observation of the client's use of eye contact will be most useful in determining the best way to communicate effectively with the client. 2) Looking directly at the client may be appropriate, depending on the client's individual cultural beliefs. 3) Avoiding eye contact may be appropriate, depending on the client's individual cultural beliefs. 4) The nurse should assess the client, rather than asking family members about the client's beliefs.

The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1.Asking if the client understands the instruction. 2.Demonstrating the procedure and having the client return the demonstration. 3.Asking an interpreter to replay the instructions to the client. 4.Writing out the instructions and having a family member read them to the client.

1) Clients may claim to understand discharge instructions when they do not actually understand. 2) CORRECT — When the client can repeat the action that was taught by the nurse, that best ensures that the client can perform wound care correctly at home. 3) An interpreter or family member may communicate verbal or written instructions inaccurately. 4) Family members are not considered appropriate and objective interpreters for clients.

The nurse provides care for a hospitalized client. The client's room is located close to the nurses station. The client tells the nurse, "I don't know how anyone can get any rest around here, it is so noisy." The nurse reports these concerns to the nursing supervisor. Which change to the nursing unit should the nursing supervisor implement? (Select all that apply.) 1. Encourage staff to change shoes to clogs to reduce noise. 2. Reduce the volume of phones and pagers. 3. Turn off all lights in the hallways. 4. Keep conversations quiet. 5. Close the client's room door if possible.

1) Clogs are noisier. Staff should wear rubber soled shoes. 2) CORRECT - Reducing the volume of phones and pagers to a level audible but not as disruptive can make the environment more conducive to sleep. 3) It is unsafe to turn off the lights in the hallway in case clients need to leave their rooms. It is appropriate to dim them. 4) CORRECT - Voices carry; reduce the volume of voices at night. 5) CORRECT - Closing the door will reduce disruptive noise if the client allows and can have the door closed.

The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child? 1.Contact precautions. 2.Airborne and contact precautions. 3.Airborne and droplet precautions. 4.Droplet precautions.

1) Contact precautions are not sufficient. 2) CORRECT — The client demonstrates signs of a varicella infection. Airborne and contact precautions are needed and should be maintained for at least 5 days after the onset of the rash and until the vesicular lesions are gone. 3) Airborne precautions are not sufficient and droplet precautions are not indicated. 4) Droplet precautions not are indicated.

The nurse auscultates a client's lungs during a comprehensive assessment. Which finding will the nurse consider to be normal? 1.Dullness above the 10th left intercostal space. 2.Tympany over the right upper lobe. 3.Resonance over the left upper lobe. 4.Hyperresonance over the left lower lobe.

1) Dullness would normally be heard below, rather than above, the 10th intercostal space. Dullness cannot be auscultated. 2) Tympany is normally heard over the stomach. Tympany cannot be auscultated. 3) CORRECT - Resonance is a normal sound over lung tissue. 4) Hyperresonance is never a normal finding.

A client receives treatment with internal radiation for cervical cancer. Which observation by the charge nurse poses the greatest risk to the person involved? 1.Housekeeper leaves the client's room with full trash bags for disposal. 2.Food service worker who is pregnant delivers a breakfast tray into the room. 3.Client's spouse visits for 1 hour and brings flowers into the room. 4.Client's nurse enters the room without the dosimeter badge during shift report.

1) Environmental service staff should not enter the room nor bring trash out of the room. The trash may be too radioactive to be serviced like other trash. Education and follow up are needed to reinforce proper waste disposal and exposure concerns. However, this situation does not pose the greatest risk to the staff involved. 2) CORRECT — All the listed scenarios are concerning, but the pregnant worker needs follow-up to monitor the unborn child for teratogenic-related abnormalities. Education is needed to prevent the dietary staff from entering the room. Reentry into the room may occur if the worker is not educated immediately. 3) The client's spouse should stay in the room for only 30 minutes, but the risk is fairly low. 4) The nurse should not enter the room without the dosimeter badge to monitor radiation exposure, but the time it took to receive the report represents a small risk.

The nurse prepares to administer fondaparinux to a client. Which laboratory test result will the nurse monitor in the client receiving this medication? 1.International normalized ratio. 2.Prothrombin time. 3.Creatinine level. 4.Partial thromboplastin time.

1) Fondaparinux, an anticoagulant that inhibits factor Xa, has no effect on routine coagulation tests, such as international normalized ratio. 2) Fondaparinux, an anticoagulant that inhibits factor Xa, has no effect on routine coagulation tests, such as prothrombin time. 3) CORRECT - Fondaparinux is excreted by the kidneys; creatinine level should be monitored periodically, and the drug stopped in clients who develop unstable kidney function or severe renal impairment. 4) Fondaparinux, an anticoagulant that inhibits factor Xa, has no effect on routine coagulation tests, such as partial thromboplastin time.

The nurse is assisting in the care of a client with ventricular fibrillation. The "code" leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level? 1.80 to 100 Joules. 2.100 to 110 Joules. 3.120 to 200 Joules. 4.300 to 360 Joules.

1) For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200, not 80 to 100, Joules for biphasic machines. 2) For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200, not 100 to 110, Joules for biphasic machines. 3) CORRECT - For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200 Joules for biphasic machines. 4) For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200, not 300 to 360, Joules for biphasic machines.

The nurse provides care for a client with the following arterial blood gas (ABG) results: pH 7.29, pCO231 mmHg, and HCO3 19 mEq/L. Which electrolyte alteration does the nurse monitor for based on this client data? 1.Hypocalcemia. 2.Hypernatremia. 3.Hypomagnesemia. 4.Hyperkalemia.

1) Hypocalcemia is anticipated with alkalotic, not acidotic, processes. 2) Hypernatremia is not typically associated with metabolic acidosis. 3) Hypomagnesemia is not typically associated with metabolic acidosis. 4) CORRECT — Serum potassium levels are often high in metabolic acidosis. As the pH drops, excess hydrogen ions enter the red blood cells, causing potassium to leave the cells, resulting in hyperkalemia.

The nurse is assessing a neonate born at 44 weeks' gestation. Which finding does the nurse document as consistent with the newborn's gestational age? 1.Slow recoil of the pinna. 2.Absence of plantar creases. 3.Cracked, peeling skin. 4.Abundant vernix.

1) In preterm neonates of less than 34 weeks gestation, the ear has little cartilage to keep it stiff. It will remain folded over or return slowly when folded longitudinally and horizontally. In a full- or post-term neonate, the ear springs back to the original position immediately. 2) Full- and post-term neonates have deep plantar creases. A preterm newborn has few creases on the foot. 3) CORRECT — A post-term neonate has dry, cracked (desquamating) skin at birth. 4) There is little vernix on the body of a full-term neonate except small amounts in the skin creases. No vernix is on the body of a post-term newborn. A preterm neonate has a thick covering of vernix.

The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first? 1.Place the client on continuous pulse oximetry. 2.Monitor the client for changes in blood pressure. 3.Notify the health care provider. 4.Assist the client to use the incentive spirometer.

1) It is important to monitor pulse oximetry before hypoxia occurs; however, the client has urgent signs that warrant priority action. 2) It is important to monitor blood pressure changes before hypotension occurs; however, the client has urgent signs that warrant priority action. 3) CORRECT — The client is demonstrating signs of early shock and the health care provider should be notified. 4) Using an incentive spirometer may be helpful later; however, the client has urgent signs that warrant priority action.

The nurse reviews prescriptions from a health care provider for a client's care. Which prescription will the nurse question before implementing? 1.Monitor intake and output. 2.Begin a 2 L/day fluid restriction. 3.Start heparin infusion by 0800 hours. 4.Continue intravenous fluids D5W at 150 mL/hour.

1) Monitoring intake and output does not require clarification before implementing. 2) Beginning a fluid restriction does not require clarification before implementing. 3) CORRECT - The heparin infusion is missing a dose or amount of heparin to be infused. This prescription should be questioned before implementing. 4) Since the prescription begins with the word "continue," and provides the type of fluid and amount, this prescription does not need to be questioned before implementing.

The nurse provides cares for a client with a wound. The client's wound culture is positive for vancomycin-resistant Staphylococcus aureus (VRSA). Which personal protective equipment (PPE) does the nurse don before entering the client's room? (Select all that apply.) 1.Mask. 2.Gown. 3.Gloves. 4.Face shield. 5.N-95 respirator mask.

1) Organisms spread by respiratory droplets, such as influenza, require a mask. A client diagnosed with VRSA requires contact precautions. 2) CORRECT - A client diagnosed with VRSA, a resistant organism, requires contact precautions (in addition to standard precautions) to prevent the spread of infection. Contact precautions require the use of gloves and a gown when entering the client's room to protect against contamination with the resistant organism. 3) CORRECT - A client diagnosed with VRSA, a resistant organism, requires contact precautions (in addition to standard precautions) to prevent the spread of infection. Contact precautions require the use of gloves and a gown when entering the client's room to protect against contamination with the resistant organism. 4) A face shield or goggles is required when splashing with blood or body fluids is likely; it is not required for contact precautions. 5) Airborne precautions require an N-95 respirator mask. Airborne precautions are required for organisms that are spread by droplet nuclei, such as pulmonary tuberculosis.

