NCSBN Practice Questions 106-120

The nurse has an order for a postsurgical client to receive enoxeparin 40 mg subcutaneously once a day as prophylaxis for deep vein thrombosis. Enoxeparin is supplied from the pharmacy as 60 mg/mL. How much enoxeparin will the nurse administer? (Round the number to the nearest 10th and write only the number.)

0.7 Desired: 40 mg in ? mL Supplied: 60 mg in 1 mL; 60 mg/1mL = 40 mg/X mL; 60X = 40; (40/60) x 1 = 0.66 or 0.7; x = 0.7 mL

The health care provider orders a methylprednisolone sodium succinate (Solu-Medrol) taper for a client admitted with exacerbation of COPD. The order is for 200 mg IV push for three days (November 7, 8 and 9); 100 mg IV push for the following three days (November 10, 11 and 12); and then 50 mg IV push for the next three days (November 13, 14 and 15). It is now day seven of the taper. The methylprednisolone sodium succinate concentration on hand is 40 mg/mL. How many milliliters will the nurse administer IV push to the client today? (Report the dosage to 2 decimal points and write only the number.)

1.25 Have on hand: 1 mL/40 mg Need to administer 50 mg IV push40 mg/1 mL = 50 mg/X mL50/40 = 1.25 mL

The provider ordered 500 mg erythromycin oral suspension every six hours for a client diagnosed with pneumonia. The client has a gastrostomy tube. The pharmacy sends up the medication in a liquid suspension of 250 mg/5 mL. How much medication will the nurse administer every six hours?

10 250 mg/5 mL = 500 mg/X mL 250x = 2500 x = 2500/250 = 10 mL

A nurse is caring for a 4 year-old child admitted after being burned over more than 50% of the body. Which laboratory data should be reviewed by the nurse as a priority in the initial 24 hours? A. Blood urea nitrogen B. Blood glucose C. Hematocrit D. White blood count

A Glomerular filtration is decreased in the initial response to severe burns. A fluid shift occurs from the loss of fluid from the burned areas. Kidney function must be monitored closely, or renal failure may follow in a few days from a lack of circulating volume. In the initial 48 hours, fluids are given IV at high rates to maintain the circulation. After this the clients are evaluated for fluid overload and heart failure, as well as infection.

A nurse is assessing a 2 year-old client with a possible diagnosis of congenital heart disease. Which of these findings is most likely to be seen with this diagnosis? A. Takes frequent rest periods while playing B. Weight and height in the 10th percentile since birth C. Several otitis media episodes in the last year D. Changing food preferences and dislikes

A Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children.

A client asks the nurse to use a treatment method that the client read about on the internet. What is the most appropriate response by the nurse? A. "Can you tell me more about the website where you read the information?" B. "Why are you questioning your doctor's order? She is an expert in the field." C. "You shouldn't really use the internet for health care information. Most of it is incorrect." D. "I am willing to give it a try. Does it say what the success rate is for using this treatment?"

A Clients are internet savvy and often search the internet for medical information about their conditions and request information from others using social media. Since there is a lot of information on the internet, clients need the expertise of nurses and other health care providers to direct clients to information that are reliable, current and evidence-based. Many health care organizations have a list of vetted mobile apps and internet sites clients can use.Asking the client an open-ended question about the origin of the information is a therapeutic communication approach and allows the nurse to determine the quality of the information and demonstrate respect for the client's autonomy.The other responses are non-therapeutic and will most likely make the client feel guilty for taking the initiative to learn more about their health.

The nurse requires an interpreter to teach the client about a procedure to be done in the home. When using an interpreter the nurse should take which approach? A. Face the client while presenting the information as the interpreter talks in the native language B. Include a family member and direct communications to that person C. Speak directly to the interpreter while presenting information and use pauses for questions D. Talk to the interpreter in advance and leave the client and interpreter alone

A Communication is the cornerstone of an effective teaching plan, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, to face the client and to present the information to the client allows the interpreter to translate the content. Facing the client allows nonverbal communication to take place between the client and nurse.

The nurse working in a community clinic occasionally follows up with a client who has a history of substance abuse. To evaluate the client's progress, the nurse should recognize that which of these behaviors is the most resistant to therapy? A. Continued drug use B. Missed appointments C. Rationalization comments D. Recurrence of crises

A Continued use of any drug or addictive substance demonstrates lack of commitment to the treatment program. This fact must be understood by the nurse as part of the disease of addiction. This behavior is termed resistant behavior.