The nurse prepares to insert a peripheral intravenous (IV) catheter in the forearm of a client admitted with dehydration. The nurse applies a tourniquet to the client's right arm, but has difficulty palpating veins distal to the tourniquet. Which action does the nurse take next? 1.Elevate the client's arm slightly above the heart. 2.Tighten the tourniquet. 3.Apply a warm pack for 10 to 20 minutes. 4.Stroke the vein upward.

1) Positioning the arm lower than the heart (not above the heart) for several minutes uses gravity to promote vasodilation. 2) A tourniquet should be applied loosely in a manner that impedes venous flow while maintaining arterial circulation. Tightening the tourniquet may compromise the client's arterial circulation. 3) CORRECT - Applying dry heat using a heat pack causes vasodilation, increasing the likelihood of successful peripheral IV catheter insertion. 4) Stroking the vein downward (not upward) promotes vasodilation.

The nurse encourages clients in a community population to attend a diabetes screening event scheduled at a local community center. Which level of intervention is the nurse advocating? 1.Primary prevention. 2.Secondary prevention. 3.Tertiary prevention. 4.Health risk assessment.

1) Primary prevention focuses on health promotion and prevention of illness or disease, not disease screening. 2) CORRECT— Secondary prevention focuses on screening to ensure early disease detection and prompt intervention. 3) Tertiary prevention focuses on preventing deterioration associated with disease and improving the client's quality of life, not disease screening. 4) Health risk assessment plays an important role in primary prevention, not disease screening.

The nurse provides care for a newly admitted client with chest pain. Which task will the nurse complete instead of delegating to nursing assistive personnel (NAP)? 1.Set up the client's meal tray. 2.Obtain a urine specimen and send it to the laboratory. 3.Remove the client's oxygen if chest pain is rated as zero. 4.Place the client on the cardiac monitor.

1) Setting up a meal tray is appropriate for NAP to complete. 2) Obtaining a urine specimen and sending it to the laboratory is appropriate for NAP to complete. 3) CORRECT - The nurse is telling NAP to assess chest pain and perform an intervention based on that assessment. This is not an appropriate task for NAP. 4) Placing cardiac leads and attaching to a monitor is appropriate for NAP to complete.

The nurse provides care for a client diagnosed with a stage 2 sacral pressure injury. The nurse educates the client's family members about proper positioning. Which statement by the family members indicates a need for further teaching? 1."We will not keep our parent sitting on the bedpan for too long." 2."We will encourage our parent to change position every few hours." 3."We will use a draw sheet to help position our parent when in bed." 4."We will put our parent on a rubber ring cushion when he is sitting up."

1) Sitting on the bed too long puts the client at risk for skin breakdown. 2) Coaching and assisting client to turn to each side relieves pressure. 3) Using a draw sheet prevents shearing. 4) CORRECT — Any type of ring cushion should not be used because it can lead to additional or worsening pressure injuries.

A client takes a statin as prescribed. Which action does the nurse implement to identify if the client is experiencing any side effects of the medication? 1.Measure height and weight. 2.Check recent cholesterol level. 3.Inquire about the consistency of stool. 4.Assess for muscle tenderness.

1) Statins do not affect height and weight. 2) Monitoring cholesterol evaluates the effectiveness of the medication. It does not assess for side effects. 3) Statins do not effect stool consistency. 4) CORRECT - Myalgia or muscle tenderness may indicate the development of rhabdomyolysis, which is an adverse reaction to statin medication

A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take when performing cardiopulmonary resuscitation (CPR)? 1.Deliver 12 breaths per minute. 2.Compress the sternum with both hands at a depth of 2 inches (4 to 5 cm). 3.Use the heel of one hand for sternal compressions 4.Use two fingers for sternal compressions.

1) The breathing rate for a small child is 20 breaths per minute. 2) When performing CPR on a child, use the heel of one hand for chest compressions. 3) CORRECT — To perform chest compressions on a child, use the heel of one hand and compress the sternum 2 inches. 4) Using two fingers for chest compressions is recommended for an infant. For a child, use the heel of one hand.

The health care provider prescribes an external urinary catheter for a client with urinary incontinence. Which action does the nurse take after the catheter is rolled onto the penis? 1.Secure the catheter to the tubing. 2.Connect the drainage tube system. 3.Ensure there is 1 to 2 inches of space at the end of the catheter. 4.Observe for urinary drainage to occur within 5 minutes.

1) The catheter is attached to the tubing after 1 to 2 inches of space is added to the end of the catheter. 2) The drainage type system is connected after securing the catheter tubing to the thigh. 3) CORRECT - Before securing the catheter, ensure that there is 1 to 2 inches of space for urine to collect in condom catheter. 4) Observing for urinary drainage is done last; however, output may not be immediate. The nurse may have to observe for urine output over the next hour.

The nurse prepares a school-age client diagnosed with a fractured humerus to be discharged home with the parents. Which observation requires the nurse to make a referral to home health? 1.The child does not play with toys during the hospital stay. 2.One parent is working the night shift. 3.The mother has bruises around the wrists. 4.The father is anxious to leave the hospital.

1) The child may not play with toys because of pain or not feeling well related to the fracture. 2) This is not concerning if one parent works a second or third shift as long as the other parent is home or the child has proper supervision if the other parent is gone. 3) CORRECT — If the mother has bruises around her wrists, she could be getting abused at home. Violence in the family is a risk factor for child abuse and this child should be followed up with in the home. 4) Anxiety is not uncommon with parents, especially if one parent needs to get to work or is not comfortable in a hospital setting.

The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act? 1."A client needs to complete an advance directive and identify a health care proxy to become an organ donor." 2."The health care provider is the person who requests organ donation from a client's family members." 3."The health care provider who signs the client's death certificate must supervise the removal of the client's donated organs." 4."Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated."

1) The client does not need to complete an advance directive and identify a health care proxy to become an organ donor. 2) The health care provider is not usually the person who requests organ donation from a client's family members. 3) The health care provider who signs the client's death certificate is not the person who removes the client's donated organs 4) CORRECT — Family members can consent to organ donation after the client's death, even if the clients had not expressed a desire to have organs donated.

The nurse teaches a group of nursing students about managed care. Which information will the nurse include in the teaching session? 1.Provides full coverage of health care costs. 2.Allows providers to focus on illness care. 3.Assumes the financial risk involved. 4.Encourages providers to focus on prevention.

1) The health care provider or the health care system receives a predetermined capitated (fixed amount) payment for each patient enrolled in the program. 2) The focus of care shifts from individual illness care to prevention, early intervention, and outpatient care 3) The managed care organization (provider) assumes financial risk, in addition to providing patient care. 4) CORRECT - The focus of health care shifts from illness to health and wellness.

The nurse assesses a client being considered for thrombolytic therapy. Which question is most appropriate for the nurse to ask? (Select all that apply.) 1."When was the last time you had a bowel movement?" 2."Can you tell me the exact time your chest pain began?" 3."Are you taking any medications to thin your blood?" 4."Did you have the flu and pneumonia vaccination?" 5."When was the last time you ate?"

1) The last time the client had a bowel movement does not impact the decision to use thrombolytic therapy. 2) CORRECT - Establishing the exact time of onset of chest pain is essential in thrombolytic therapy screening because the medicine is ideally given within 6 hours of a coronary event. 3) CORRECT - Concurrent use of anticoagulants such as warfarin is a relative contraindication for thrombolytic therapy. 4) Flu and pneumonia vaccination status does not impact the use of thrombolytic therapy. 5) Timing of client's last meal does not impact the use of thrombolytic therapy.

The nurse provides care for a very low birth weight (VLBW) preterm newborn receiving oxygen therapy. The nurse assesses the infant for which complication of oxygen therapy? 1.Nonshivering thermogenesis. 2.Hyperbilirubinemia. 3.Polycythemia. 4.Retinopathy of prematurity.

1) The primary means by which newborns generate heat is via nonshivering thermogenesis. In an underdeveloped and premature central nervous system, this type of heat production may be inadequate, but the act of thermogenesis is not a complication. 2) Hyperbilirubinemia is a common complication in the VLBW infant, but this is not a complication of oxygen therapy. 3) Anemia is more common in preterm infants than polycythemia. 4) CORRECT - Visual impairment or blindness in preterm infants, especially VLBW, due to injury of developing retinal blood vessels is sometimes precipitated by high levels of oxygen.

The nurse notes that four clients have returned from surgery within the last 24 hours. Which client is at the highest risk for developing a post-operative infection? 1.A school-age client recovering from a tonsillectomy. 2.An adolescent client who had an unruptured appendectomy. 3.An older adult client with gastric tube placement. 4.A middle-age client with a coronary artery by-pass graft.

1) The school-age client has one risk factor, which is the recent surgery. 2) The adolescent client has two risk factors, which are the recent surgery and appendicitis. 3) CORRECT - The older adult client has three risk factors. These risk factors are recent surgery, age, and compromised nutritional status. This client is at the greatest risk for a post-operative infection. 4) The middle-age client has one risk factor, which is the recent surgery.