A client with liver failure has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care? A. Potential complication hemorrhage B. Ineffective individual coping C. Fluid volume excess D. Altered nutrition, less than body requirements

A Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture and acute hemorrhage if portal circulation pressures rise, or if the esophagus is injured.

A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and displaces the tracheostomy tube out of the stoma. This negative outcome could have been avoided by which action? A. Fasten the clean tracheostomy ties before removal of the old ties B. Place the client in a flat, supine position C. Placement of an obturator at the client's bedside D. Have another nurse assist with the procedure

A Fastening clean tracheostomy ties before removal of the old ones will ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the airway open only after the tracheostomy outer tube is coughed out. However, the question asks how to prevent the situation. A second nurse is not needed during the procedure. A change in the position of the client does not prevent a dislodged tracheostomy.

An unlicensed assistive staff member asks the nurse manager to explain the spiritual beliefs of Christian Scientist's clients. The best response of the nurse would be which of these statements? A. "Spiritual healing is emphasized and the mind contributes to the cure." B. "Meditation is intensive in the initial 48 hours and daily thereafter." C. "The primary belief is that dietary practices result in health or illness." D. "Fasting and prayer are initial actions to take in physical injury."

A For clients who follow Christian Scientist beliefs, a mind cure uses spiritual healing methods. For the believer, medical treatments may interfere with the drawing closer to God.

The nurse receives a telephone call from a health care provider who wants to give a telephone order. Which of the following actions should the nurse take? (Select all that apply.) A. Verify understanding by reading the order back to the provider before hanging up B. Ask a second nurse to listen on another extension while the order is being given C. Record the order word-for-word and sign the order D. Request that the order is signed by the provider before implementation E. Begin the order with the abbreviation "P.O." to indicate that it was a "phone order"

A, C Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" as abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility.

There is an order to obtain an aerobic wound culture from a client's wound. Place the nursing actions in the correct order. Click and hold the reorder icon to drag and drop the steps into the correct order. A. Remove the existing dressing B. Wipe the wound edges C. Perform hand hygiene and apply clean gloves and a face shield D. Obtain a culture by rotating a sterile swab in the open wound E. Irrigate the wound F. Perform hand hygiene and apply clean gloves

A, C, E, B, F, D Cultures are obtained from wounds after irrigation. The edges are cleaned since the exudate may be contaminated with normal skin flora. Hand hygiene and application of new gloves is done after removing the dressing and before irrigation to prevent contamination of the wound. A face shield is worn to protect the nurse from spraying during irrigation.

The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.) A. Oranges B. Marinated cauliflower and broccoli C. Grilled sirloin steak D. Broiled or wood-grilled salmon E. Barbecued pork chops F. Acetaminophen

A,B,C Foods like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test; chicken, pork and seafood can be consumed. Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test; acetaminophen does not affect the test.

The client is admitted with a diagnosis of ulcerative colitis. Which laboratory values should the nurse be sure to check? (Select all that apply.) A. Hematocrit and hemoglobin B. Blood urea nitrogen (BUN) C. T3 and T4 count D. Erythrocyte sedimentation rate (ESR) E. White blood cell count (WBC) F. Albumin

A,D,E,F Decreased hematocrit and hemoglobin may reveal the client has anemia as a result of the bloody diarrhea characteristic of this inflammatory bowel disease A low protein albumin level would indicate that the client is experiencing a nutritional deficit due to malabsorption. Increased numbers of white blood cells and an elevated erythrocyte sedimentation rate (ESR) indicate active inflammation. Blood urea nitrogen is related to kidney function and T3 and T4 are related to thyroid function; these lab values do not provide information related to the diagnosis.

The client has received fentanyl, atropine and benzocaine for an endoscopic procedure. The nurse is monitoring the client and notes the pulse has increased from the preprocedure baseline. Which medication could cause an increased pulse rate? (Write the name of the medication.)

Atropine Atropine is anticholinergic drug that dries secretions. However, it can also increase heart rate and dilate the pupils. Fentanyl is a short-term CNS depressant and should provide some relief from anxiety and discomfort during the procedure; it slows breathing and often lowers heart rate and blood pressure. Benzocaine is a topical anesthetic and should not affect heart rate.

A 7 year-old child is hospitalized for acute glomerulonephritis. Which nursing action is a priority on the plan of care? A. Monitor for increased urinary output B. Note patterns of increased blood pressure C. Encourage rest during hyperactive periods D. Assess for generalized edema

B All of the actions should be included in this child's plan of care. The priority is the evaluation for hypertension because in the the course of the disease, high blood pressure has the most potential for complications.

A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home two days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss? A. A change to formula is indicated for an increase B. The newborn needs additional follow-ups C. The loss is within normal limits for this time period D. The mother should breast-feed more frequently

C A newborn is expected to lose 5 to 10% of the birth weight in the first few days postpartum because of changes in elimination and feeding. Within one week the newborn should regain the weight or exceed the birth weight.

A client with heart failure exhibits fatigue and dyspnea on exertion. What is the priority nursing diagnosis for these findings? A. Pain B. Impaired gas exchange C. Decreased cardiac output D. Fluid volume excess

C All nursing interventions should be focused on improving cardiac output, as the other client issues are consequences of poor cardiac output. Comfort and the respiratory status will improve as cardiac output increases.

The home care nurse has been managing the care of a client for six weeks. In order to determine the quality of care provided by a home health aide who has been assisting with the care of this client, what should be the priority action by the nurse? A. Ask the client and family if they are satisfied with the care given by the home health aide B. Investigate if the home health aide is prompt and stays an appropriate length of time to provide care C. Determine if the home health aide's care is consistent with the plan of care D. Check the documentation of the home health aide for appropriateness and comprehensiveness

C Although the nurse must investigate all of these things, the first priority is an evaluation of the adherence to the plan of care. The plan of care is based on the reason for referral, the provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.

The nurse is educating a client about how to use a metered-dose inhaler with spacer. Drag and drop the options below in the order that demonstrates correct use of a metered-dose inhaler with spacer. A. Remove the mouthpiece from the lips B. Breathe out slowly C. Breathe in deeply D. Hold breath for 10 seconds E. Release the medication into the spacer

E, C, A, D, B Release the medication into the spacer. Breathe in deeply. Remove the mouthpiece, then hold breath for 10 seconds, then breathe out slowly. Spacers are highly recommended when inhalers are used because they increase the availability of the medication to the client.

A home health nurse is at the home of a client diagnosed with diabetes mellitus and arthritis. The client exhibits a difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to which resource? A. Another client diagnosed with diabetes mellitus who takes insulin B. A social worker from the local hospital C. An activity therapist from the community center D. A occupational therapist to improve fine motor coordination

D A occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection. The other resources would not be helpful for this problem.

A nurse is teaching a class for new parents at a local community center. Which activity would the nurse stress as being the most hazardous for an 8 month-old? A. Jumping on a bed B. Eating whole peanuts C. Playing around electrical outlets D. Riding in a car

D Car accidents are a leading cause of death in babies and children, as well as a major cause of permanent brain damage and spinal cord injury. Although all the other options pose a danger to young children, drowning is actually the second most common cause of accidental death among children.

A nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family diagnosed with this disease, and ask about the risk to future children. What is the best response by the nurse? A. One in two chance that each child will have the disease B. One in four chance for each child to carry that trait C. One in two chance of avoiding the trait and disease D. One in four risk for each child to have the disease

D Cystic fibrosis has an autosomal recessive transmission pattern. In this situation, both parents must be carriers of the trait for the disease because neither one of them has the disease. Therefore, for each pregnancy, there is a 25% chance of the child having the disease, 50% chance of carrying the trait and a 25% chance of having neither the trait nor the disease.

The nurse is caring for an unconscious client. To prevent exposure keratitis, which of the following interventions would be appropriate? A. Paint the toenails with an antifungal (Lamisil) ointment B. Irrigate the ear canal with hydrogen peroxide C. Apply barrier cream to the perineum D. Apply lanolin alcohol (Lacri-lube) to the inside of the eyelids

D Exposure keratitis is an inflammation of the cornea caused by exposure to air, which occurs in clients who cannot adequately close their eyelids or blink. It requires regular applications of moisturizing eye drops or ointment to the exposed cornea. The nurse should also tape the eyelids closed or apply a plastic bubble shield or eye patch.

A nurse is caring for a client whose family practices Chinese medicine. The nurse anticipates that the priority therapeutic goal for the family would be which of these? A. Maintain a balance of energy B. Achieve harmony C. Respect life D. Restore yin and yang

D For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.