The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart? 1.Second left intercostal space. 2.Second right intercostal space. 3.Fifth intercostal space, left midclavicular line. 4.Fifth right and left intercostal spaces.

1) The second left intercostal space is the location of the pulmonic area of the heart. 2) CORRECT - The second right intercostal space is the location for auscultating the aortic area. 3) The fifth intercostal space at the left midclavicular line is the mitral area. 4) The fifth right and left intercostal spaces make up the tricuspid area.

Several clients just arrived at the emergency department at the same time. Which client does the nurse see first? 1.Young adult with a closed leg fracture and a 2+ dorsalis pedis pulse. 2.Adolescent with a compound fracture who is bleeding and pale. 3.Older adult with confusion and a respiratory rate of 28 breaths/minute. 4.Young child with a cut on the forehead who is crying.

1) The young adult with a fracture and a strong distal pulse is stable. Assessment is needed, but this client is not the priority. 2) The adolescent is experiencing bleeding. Further assessment of the client's cardiovascular status is required, but there is another client who is a higher priority. 3) CORRECT - This older adult is demonstrating symptoms of hypoxia (confusion) and has an elevated respiratory rate, indicating compromised breathing. Immediate assessment is needed. 4) The child with the forehead cut may need stitches, but is stable. There is another client who is the priority.

The nurse is teaching the client about the warning signs and symptoms of lung cancer. Which statement is appropriate for the nurse to include in the teaching? 1."There are hardly any signs and symptoms with lung cancer." 2."Early symptoms of lung cancer include constant cough and bloody sputum." 3."Symptoms of lung cancer are vague and often present late in the disease." 4."Wheezing on exhalation is usually considered a positive sign of lung cancer."

1) There are symptoms associated with lung cancer that are often vague and nonspecific. 2) Constant coughing and bloody sputum are late, not warning, symptoms of lung cancer. 3) CORRECT — Lung cancer is often diagnosed in late stages because the symptoms are vague and often attributed to other causes. 4) Wheezing can be due to a number of conditions and is not a positive sign for lung cancer.

The nurse provides care for a group of clients with full term pregnancies who are in active labor. Which client does the nurse assess first? 1.Primigravida, dilated 4 cm, who is reporting nausea and the feeling of pelvic floor pressure. 2.Multigravida, in the transitional phase of labor, requesting assistance to use the commode. 3.Primigravida, in early labor, with a fetal heart rate of 110 and a variation of 20 beats independent of contractions. 4.Multigravida, dilated 9 cm, with a fetal heart rate of 160 and a variation of 5 beats occurring with each contraction.

1) This client requires further assessment. However, there is another client who is the priority. 2) Increased pressure during transition and the feeling of needing to urinate is common during the transition phase. This client is stable. 3) CORRECT - Variable fetal decelerations that occur unrelated to the contractions and with significant heart rate changes are due to cord compression and indicate that an urgent assessment is needed. Also, the fetal heart rate is on the lowest end of the acceptable range of 110 to 160. These findings are particularly concerning in the early stages of labor. This client requires immediate intervention to prevent fetal demise. 4) A fetal heart rate of 160 beats per minute with a slight variation during a contraction is an expected early deceleration. This client is stable.

The nurse performs a pelvic exam on a client admitted in labor to determine the station of the presenting part. The client asks the nurse, "What does the term station mean?" Which explanation does the nurse give to the client? 1.The relationship of the presenting fetal parts to the perineum. 2.The relationship of the presenting fetal parts to the true pelvis. 3.The relationship of the presenting fetal parts to the ischial spines. 4.The relationship of the fetal parts to the external cervical os.

1) This is not the definition of station. The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. 2) This is not the definition of station. The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. 3) CORRECT — The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. The station of the presenting part is determined when labor begins so the rate of descent of the fetus during labor can be determined accurately. 4) This is not the definition of station. The station is the relationship of the presenting fetal part to an imaginary line drawn between the maternal ischial spines.

The nurse provides care for a client after an above the knee amputation (AKA) 2 days ago. The nurse places the client in which position? 1.Reverse Trendelenburg position. 2.Prone position. 3.Lithotomy position. 4.High Fowler position.

1) This position does not prevent hip contracture and may greatly increase edema. 2) CORRECT — The client is placed in the prone position for a short time on the first postoperative day and then for 30 minutes three times a day to stretch the flexor muscles and prevent hip contracture. 3) This position does not prevent hip contracture. 4) This position does not prevent hip contracture but may actually cause it.

The client says to the nurse, "I'm so upset! I've tried my hardest to give my children everything, but they still hate me." Which response by the nurse is appropriate? 1."I'm sure they don't hate you." 2."Children say things they don't mean." 3."What would make them feel that way?" 4."You think your children hate you?"

1) This statement offers false reassurance and is non-therapeutic. 2) This statement dismisses the client's expressed concerns and is non-therapeutic. 3) Asking a "what" question is another variation of asking why (i.e. "Why would your children feel this way?"). This question is a non-therapeutic communication response. 4) CORRECT - Restating the client's statement is a therapeutic communication technique. This question repeats the main idea expressed by the client and gives the client an idea of what has been communicated. If the message has been misunderstood, the client can clarify it.

The nurse receives a prescription to provide aspirin to a client with an emergent acute myocardial infarction. What is the best method to administer aspirin to this client? 1.Administer as a rectal suppository. 2.Administer with a glass of milk or antacid. 3.Give sublingually, times three doses. 4.Have the client chew non-enteric coated ASA.

1) To maximize immediate antiplatelet action of aspirin across the buccal mucosa, it is best to be chewed. 2) Antacid will reduce absorption of aspirin. 3) In acute myocardial infarction aspirin is given once, not in three doses. 4) CORRECT - To maximize immediate antiplatelet action of aspirin across the buccal mucosa, it is best to be chewed.

The nurse notes that an older client is hearing impaired. Which action is the most appropriate for the nurse to use when communicating with this client? 1.Raise voice volume. 2.Lower voice pitch. 3.Use exaggerated lip movements. 4.Turn down the volume of the television.

1) When conversing with a hearing-impaired older adult, it is best to maintain a normal voice volume. 2) CORRECT— Age-related presbycusis leads to difficulty hearing sounds or a voice with higher pitches. A lower voice pitch by the nurse may make it easier for the client to hear. 3) Exaggerated lip movements do not improve hearing and may cause embarrassment. 4) Noise distractions, such as a radio or television, should be turned off and not down.

The nurse cares for the client admitted with a dx of a stroke and facial paralysis. Nursing care is planned to prevent which complication. 1. inability to talk 2. loss of gag reflex 3. Inability to open affected eye. 4. corneal abrasion.

1, 2, 3 - Incorrect - nursing care cannot prevent it but is may occur 4. CORRECT - Client witll be able to close eye voluntarily; when facial nerve is affected, the lacrimal gland will no longer supply secretions that protect the eye.

The client is receiving imipramine. It is most important for the nurse to instruct the client about which possible adverse effect that indicates serotonin toxicity. 1. fever 2. changes in mental status 3. muscle twitching 4. diarrhea 5. dry mouth 6. loss of coordination

1, 2, 3, 4, 6,

The nurse plans a diet for a child dx with CF. Which dietary requirement does the nurse consider? 1. high protien 2. low sodium 3. high calorie 4. low protien 5. low carb 6. low potassium

1, 3 High protein and calories

A client is admitted for a series of tests to verfiy dx of cushings syndrome. What assessment findings supports this dx? SATA 1. buffalo hump 2. intolerance to heat 3. hyperglycemia 4. hypernatremia 5. intolerance to cold 6. irritability

1, 3, 4, 6

The nurse cares for the client with a diagnosis of Guillain Barre syndrome. Which initial symptom supports this dx? 1. resp failure 2. pulmonary congestion 3. HTN 4. flaccid paralysis 5. Hemiplegia 6. Urinary retention

1, 4, 6 Classic symptoms include resp failure and flaccidity d/t paralysis of the msucle and urinary retention d/t loss of sensation.

The nurse receives report on these client from the previous shift. In which order does the nurse see the clients? A. Client scheduled to receive Heparin and the aPPT is 70 seconds B. The client receiving IV K+, who reports burning at the IV site. C. The client receiving ciprofloxacin IV who reports a fine macular rash on the chest D. The client receiving a blood transfusion who reports a dry mouth.

1. C. Indicates a hypersensitivity reaction to cipro; shoudl stop medication and notify HCP 2. B. the client receiving K+ should decrease rate to prevent irritation of vein, but hypersensitivity reaction requires first attention. 3. A. lower limit of normal 20-25sec and upper limit of normal is 30-39 sec. aPTT is within therapeutic range. Therapeutic level increases aPTT 1.5 - 2 times control value. should give medication 4. D. Not an immediate concern; routine transfusion eval

The outpatient clinic nurses cares for an elderly client diagnosed with type one diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing because of which reason? 1. the renal threshold for glucose is elevated in the elderly 2. blood glucose monitoring is easier and less costly 3. urine test for glucose provides false positive readings 4. determination of the color on a reagent strip varies from person to person

1. Correct The level at which glucose starts to appear in the urine increases, leading to false negative reasons; results in elevated glucose levels 2. Incorrect. More expensive procedure. 3. Incorrect. Provides false negative readings 4. Incorrect results are expressed as a percentage according to color change

The nurse cares for the client admitted with a dx fo acute hypoparathyroidism. It is important for the nurse to have which item available? 1. tracheostomy set 2. cardiac monitor 3. IV monitor 4. heating pad

1. Correct most important for the clients safety d/t risk for laryngospasm

The client is evaluated with infertility and the HCP prescribes clomiphene citrate 50mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best? 1. Clomiphene citrate induces ovulation by changing hormonal effects on the ovary. 2. Clomiphene citrate changes the uterine lining to be more conductive to implantation 3. Clomiphene citrate alters vaginal pH to increase sperm motility 4. Clomiphene citrate produces multiple pregnancy for those who desire twins.