An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication? A. Determine third-party payment plan B. Identify the client's proximity to health care services C. Evaluate the client's manual dexterity D. Assess the client's ability to use visual assistive devices

C An inability to self-administer eye drops is a common problem among the older adult due to decreased finger dexterity along with decreased vision to see things clearly within 2 or 3 feet in front of the face.

The nurse is planning the care for an 18 year-old female diagnosed with anorexia nervosa who is a long-distance runner. Which of these concerns, related to promoting the client's exercise patterns both now and in the future, should the nurse determine to be the priority? A. Electrolyte imbalance B. Digestive problems C. Amenorrhea D. Blood disorders

C Anorexia affects the whole body. But young women athletes with anorexia nervosa experience a decrease in hormones, which causes irregular periods or even amenorrhea. Low estrogen levels and poor nutrition, especially low calcium intake, can lead to premenopausal osteoporosis. Young women athletes are also at a much higher risk of stress fractures and other bone pathology. The three conditions (eating disorder, amenorrhea and osteoporosis) are sometimes referred to as the female athlete triad.

An 80 year-old resident in an assisted living facility has a temperature of 100.6 F (38.1 C). This is a sudden change from the resident's usual temperature. Which should a nurse assess first? A. Appetite B. Urine output C. Level of alertness D. Lung sounds

C Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute temperature elevation and the possibility that this represents an infection. Confusion and decreased level of consciousness are commonly seen in older adults with an infection and are often the first sign of infection (even in the absence of a fever). If the client is alert and responds to questions appropriately, then the temperature should be rechecked. The urine and lungs should be assessed for findings of infection because urinary tract infections and pneumonia are common causes of fever in the older adult.

The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program? A. Increase satisfaction with nursing care B. Increase client understanding of discharge instructions C. Reduce readmissions to the hospital D. Reduce insurance costs

C Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The Affordable Care Act mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions.

The nurse is preparing to administer acetaminophen 325 mg oral suspension per gastric feeding tube to a client. The label on the supplied container reads, "Acetaminophen 100 mg per 5 mL." The total volume of the container is 100 mL. How many mL shall the nurse administer? (Round to the nearest whole number.)

16.25=16 100 mg in 5 mL. 325 mg in ___ mL. 325 X 5= 1625 1625 / 100= 16.25 Rounded= 16mL The total volume of the container does not matter in this calculation.

The order reads: infuse IV aminophylline at 30 mg/hr. The pharmacy sends a 1000 mL bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, how many milliliters per hour will the nurse set on the infusion pump? Report the answer to the nearest whole number.

60 Ratio: 30 mg/hour = 500 mg/1000 mL = 30 X 1000/500 = 60 mL/hourDimensional Analysis: mL/hour = 1000 mL/500 mg X 30 mg/hour = 60 mL/hour

During the assessment of a client who has just undergone cardioversion, the nurse finds the respirations to be 10 breaths per minute. Which action should the nurse take? A. Evaluate breathing for depth and effort B. Notify the health care provider within 10 minutes C. Vigorously stimulate until normal rate of breathing D. Measure the pulse oximetry for drops in saturation

A A rate of 10 respirations per minute is near the normal low of 12 per minute. A range from 8 to 10 would be cause for concern. The next focus is the depth and effort. If effort is hard and struggling, the nurse would act on that. If the effort is easy with deep breathing then the nurse should monitor the breathing. If the depth is shallow, then immediate action is needed by the nurse. Of these three parameters, the respiratory effort is a priority and the respiratory rate is the secondary concern.

A client is being discharged with a prescription for chlorpromazine. Before the client leaves for home, which finding should the nurse teach the client to report right away? A. Sore throat and fever B. Abdominal pain and nausea C. Lethargy and drooling D. Change in libido and breast enlargement

A A sudden sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine). If white blood cell and differential counts are low, the treatment should be stopped and antibiotic therapy started. Other common side effects of chlorpromazine include dry mouth and nasal congestion, extrapyramidal reactions, motor restlessness and hypotension.

The nurse is teaching a client diagnosed with asthma about the medication albuterol. Which statement demonstrates proper teaching? A. "Notify the health care provider if you need the drug more often." B. "Use this medication at bedtime to promote rest." C. "Use this medication after other asthma inhalers." D. "Discontinue the inhalation if you are dizzy."

A Albuterol (AccuNeb, ProAir HFA, Proventil HFA, Ventolin HFA) is a bronchodilator used for the relief of bronchospasm. If the client notices the need to use the inhaler more frequently, the health care provider should be notified so that a change in dose or medication can be ordered. Be sure the client understands how to correctly use this medication.

A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take? A. Talk with the client to find out about the preferred herbal preparation B. Contact the client's primary care provider C. Explain the importance of the medication to the client D. Report the behavior to the charge nurse

A All the options are correct, but the question asks for an "initial" action. The correct answer is further assessment of the situation; it is the first action to be taken. The other options may be implemented afterward. The challenge for the health care provider is to understand the client's perspective and to support, facilitate or enable cultural values that can help the client recover from illness or to cope with any handicaps and/or death.

A nurse is counseling a 6 year-old child who has been diagnosed with nocturnal enuresis. What must a nurse understand about the pathophysiological basis of this disorder? A. It often has no clear etiology B. Enuresis is a sign of willful misbehavior C. Enuresis may be associated with sleep phobia D. It has a definite genetic link

A Although predictive factors associated with enuresis have been identified, no clear etiology has been determined.

A mother with a Roman Catholic belief system has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared for? A. Baptize the neonate on the way to the hospital B. Point the neonate's face toward Mecca C. Arrange for a church elder to be at the hospital for a "laying on of hands" D. Place a thread around the neonate's neck or wrist

A Baptism may be requested and anyone may perform this if the infant or child is gravely ill. Mormons believe in divine healing with the laying on of hands. Buddhists may place a thread around the neck or wrist after death. After someone's death, Muslims may want to wash the body and point their deceased loved one's face toward Mecca.

The nurse is monitoring a client's initial postoperative condition after a thyroidectomy. Which of these findings should the nurse report immediately? A. Tetany and paresthesia B. Irritability and insomnia C. Mild sore throat and hoarseness D. Headache and nausea

A Because the parathyroid gland may be damaged in this surgery, secondary hypocalcemia may occur with outcomes of these findings. Other assessments for hypoparathyroidism include muscle cramps and seizures. The other findings may be expected outcomes from any surgery in the postop phase.

A nurse admits a client newly diagnosed with hypertension. What is the best method for assessment of the blood pressure? A. In both arms B. Standing and sitting C. Supine position D. After exercising

A Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed and this results in a false high BP in that arm.

The nurse is caring for a client who is involved in an abusive relationship. The nurse understands that during the "tension building" phase, the battered client may experience which of these feelings? A. Helplessness B. Optimism C. Anger D. Calm

A Intimate partner violence and abuse is all about gaining and maintaining total control over the victim. Victims of abuse often have poor self-esteem. They feel helpless and believe no one can help them. In the tension-building phase, the abuser finds more things to criticize and becomes more cruel. Victims may become more compliant or withdraw; they cannot allow themselves to become angry or fight back. The fear of violence is often as coercive as the violence itself.

The nurse is discharging a client after a laparoscopic cholecystectomy. Which finding should the client be instructed to report to the primary care provider? A. Temperature of 101 F (38.3 C) B. Seeing spots of blood on the Band-Aids® C. Experiencing shoulder pain D. Decrease in appetite

A Laparoscopic surgery allows quick discharge and recovery. However, clients need to know what to expect and which postop discomforts are reportable. A temperature of 101 F (38.3 C) and above may signal infection and should be reported. The other listed symptoms are expected after this surgery. Shoulder pain (ranging from mild to severe) is due to the CO2 gas injected during surgery; it will dissipate within days. Band-Aids or other small dressings will be placed over the small incision sites and may have some spots of blood on them. It may take a day or two before appetite returns to normal.

Which statement describes factors that help build personal power in an organization? A. Goals are met with the use of networking, mentoring, and coalition building B. High visibility and formal power are maintained with a confrontational style C. Longevity in an organization, associating with people in power positions, and a history as someone who does not back down. D. Credibility to one's position is enhanced when professional dress and demeanor are employed

A Networking, mentoring, and coalition building are positive uses of personal power to meet goals.

A polydrug user has been in recovery for eight months. The client has been skipping breakfast, not eating regular dinners, and frequenting bars to "see old buddies." The nurse should understand that the client's behaviors are warning signs to indicate what situation? A. Heading for relapse B. Needing increased socialization C. Feeling hopelessness D. Approaching recovery

A Recovery from addictions takes 9 to 15 months to adjust to a lifestyle free of chemical use. Clients need to acknowledge that relapse is a possibility and to identify early signs of relapse. The behaviors given in the stem strongly suggest relapse.