1. Correct Induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum 2 & 3. Incorrect Infertility problem, but this medication does not affect it. 4. Incorrect. Not a desired effect.

The parent tells the nurse about having difficulty forming relationships. The parent is worried the 7 yr old will have the same problem. Which is the best statement? 1. Children develop trust between birth to 18 mo 2. Children develop trust between 18 mo to 3yrs 3. Children develop trust between 3 to 6 yrs old 4. Children develop trust between 6 to 12 yo

1. Correct - erikson states that trust results from interaction with dependable, predictable, primary caretakers

The child has closed transverse fracture of the right ulna. Which nursing action before the application of a cast is most important? 1. check radial pulse bilateral and compare 2. evaluate the skin temp and tissue turgor in the area 3. assess sensation of each foot while the child closes the eyes. 4. Apply baby powder to decrease skin irritation under the cast

1. Correct. Assess neurovascular status, check pain, pallor, paralysis, paresthesia, and pulselessness

A client receives a blood transfusion and experiences hemolytic reaction. The nurse anticipates which assessment findings? SATA 1. hypotension 2. low back pain 3. wet breath sounds. 4. fever 5. urticaria 6. severe SOB

1. Correct. BP drops in hemolytic reaction 2. Correct. Low back pain is a classic symptom related to hemolytic reaction d/t the destroyed cells being caught in the kidneys. 4. Correct. Fever is an expected symptom

A client comes to outpatient psych clinic for tx of fear of heights. The nurse knows that phobias involve which behaviors? 1. projection and displacement 2. sublimation and internalization 3. rationalization and intellectualization 4. Reaction formation and symbolization

1. Correct. Both projection and displacement are correct. Projection is blaming on an external object and displacement involves ventilation of intense feeling

The client develops a postoperative infection and receives ceftriaxine sodium IV every day. What is the most important for nurse to monitor for changes? 1. surface of tongue 2. H&H 3. Skin surfaces in skin folds. 4. Changes in urine characteristics.

1. Correct. Cephalosporins long term can cause overgrowth of organisms in mouth and tongue. 2,3,4 - does not reflect a problem with this medication

A school aged client is in the early stages of nephrotic syndrome. The nurse discusses which protein adjustments with the parents. 1. adequate protein, low sodium. 2. low protein, low potassium 3. high protein, high K+ 4. Limited protein, High Na

1. Correct. If the child can tolerate the protein intake, then this diet is encouraged to speed healing and sodium is usually restricted

The nurse cares for a client one day post op thoracotomy. Nursing actions in the care plan include turn, cough, deep breath q2h. Which does the nurse understand to be the purpose of this nursing action? 1. promote ventilation and prevent resp acidosis 2. increase oxygenation and removal of secretions 3. Increase pH and facilitate balance of bicarb 4. prevent resp alk by increasing oxygenation.

1. Correct. Primary purpose of this measure is to improve and/or maintain good gas exchange, especially removal of CO2 in order to prevent resp acidosis. 2. Incorrect. promoting ventilation and preventing resp acidosis is better because it refers to ventilation rather than oxygenation 3. Incorrect. increasing the pH is not desirable. 4. Incorrect. resp alkalosis is not prevented by this nursing measure.

The nurse prepares the client for an IV pyelogram scheduled in 2 hrs. The nurse contacts the HCP if the client makes which statement? 1. I take metformin for DM type 2 2. I completed the bowel prep last evening 3. I ate a light meal last evening 4. I had an IVP 3 yrs ago

1. Correct. Should discontinue 48 hrs prior to the procedure, contrast media causes life threatening lactic acidosis 2. Incorrect. appropriate action; removes feces, fluid, and air from bowel so kidneys, ureters, and bladder will not be obscured. 3. Incorrect. appropriate action 4. Incorrect. no reason to contact HCP

The client with bipolar illness is extremely dangerous. The client tells the nurse, " I just found out my spouse has filed for divorce. I need to use the phone right now!". Which action by nurse is most important? 1. allow the client to use the phone 2. confront the client about the anger and inappropriate plan of action 3. do not allow the client to use the phone because this is an involuntary admission 4. Set limits on the client phone use because of inability to control behavior

1. Correct. The client is able to use the phone unless otherwise indicated by court order or HCP order. even if client is angry, it is not inappropriate anger

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? 1. The colostomy needs to be irrigated at the same time every day. 2. Irrigate the colostomy after meals to increase peristalsis. 3. Insert the catheter about 10 inches into the stoma. 4. The solution should be at least 110 F to increase dilation and flow.

1. Correct. The colostomy irrigation should be done at the same time every day to assist in establishing a normal pattern of elimination. 2. Incorrect. A colostomy should only be irrigated once a day. 3. Incorrect. The irrigation catheter should never be inserted more that 4 inches. 4. Incorrect. The irrigation solution should be at body temp. Increasing the temp does not make the irrigation more efficient.

The client is admitted with IBS. The nurse anticipates the client hx will reflect which info? 1. pattern of alternating diarrhea and constipation 2. chronic diarrhea stools occurring 10-12 times per day 3. diarrhea and vomiting with severe abdominal distention 4. bloody stools with increased cramping after eating

1. Correct. condition often called spastic bowel disease; no inflammation is present 2. Incorrect. UC or crohns 3. Incorrect. UC or Crohns 4. Incorrect. bloody stools do not occur with IBS

The client is admitted to the hospital for a hemiglossectomy with lymph node dissection. The cilents preop care inlcludes frequent oral hygiene with normal saline. The nurse knows the purpose of this is what? 1. minimize the bacterial count in mouth 2. softens the mucous membranes of the tongue before surgery 3. stimulates the microcirculation of the mouth 4. hydrates the tissues of the gums

1. Correct. destroys bacteria found in the mouth, reduces the chance of infection

The nurse evaluates the desired client response to diuretic therapy. Which action is the most reliable client measure for the nurse to use? 1. obtain daily weights 2. obtain urinalysis 3. Monitor Na and K levels 4. monitor intake

1. Correct. effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights 2. Incorrect. does not relate to the effects of diuretic therapy 3. Incorrect. Important to consider but not priority 4.Incorrect. Important to consider but not priority

The nurse cares for the older client recieving IV fluids at 0.9% NaCl at 125 ml/hr in left arm. During a routine assessment, the nurse finds the client has distended neck veins, SOB, and crackles in both bases of lungs. Which action does the nurse take first? 1. decrease IV to 20 ml/hr and notify the HCP 2. Decrease IV to 100 and continue to monitor 3. d/c the IV and start O2 at 6 L/min 4. assesses for infiltration of the IV solution

1. Correct. the client is experiencing fluid overload. Decreasing the IV to 20 to keep vein open while the HCP is notified and prescription are received 2. Incorrect. Rate still too much but IV needs to be kept open while contacting HCP. 3. Incorrect. IV shouldnt be d/c and needs to be there for meds. 4. Incorrect. Stem indicates circulatory overload, not infiltration.

The client has a permanent trach and a total laryngectomy. The nurse plans nutritional intake for the next 3 days. Which action is necessary for the nurse to consider regarding the clients nutrition? 1. to facilitate healing of the surgical area, a NG tube may be utilized and tube feedings may be implemented 2. The client will be unable to maintain oral intake as long as the trach is in place 3. nutritional and or gastric feedings will not be attempted for approx 3 weeks to decrease risk of aspiration 4. because the client is dependent on ventilator, nutritional intake will be delayed

1. Correct. tube feedings are frequently started as the initial nutritional intake. The initial insertion site is done carefully to prevent trauma to surgical site. Using tube feeds prevents further trauma to suture area while healing occurs.

The client dx with an adjustment disorder with a depressed mood. The client has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time? 1. during the morning 2. middle of the day 3. afternoon 4. evening

1. Correct. - client with reactive depression has the highest energy in the morning.

The nurse receives report from the previous shift. In which order does the nurse se each client? A. the client dx with type 1 diabetes scheduled for a cardiac cath at 1400 B. the client dx with cardiomyopathy being evaluated for a heart transplant C. The client post CABG having atrioventricular wires removed at 1500 D. The client with 1 day post op with an epidural catheter in place

1. D- The most unstable client with epidural needs assessment for adverse effects of epidural and is fresh post op with resp considerations 2. B- client needing heart transplant will be unstable; requiring monitoring and early assessment; circulation considerations 3. A- needs assessment of blood glucose and preop needs but falls behind resp and unstable circulation 4. C- stable client having atrioventricular wires removed.

A client is brought to the ED after being raped in the home by an intruder. The client asks the nurse to call the spouse to come to the ED. The nurse knows the most common reaction for the SO to a rape victim is reflected in which behavior? 1. Supportive and helpful to the victim 2. disconnected from and apathetic toward the victim 3. frustrated and feeling vulnerable but denying the need for help 4. Emotionally distressed and or needing assistance

1. Incorrect SO may want to be helpful however, they generally do not have the immediate coping strategies to do so. 2. Incorrect. A SO rarely feels disconnected but desires to support the victims 3. Incorrect. Usually family members will need and responds well to psychological intervention 4. Correct. SA by rape is a crisis situation for the victim, family, and friends

The nurse cares for client with radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1. Clean the radium implant carefully with a disinfectant using long forceps 2. handle radium carefully using forceps and rubber latex gloves 3. Document the date and time of removal together with the total time of implant treatment. 4. Double bag radium implant before the person from radiology removes it from the room

1. Incorrect at no time should the nurse handle it. 2. Incorrect. at no time should the nurse handle it. 3. Correct. Important that accurate documentation be maintained on the internal radium implant 4. Incorrect. at no time should the nurse handle it.

The nurse knows that cortisol is responsible for which action. 1. Prepare the body for fight or flight 2. Regulating the calcium metabolism 3. Converting proteins and fat into energy sources 4. Enhancing musculoskeletal activity

1. Incorrect while cortisol is released during stress situations, fight or flight is action of epi 2. Incorrect. Regulation of calcium metabolism is the action of the parathyroid hormone parathormone 3. Correct. The action of cortisol is to process the conversion of proteins and fats into energy sources such as glycerol and fatty acids. It is also an anti-inflammatory agent. 4. Incorrect. Enhancing muscle and skeletal activity is an action norepi

The HCP diagnoses Graves disease for the client. The nurse expects the client to exhibit which symptom? 1. Lethargy in early morning 2. sensitivity to cold. 3. weight loss of 10 lb in 3 weeks 4. reduce deep tendon reflexes

1. Incorrect will be restless 2. Incorrect. will have heat intolerance d/t increased metabolic rate. 3. Correct. Increased metabolic rate causes weight loss even with increased appetite 4. Incorrect. reflexes will be hyperactive.

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how nurses performs the procedure? 1. Inserts the suction catheter 4 in into the tube. Applies suction for 30 sec, then withdraws. 2. Hyperoxygenates the client. Inserts the suction catheter into the tube, and suctions, then wipes catherter with alcohol swab after removal 3. Explained the procedure to the client. Inserts the catheter gently while applying suction, then assesses client status. 4. Inserts the suction catheter until resistance is met and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn.

1. Incorrect. Catheter is inserted until resistance is met and then withdrawn slightly. Never suction more than 10 to 15 seconds. 2. Incorrect. The catheter is kept secure in the sterile plastic sheath and never cleaned with alcohol swab 3. Incorrect. Suction is never applied with the cath is inserted 4. Correct. Insert suction cath until resistance is met without applying suction then withdraw 0.4-0.8 in and apply intermittent suction during removal.

The client is gravida 2 para 1 and admitted with hypertension at 32 week gestation. The client reports her wedding band tight. The nurse assesses for which additional indication of preeclampsia? 1. general edema and visual disturbances 2. epigastric pain and headache 3. proteinuria and retinal vascular constriction 4. polyuria and hypertonic reflexes

1. Incorrect. General edema is no longer considered a symptom of preeclampsia because of the frequent occurence of edema toward the end of pregnancy. Visual disturbances usually occur close to the seizure and are symptoms of severe preeclampsia. 2. Incorrect. Epigastric pain and continuous headache are usually a significant precursor of eclampsia just before a seizure. They are associated with severe preeclampsia. 3. Correct. Proteinuria and retinal vascular constriction are additional symptoms of preeclampsia 4. Incorrect. polyuria is not seen with preeclampsia. Oliguria is seen later with eclampsia. Hypertonic reflexes are seen with severe preeclampsia.

A client is diagnosed with an aggressive behavior. The nurse declines the clients request to organize a party on the unit for the clients friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicated the nurse has an understanding of the clients behavior? 1. Allowing the client to use abusive language will undermine the authority of the nurse. 2. Responding with kind words to a client who uses abusive language will calm the behavior. 3. Expressing empathy toward the clients frustration and feelings in not planning a party. 4. Modeling acceptable behavior and language by the nurse will help change all clients unacceptable behavior.

1. Incorrect. If a client uses abusive language, it doesnt undermine the authority of the nurse, it is just a symptom of the illness. 2. Incorrect. A response of kinds words will not calm the abusive behavior. That is the illness. Also, the nurse should never respond to abusive language with abusive language. Both responses show lack of understanding of the cause for the clients behavior 3. Correct. An angry aggressive client will express feelings. The nurse will need to let the client know the nurse hears what is being said and can reflect back with empathy. 4. Incorrect. While the nurse should always use therapeutic communication and model appropriate behavior, that suggests that using acceptable behavior will change the clients behavior. This shows a lack of the reason for the clients behavior.

The nurse prepares the adult client diagnoses with an intellectual delay for discharge. The healthcare provider ordered Wafarin sodium 5mg every day. To maintain client safety, which action does the nurse take first? 1. instructs the significant other about the medication regimen 2. Determines the client comprehension of the med admin. 3. prepackages the medication to encourage correct admin 4. encouraged a return demo of the med self-admin

1. Incorrect. Implementation may be done after the assessment of the comprehension level 2. Correct. Assessment of intellectually delayed client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent over or under dosage 2. Incorrect. Implementation may be done after the assessment of the comprehension level 4. Incorrect. Implementation may be done after the assessment of the comprehension level

The nursing UAP assists the client with anemia at lunch time. The UAP tells the RN that the client reports weakness. Which nursing response to the UAP is best? 1. listen to the clients breath sounds and report back to me. 2. Set up the clients lunch tray 3. obtain a diet hx from the client 4. instruct the client to balance rest and activity

1. Incorrect. Listening to breath sounds require RN - involves assessment and interpretation 2. Correct. Setting up a diet tray is a standard unchanging process. If the tray is set up so all the client needs to do is to eat,it decreases cardiac workload during a time of weakness. 3. Incorrect. obtaining diet hx is not in UAP scope - involves assessment and interpretation 4. Incorrect. All teaching requires assessment of the client needs it is performed by the RN

The nurse cares for the client newly dx with hypoparathyroidism. Which nursing action has the highest priority? 1. develop a teaching plan 2. Plan measures to deal with cardiac dysrhythmias 3. take measures to prevent a respiratory infection 4. assess lab results

1. Incorrect. Needed but not priority 2. Correct. Cardiac dysrhythmia related to low serum Ca would be a highest priority. hypocalcemia with hypoparathyroidism is hallmark sign. 3. Incorrect. the potential for resp infection is not major threat 4. Incorrect. not the priority.

A post op patient is cautioned about not making sudden movement s or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication? 1. Impairment of cerebral blood flow and headaches. 2. Increased intracranial pressure. 3. Pressure on the ocular suture line. 4. Displacement of the lens implant.

1. Incorrect. Not relevant to this situation 2. Incorrect. Not relevant to this situation 3. Correct. Sudden changes in position, constipation, vomiting, stooping, or bending over increases the intraocular pressure and puts pressure on the suture line. 4. Incorrect. Occurs because of the pressure on the suture area; not all clients have lens implants. 3 is a more comprehensive answer.

The nurse cares for the client admitted with a dx of closed head injury. Which sx indicates the client has developed DI? SATA 1. glucosuria 2. Cracked lips 3. weight gain of 5 lb 4. BP 160/100 pulse 56 5. urinary output of 4 L/24 hr 6. urine specific gravity of 1.004

1. Incorrect. Occurs with DM 2. Correct. d/t dehydration caused by excessive water loss 3. Incorrect. weight loss occurs; symptoms of SIADH opposite of DI 4. Incorrect. Late sign of increased ICP or brain damage 5. Correct. excessive fluid loss is major occurrence of DI 6. Correct. Specific gravity very low as urine is not concentrated in the kidney.

A 7 y/o child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1. Abnormal body proportions 2. early sexual maturation 3. Delicate features 4. Coarse, dry skin

1. Incorrect. Some forms of dwarfism includes abnormal body proportions. That is the limbs may be very short but body size is normal for age. In pituitary dwarfism, the entire body and limbs are small for age and proportions match. 2. Incorrect. Persons with pituitary dwarfism have delayed sexual maturation. 3. Correct. The persons features appear delicate and younger than the chronological age. The person appears younger than the actual age because the features are delicate. 4. Incorrect. The skin appears soft and smooth, not course and dry.

The clients is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? 1. Low BP and weight loss 2. Thin extremities with easy bruising 3. decreased urinary output and decreased serum k+ 4. tachycardia with reports of night sweats

1. Incorrect. The BP increases and client gains weight and adipose tissue increases in the trunk and upper body 2. Correct. Client with Cushing tend to lose muscle mass in their legs and have petechiae and bruising 3. Incorrect. There is no correlation with urinary output and cushings. the k+ does decrease tho 4. Incorrect. no correlation

The nurse care for the prenatal client at 8 weeks gestation. The client has a positive Venereal Disease Research Lab test (VDLR). It is determined the client is in the tertiary stage. When the nurse prepares the teaching plan, it is the MOST important for the nurse to include which information? 1. Advise the client to not take OTC medication 2. Instruct the client to return for the additional 2 injections of the medication. 3. Inform the client to refrain from sexual activity for 6 months after the 3rd dose of the medication. 4. Ensure the client that confidentiality of sexual partners is maintained.

1. Incorrect. This is a physical action, and the nurse would tell the client to talk with the HCP about OTC medications. Syphillis in the tertiary stage has no symptoms. 2. Correct. This is a physical action, and it is imperative that the client completes the medication. Tertiary syphillis has no symptoms but requires three doses of injectable penicillin G bezathine. 3. Incorrect. This is a physical action. Client should refrain from sexual activity for at least 1 week after the for at least one week after final injection. 4. Incorrect. This is a psychosocial action, which follows the physical actions. Communicable diseases are reported and the client needs to notify partners for treatment.

Which statement is documented by the nurse to reflect a clients emotional adjustment to being hospitalized in the ICU? 1. The client is unable to complete ADLs without assistance 2. The client appears to be depressed and anxious regarding impending surgery 3. The client constantly calls for nurses and cries uncontrollably 4. The family is unable to visit more than once a week because they live far away.

1. Incorrect. This statement does not describe emotional adjustment. It is factual, but refers to physical abilities 2. Incorrect. This is subjective and draws conclusions without supporting data. There is no indications of objective data to support the appearance of depression or anxiety. 3. Correct. This statement is objective and contains information that is observable. it gives an objective description of the clients behavior and affect. 4. Incorrect. This statement describes the clients family, not related to the clients emotional adjustment

A client has a hx of HTN and angle closure glaucoma. Which medication order does the nurse question 1. Propanolol 80 mg PO QID 2. Verapamil 40 mg PO TID 3. Tetrahydrozoline 2 drops in each eye TID 4. Timolol 1 drop in each eye once daily

1. Incorrect. antihypertensive, beta blocker used asd an antianginal, reduces CO, no effect on glaucoma 2. Incorrect CCB use as antianginal; not contraindicated 3. CORRECT. Contraindicated, opthalamic vasoconstrictor 4. Incorrect. Reduces aqueous formation and increases outflow for glaucoma

The nurse in the outpatient clinic assists with the application of a cast to the left arm of the preschool aged child. After the cast is applied, the nurse takes which action first.? 1. petals the edges of the cast to prevent irritation 2. elevates the childs left arm on two pillows 3. applies cool humidified air to dry cast 4. asks the client to move the fingers to maintain mobility

1. Incorrect. done when cast is dry 2. Correct. minimize swelling, elevated for first 24 to 48 hrs 3. Incorrect. would delay drying of cast 4. Incorrect. maintaining mobility of fingers is not most important after application of cast

Promethazine Hydrochloride 25 mg IV push is ordered for the client. Prior to admin this medication, the nurse makes which assessment? 1. The color of the medication solution 2. the clients pulse and temp 3. the time of the last analgesic dose the client received 4. the patency of the clients vein

1. Incorrect. is true but not as high priority as IV patency 2. Incorrect. No relevance to the question 3. Incorrect. used as adjunct to analgesic but has no analgesics activity itself 4. Correct. Is very important to determine absolute patency of the vein; extravasation will cause necrosis

The newborn is dx with fetal alcohol spectrum disorder. The nurse knows which action is and important consideration for this newborn? 1. prevent iron deficiency anemia 2. Decrease touch to prevent overstimulation 3. provide feedings via gavage to decrease energy expenditure 4. replace vitamins depleted as a result of poor maternal diet

1. Incorrect. not all FASD baby have anemia 2. Incorrect. needs to be snuggles and held d/t poor developed CNS 3. Incorrect feeding may be problematic for fasd newborns but gavage not usually required 4. Correct. Frequently maternal diet is poor and newborn malnourished. Missing b complex vitamins.

The nurse cares for the elderly client who is admitted with confusion, mood liability, impaired communication, and lethargy. Which order from the HCP does the nurse question? 1. dexamethasone suppression test 2. thyroid studies 3. drug tox screen 4. Trendelenburg test

1. Incorrect. ordered to determine adrenal gland function 2. Incorrect. ordered to check for endocrine cause 3. Incorrect. ordered to see if cause is excessive alcohol or medications 4. Correct. This test is used for clients who may have varicose veins, which have no relationship to the symptoms described in this situation.

Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1. I love my family with all my heart, even though they don't live me 2. I was unable to take my final exam because I was unable to write 3. I don't believe I have diabetes. I feel perfectly fine 4. If my spouse was a better housekeeper I wouldn't have such a problem

1. Incorrect. reaction formation 2. Correct. client has converted anxiety over school performance into a physical symptom that interferes with ability to perform 3. Incorrect. Denial 4. Incorrect. Projection.

The nurse cautions the client with hypothyroidism to avoid which implementation? 1. warm environmental temperatures 2. narcotic sedatives 3. increase physical exercise 4. a diet high in fiber

1. Incorrect. the client with hypothyroidism cannot tolerate cold temps. The slowed metabolism decreases the ability to produce sufficient body heat 2. Correct. The client with hypothyroidism is very sensitive to narcotics, barbiturates, and anesthetics. This is likely related to the decrease in metabolic activity causing reduces ability to metabolize this medication 3. Incorrect. Exercise shouldnt be avoided even tho the client may have a lowered tolerance for exercise. 4. Incorrect. The hypothyroid pt required increase in fiber, high cellulose foods to prevent constipation bc of slower metabolism.

An adolescent child is scheduled for a below the knee amputation following a motorcycle accident. The nurse includes which of the following information in preop teaching session? 1. explain that the client will walk with a prosthesis soon after surgery 2. encourage the client to share feelings and fears about the surgery 3. instruct the client that only the legal guardian can sign the informed consent 4. evaluate how the client plans to complete schoolwork during hospitalization

1. Incorrect. this action fails to recognize clients immediate concerns 2. CORRECT. discussing feelings and fears is important in dealing with anxiety d/t a change in body image and function. 3. Incorrect even if the client is under 18 the informed consent can be signed by adolescent 4. Incorrect. more appropriate to discuss school work later

The nurse cares for a child diagnosis with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes with info when instructing the childs parents? 1. Apply the cream rinse every other day for 1 week. 2. Wash the childs clothing and personal belongings in soap and cool water. 3. Repeat the application of the cream rinse in 7 days if nits are still present 4. Comb the childs hair weekly with a nit comb

1. Incorrect. too frequent application 2. Incorrect Wash with detergent in very hot water and dry in dryer for 20 minutes 3. Correct. May be repeated 7 days after first application 4. Incorrect. Hair should be combed daily with nit comb.

Several days after the delivery of a stillborn, the parents say "we wish we could talk with other couples who have gone through this trauma". Which organization is best? 1. First Candle 2. Share 3. Resolve 4 Candlelighters

1. Support group for SIDS 2. Correct. Support group for parents who lost a newborn or had a misscariage. 3. National infertility association support group 4. Childhood cancer family alliance for families who have lost a child to cancer.

The nurse cares for an elderly client admitted for a possible fractured right hip. During the initial nursing assessment, which nursing observation of the right leg validates this diagnosis? 1. The leg appears to be shortened and is adducted and externally rotated. 2. Plantar flexion is observed with sciatic pain radiating down the leg. 3. From the hip, the leg appears to be longer and is externally rotated. 4. There is evidence of paresis with decreased sensation and limited mobility.

1. The leg appears to be shortened and is adducted and externally rotated. - Correct: accurate assessments of the position of a fractured hip prior to repair 2. Plantar flexion is observed with sciatic pain radiating down the leg. - Incorrect: Plantar flexion occurs with foot drop 3. From the hip, the leg appears to be longer and is externally rotated. - Incorrect : leg would not appear longer 4. There is evidence of paresis with decreased sensation and limited mobility. - Incorrect: occurs with injury to the lumbar disc area

The parent brings a 9 month old with a fever of 102.2 and frequent vomiting. The nurse expects to find what reflex? 1. babinski 2. moro 3. tonic neck 4. grasp

1. correct disappears after 1 yr

The nurse cares for the client recieving continous tube feeds. which nursing action is appropriate. 1. rinse the bag and change formula every 4 hrs 2. rinse the bag and change formula every shift 3. rinse the bag and change the formula every 12 hrs 4. rinse the bag and change formula every 2 hrs

1. correct - 4hrs

The nurse cares for the client receiving haloperidal. The nurse anticipates which adverse effects? 1. blood dyscrasia and extrapyramidal symptoms 2. hearing loss and unsteady gate 3. nystagmus and vertical gaze palsy 4. alteration in LOC and increased confusion

1. correct - major advere effects are hematological problems, primarily blood dyscrasia and EPS

The nurse assesses a client dx with a spinal cord injury. Which finding suggests the complication of autonomic dysreflexia? SATA 1. urinary bladder spasm pain 2. severe pounding headache 3. profuse sweating 4. dysrhythmia 5. severe hypotension 6. nasal congestion

1. incorrect. an overfilled bladder may be the cause of autonomic dysreflexia but pain is not percerived. 2. Correct a severe headache results from rapid onset of HTN and is one of the classic signs of dysreflexia 3. Correct. Profuse sweating especially on the forehead is a classic sign 4. Incorrect. Bradycardia is the most common change in pulse. Dysrhythmias are not a symptom of dysreflexia. 5. Incorrect. The BP will increase and may rise to a very high level with dysreflexia 6. Correct. Nasal congestion occurs with dysreflexia and piloerection may also occur

The client is admitted with a tentative dx of late stage AIDS dementia complex. The nursing assessment is MOST likely to reveal what? 1. hyperactive DTR 2. peripheral neuropathy affecting hands. 3. Disorientation to person, place, and time 4. Impaired concentration and memory loss

1. incorrect. not relevant to condition 2. Incorrect. not relevant to condition 3. Correct. Approx 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debillitaiton; late stage is typified by cognitive confusion and disorientation 4. Incorrect. a sign of early onset dementia

Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as " my breathing is much improved now" 2. Notes objective findings such as decreased RR and pulse 3. consults with the RT to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds

1. incorrect. subjective data and not as conclusive 2. Incorrect Correct but not as effective 3. Incorrect. not appropriate 4. Correct. To assess the effectiveness of suctioning, auscultate the clients chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? SATA 1. paranoia 2. grandiose delusions 3. somatic difficulties 4. difficulty concentrating 5. agitation 6. Distorted perceptions

2, 4, 5

The nurse performs medication reconciliation for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which class of medication does the nurse question because of possible adverse effects in clients with COPD? 1.Anticoagulants. 2.Benzodiazepines. 3.Loop diuretics. 4.Angiotensin converting enzyme inhibitors.

2. Benzodiazepines depress respirations and may cause CO2 retention in the client with COPD.

The nurse cares for a multipara client who delivered an infant 1 hr ago. She has soft breast, boggy uterus that is right of midline and 2cm below umbilicus, and has moderate rubra lochia. What is most important action? 1. perform straight cath 2. offer bedpan 3. put baby to breast 4. massage fundus

2. Correct boggy uterus deviated to right indicated full bladder

The health care provider inserts a temporary pacemaker in a client following a MI. The nurse knows that which outcome is the primary purpose for the pacemaker? 1. increase the force of myocardial contraction 2. Increase cardiac output 3. Prevents PVCs 4. Prevents systemic overload

2. Correct A pacemaker acts to regulate cardiac rhythm. This can be atrial or ventricular, or both. The outcome of the intervention is to increase the CO.

The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior for a 5yr old? 1. plays with a large truck with another child 2. talks on a toy telephone and imitates parent 3. child works on a small piece puzzle with several other children 4. The child holds and cuddles a large stuffed animal beside another child

2. Correct Imitation is the most common type of play in preschool age children

An infant is admitted to the hospital for vomiting and diarrhea. The infants anterior fontanelle is depressed and temp of 103.2. Which nursing action best? 1. obtain daily weights to evaluate weight loss 2. start isotonic IV infusion, as prescribed. 3. place a full bottle of pediatric electrolyte solution at the bedside 4. observe the infants ability to consume fluids by mouth

2. Correct Indicates fluid volume deficit

The nurse cares for an older client dx with dementia, Which action is best? 1. place the client in soft hand restraints 2. monitor wandering behaviors during a 48 hr period 3. keep lounge tv at low level 4. encourage a diet high protein, iron, and vitamins

2. Correct Monitoring is appropriate assessment to determine if client wanders during specific times of the day or in certain circumstances.

The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle does the nurse instruct the client to exercise regularly? 1. anal sphincter 2. abdominal 3. trapezius 4. rectus femoris

2. Correct strengthening the abs adds support for the muscles supporting the spine

The client is admitted to the ED in acute respiratory distress. The client is very anxious, edematous, and cyanotic. The client recieves morphine sulfate. Which finding does the nurse recognize as the desired response to medication? 1. increase in pulse pressure 2. decrease in anxiety 3. depression of SNS 4. Enhanced ventilation and decreased cyanosis

2. Correct - morphine sulfate is administered to minimize anxiety associated with resp distress from pulmonary edema

The nurse cares for a pt dx with menieres syndrome. The nurse stands directly in front of the client with speaking. Which best describes the rationale for the nurses position? 1. enables the client to read the nurses lips 2. the client does not have to turn the head to see the nurse 3. the nurse will have the clients undivided attention 4. there is a decrease in the clients peripheral visual field

2. Correct. By decreasing movement of clients head, vertigo attacks may be decreased.

The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is most appropriate? 1. maintain and improve oxygenation 2. improve the status of ventilation 3. increase oxygenation of peripheral circulation 4. correct the bicarb deficit.

2. Correct. Improve quality of ventilation refers to levels of co2 and o2

The older alcoholic client receives a ling acting benzo for 2 day symptom management and reduction. The client states "get those bugs off me and clean them out of here". the nurse knows the client is exhibiting symptoms of which problem? 1. reaction to sedative medication 2. worsening course of withdrawal 3. exacerbation of schizophrenia 4. the process of aging and the effects of delirium

2. Correct. the client has most probably progressed to another level of withdrawal. This can occur 2-3 days after last drink. Characteristics include tremors, increased HR, and fever, as well as psychological problems of confusion, delusions, and hallucinations

The nurse cares for a client on the first day post op after a TURP. The client has continous bladder irrigation. The spouse asks the purpose of the CBI. Which response is best? 1. The CBI prevents bladder spasms and infection 2. The CBI dilutes the urine to prevent infection 3. The CBI enables urine to keep flowing 4. The CBI delivers medication to the bladder

3 - Continuous bladder irrigation prevents formation of clots that can lead to obstruction in the post op TURP client .

The nurse obtains a hx from the parent of a preschool aged child with a hx of epilepsy. The child was admitted with uncontrolled tonic-clonic seizure. It is most important for the nurse to ask which question? 1. which part of the body was affected by the seizure? 2. Is there a family hx of seizure disorder? 3. what was your child doing before the seizure? 4. how long has it been since previous seizure?

3. Correct A seizure may result from a triggering mechanism such as loud noise, music; flickering light, prolonged reading, medications, etc. Knowing the trigger is important to prevent recurrence

A client has an irregular pulse rate of 81 and potassium level of 3.0. The client has digoxin scheduled for administration. Which nursing action is best? 1. give the digoxin 2. Wait an hour, then give the dig 3. notify the HCP before giving dig 4. recheck the pulse

3. Correct Hypokalemia can enhance dig toxicity, therefore the med will be held, the HCP shoudl be notified. A k+ supp may be prescribed.

The client experiences d/t rheumatoid arthritis. Which nursing statement is correct? 1. if you are having a bad day, postpone exercises until next day 2. passive exercises are better for you then active 3. when inflammation is severe, decrease number of repetitions of exercise 4. you can substitute your normal household tasks to provide variety

3. Correct You should reduce repetitions but not stop all together to maintain joint mobility.

The adult client receives dexamethazone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding to the pcp 1. PTT 12 seconds; Hgb 15 2. BUN 18; Creatinint 1.0 3. K+ 3.4; Ca+ 7.8 4. AST 18; ALT 12

3. Correct hypokalemia and hypocalcemia

The nurse checks incision of the client 48 hrs after surgery for a hernia repair. Which finding indicates a possible complication? 1. there is mild swelling under sutures 2. there is crusting around incision line 3. the incision line is red 4. the incision line is approximated

3. Correct incision should be pink not red

A continent adult client undergoes admission to the hospital with a dx of hep A, Which precautions does the nurse include in the clients overall care during hospitalization? 1. contact 2. airborne 3. standard 4. droplet

3. Correct standard precautions should be used on everyone. Hep A is usually transmitted though fecal to oral. Contact precautions would be required of pt was incontinent or diapered

The client dx with metastatic lung cancer is admitted to the hospital. The clients orders include DNR and morphine 2mg/hr by continuous IV infusion. The clients BP is 86/50, RR 8, and client is non-responsive. Naloxone 0.4 mg IV ordered stat. It is important for the nurse to consider which action? 1. The BP and RR will need to increase before a second dose of naloxone can be given. 2. Naloxone should not be given to client because of the DNR status. 3. A dose of naloxone may need to be repeated in 2 to 3 minutes 4. Naloxone is effective is treating respiratory changes caused by opiates, barbiturates, and sedative.

3. Correct the half life of naloxone is short. the client may go back in resp depression. need a second rx from hcp

The client has orders for cefocitin 2g piggybacl IV in 100 ml 5% dextrose in water. The primary IV is 5% dex in lactated ringers. Which is most important for the nurse ? 1. Administer the med slowly at 20-25 ml/hr 2. Change the primary solution 3. Hang the piggyback higher then the primary 4. Obtain an infusion pump prior to admin

3. Correct - when using a gravity drip or a pump, the piggyback needs to be higher

The nurse supervises care given to clients on a med surg unit. The nurse intervenes if which activity is observed? 1. the nurse and client wear mask during a dressing change for the central catheter used for parenteral nutrition 2. the nurse injects insulin through a single lumen percutaneous central catheter for the client receiving parenteral nutrition 3. The nurse applies lip balm to own lips immediately after performing a blood draw to obtain a specimen. 4. The nurse wears a disposable particulate respirator when administering rifampin to the client with TB

3. Correct. Applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur.

The client receives tetracyclines. The nurse includes which information in the teaching plan? 1. Take this medication with milk or antacids to decrease GI problems. 2. The medication should always be taken with meals 3. Use max protection sunscreen when outdoors 4. crackers and juice will help decrease gastric irritation

3. Correct. Because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure

The client had a kidney transplant yesterday, and the clients adult child has come to visit. The nurse instructs the adult child to take which action. 1. No special actions. 2. Double mask and glove 3. Perform good hand washing 4. Gown and mask

3. Correct. Good hand washing is the most effective method of reducing infection; very important with immunosuppressed client

The client recieves parenteral nutrition. If the PN is stopped abruptly, the nurse expects the client to exhibit which signs and symptoms? 1. tinnitus, vertigo, blurred vision 2. fever malaise, anorexia 3. diaphoresis, confusion, tachycardia 4. hyperpnea, flushed face, diarrhea

3. Correct. Insulin levels remain high while glucose levels decline; resulting in hypoglycemia; we also see restlessness, headache, weakness, irritability , apprehension, lack of muscle coordination

The nurse cares for the client several days after an above the knee amputation. Which symptoms is a characteristic of an infected residual limb wound? 1. the client is anxious and restless 2. there is a small amount of dark drainage on the dressing 3. The client reports persistent pain 4. The skin is cool above the operative site.

3. Correct. Pain is characteristic of inflammation and infection

An older client is dx with pneumonia is admitted to the med/surg unit. which other client does the nurse place with the older client? 1. 20 yr old with multiple fractures of LLE 2. 35 yr old with recurrent fever of unknown origin 3. 50 yr old recovering alcoholic with cellulitis of right foot. 4. 89 yr old with alzheimers awaiting long term care placement

3. Correct. cellulitis is a generalized nonfollicular infection that involves deeper connective tissue. Its unliekly to be transmitted to client without open wounds. Younger client at less risk for pneumonia than older client with alzheimers.

A client has just indicated a wish to suicide. The client then asks the nurse not to tell anyone. Which action is best? 1. Encourage the client not to do anything without thinking it through very carefully. 2. Explain to the client that anything told to the nurse is kept strictly confidential 3. Report the clients wish to commit suicide to the HCP 4. Encourage the client to tell the nurse more about what is being felt

3. Correct. to ensure client safety, the nurse must share this information, starting with HCP. The nurse should be transparent and let the client know this information must be shared. One to one client monitoring is required

The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? 1. tetralogy of fallot 2. Talipes equinovarus 3. hemolytic disease of the newborn 4. cleft lip and palate.

3. Correct. maternal antibodies destroy fetal RBCs. bilirubin secreted because of hemolysis

The client has partial thickness and full thickness burns over 75% of body. The nurse is most concerned with what symptom? 1. epigastric pain 2. restlessness 3. tachypnea 4. lethargy

3. correct - body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cold, clammy skin, tachycardia, tachypnea, and pale color

The nurse cares for a client 1hr after ECT treatment. The nurse reports which observation to the HCP? 1. headache 2. disruption in short and long term memory 3. transient confusional state 4. backache

4 - correct backache is not usual effect. A thorough descriptor of the pain should be reported to HCP

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding? 1. 200 2. 300 3. 400 4. 500

4. 500

The nurse provides care for the client who has an above the knee amputation. The amputation site is wrapped with a pressure elastic bandage for shaping. It is MOST important for nurse to take what action? 1. assess the drainage from site drains 2. observe dressing for signs of excessive bleeding 3. elevate residual limb for no less than 40 hrs 4. observe the site for adequate tissue perfusion

4. Correct Adequate tissue perfusion is required to promote healing of amputation. observation for signs of infection are important if the dressing is changed only infrequently. Bleeding is unusual complication but if observed then should be reported.

The nurse cares for he client who has just had a prosthetic hip implant. The nurse places the client in which position? 1. with the affected hip internally rotated and flexed 2. With the affected hip adducted when turned 3. in the supine position with the knees elevated 90 degrees 4. side-lying with the affected hip in a position of abduction

4. Correct flexion of 60 degrees, adduction, and internal rotation should be avoided in early post op period.

A miller-abbot tube is ordered for the client. the nurse knows this tube is inserted for which main reason? 1. provides an avenue for nutrients to flow past an obstructed area. 2. prevents fluid and gas accumulation in the stomach 3. Administered medication that can be absorbed directly from intestinal mucosa 4. Removes fluid and gas from the small intestine

4. Correct provides intestinal decompression; intestinal tube is often used for tx of paralytic ileus

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants ask the nurse what age is best to start toileting a child. Which is the best response by the nurse? 1. 11 mo 2. 14 mo 3. 17 mo 4. 20 mo

4. Correct.

The client takes phenelzine. The nurse observes the client eat another clients lunch. After a few minutes, the client reports headache, nausea, and rapid HR, and begins to vomit. The nurse anticipates administering which medication? 1. buspirone 2. fluoxetine 3. prochlorperazine 4. nifedipine

4. Correct. Phenelzine is an MAOI. Nifedipine is an antihypertensive. The client is experiencing a hypertensive crisis d/t ingesting tyramine.

The client is dx with myasthenia gravis. It is most important for the nurse to consider what? 1. prevent accidents from falls as a result of vertigo 2. maintain fluid and electrolyte balance 3. control situations that could increase ICP and cerebral edema 4. assess muscle groups toward end of day

4. Correct. Client has increased muscle fatigue, needs more assistance toward end of day

The client is newly dx with buerger disease. The clinic nurse obtains health hx. The nurse expects the clients hx to include what? 1. heart palpitations 2. dizziness when walking 3. blurred vision 4. digital sensitivity to cold

4. Correct. Vasculitis of blood vessels in upper and lower extremities.

The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication. 1. electrolytes 2. urine output 3. weight 4. heart rate

4. Verapamil is indicated for the tx of supraventricular tachycardia, so the clients HR should be checked prior to admin

The client is dx with hiatal hernia. Which info is the assessment most likely to reveal? 1. a bulge in LRQ 2. pain in umbilicus radiating to grown 3. a burning sensation in midepigastric area each day before lunch 4. Reports of awakening at night with heartburn

4. correct - classic symptom is reflux

The nursing team consists of one RN and two LPNs and 3 UAPs. The RN cares for which patient? 1. The client with a chest tube who is ambulating in the hall. 2. The client with a colostomy requiring assistance with an irrigation. 3. The client with right sided stroke requiring assistance with bathing 4. the client declining medication to treat cancer of the colon.

4.Correct requires assessment skills of RN

The nurse cares for the clients on a psych unit and is suddenly faced with multiple issues What order does the nurse address them? A. Client with substance abuse reports harassment by another client B. the client with schizophrenia tells the nurse the TV should be destroyed. C. The client with depression says to the nurse "My plan is complete, and im ready to go" D. The client with bipolar disorder walks into the day room in only underwear

C, B, A, D

The client is dx with and obsessive compulsive ritual. The nurse recognizes the client is attempting to achieve which psychological status? 1. control of other people 2. increase in self esteem 3. avoid severe levels of anxiety 4. express and manage anxiety

C. obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase self esteem or control others with the ritualistic behaviors; client does not want to repeat act but feels compelled to do so

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? SATA 1. tremors 2. elevated temp 3. depression. 4. nocturnal leg cramps 5. night sweats. 6. Decreased concentration.

Correct - 1, 2, 4 Incorrect - 3: seen in a depressed client. 5: seen in clients with TB, leukemia, or other infections. 6: seen in a depressed client.

The 6 mo old is brought to the clinic for a well baby checkup. During the exam, the nurse expects to observe which assessment findings? SATA 1. a pincer grasp 2. sitting with support. 3. tripling the birth weight 4. presence of the posterior fontanelle 5. bears weight when held in a standing position 6. Rolling from back to abdomen

Correct - 2, 5, 6 Incorrect - 1- this occurs at 9 mo 3 - the birth weight is tripled at 1 yr. 4 - the posterior fontanelle closes at 2-3 months of age.

The HCP provider orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms? 1. Stomatitis and photosensitivity. 2. Bradycardia and dry mouth. 3. Fluid retention and Dizziness 4. Gynecomastia and impotence

Correct - 3 Adverse effects include headache, dizziness, edema, GI distress, pruritus, and rash. Kidney and cardiovascular systems may be effected which exaggerates these effects.

The nurse recognizes which symptoms as early signs of lithium toxicity? SATA 1. Fine motor tremors. 2. Involuntary muscle movements 3. Seizures 4. N&V 5. Orthostatic hypotension 6. Diarrhea

Correct 1, 4, 6. Incorrect 2, 5 - associated with antipsychotics Incorrect 3 - associated with severe lithium toxicity