A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol? A. Bed in lowest position, wheels locked, bed placed against the wall B. Knees bent, head slightly elevated, bed in lowest position C. Four side rails up, wheels locked, bed closest to door D. Lower side rails up, upper wheels locked, bed facing doorway

A Restraints are anything that will limit the movement of a client and side rails should not be used as a substitute for protective restraints. If a client is at risk for getting out of bed unsupervised and/or is a fall risk, then other precautions must be made, such as using a bed that is low to the ground (sometimes pads are also placed on the floor) or placing the bed against the wall (but the side rail cannot be up on the side that's not against the wall.) Bed alert systems and/or arranging for a sitter are other alternatives.

The nurse is measuring blood pressure at a community health fair. When the nurse tells someone that his blood pressure is 160/96 mm Hg, he states, "My blood pressure is usually much lower." What is the best response to this statement? A. "Get your blood pressure checked again within the next 48 to 72 hours" B. "Check your blood pressure again in a few months." C. "See your health care provider immediately." D. "Make an appointment to see your health care provider next week"

A The blood pressure reading is moderately high and should be rechecked within a few days. Since the client states it is "usually much lower" the elevated BP could be a concern but it is not clear what the client considers to be a "much lower" BP. The nurse should measure the blood pressure in the other arm and compare the two readings. Waiting two or three weeks for follow-up is too long.

The nurse is called to the front desk of a women's health clinic where an irate client is loudly demanding that she needs a prescription for alprazolam. "I feel nauseated, I'm stressed with work and caring for my mother who has dementia and I can't sleep. My neighbor has been giving me some Xanax and I want my own prescription, now!" What is the nurse's priority action? A. Take the patient to a quiet room and assess for acute withdrawal from benzodiazepines. B. Inform the patient that the physician will be with her soon and she should have a seat in the waiting room. C. Provide the patient with pamphlets and a referral to a self-help group for caregivers of the elderly. D. Anticipate the need for flumazenil to counteract the effects of alprazolam.

A The client is demonstrating several signs of acute withdrawal from a benzodiazepines, including irritability, sleeplessness and nausea. The priority action would be to assess the client for acute withdrawal and anticipate a tapering dose. While the physician will need to evaluate the client, the nurse can take a history and perform a nursing assessment and establish a therapeutic relationship. The client will eventually need a variety of referrals to help with identified stressors, but this can wait until after treatment for withdrawal. Flumazenil is a benzodiazepine receptor antagonist and precipitates acute withdrawal.

The client is diagnosed with panic disorder. Which of the following responses is a classic finding in clients experiencing a panic attack? A. Sense of impending doom B. Predictable episodes C. Fear of common activities D. Compulsive behavior

A The feeling of overwhelming and uncontrollable doom is a classic characteristic of a panic attack. The other options may be associated with panic disorder and may be unique to individuals.

An 82 year-old client reports having chronic constipation. To improve bowel function, the nurse should first suggest which approach? A. Increase fiber intake to 20-30 grams daily B. Monitor for a balance between activity and rest C. Avoid binding foods such as cheese and chocolate D. Use of laxatives when necessary

A The incorporation of high fiber into the diet is an effective way to promote bowel elimination in the older adult. Furthermore, health care providers will typically want to begin with a non-pharmacologic intervention for managing chronic constipation, particularly in older adults. However, clients should be instructed not to add too much fiber too quickly because this can promote intestinal gas, abdominal bloating and cramping. They should instead gradually increase fiber in their diets and be sure to have sufficient fluid intake. The other options may be recommended later based on additional findings.

The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? A. Dry off infant with a warm blanket or towel B. Apply identification bracelets C. Assign the one-minute APGAR score D. Obtain vital signs

A The priority interventions are in recovering a normal newborn. Maintaining the infant's temperature by drying, warming, and removing any wet blankets or towels are the priority interventions. All interventions are correct, but warming and drying would be the priority.

A 6 year-old child with moderate edema and severe hypertension associated with acute glomerulonephritis (AGN) is admitted to the hospital. Which intervention would be the priority for the nurse? A. Establish seizure precautions B. Encourage the child to eat protein-rich foods C. Administer prescribed antibiotics D. Relieve boredom through physical activity

A The severity of the acute phase of AGN is variable and unpredictable. A child with edema, severe hypertension and gross hematuria may be subject to complications such as the development of hypertensive encephalopathy. Assessment for findings such as headache, confusion and vomiting is indicated as well as institution of seizure precautions. The child would typically be on bed rest during the acute phase. Dietary restrictions should include fluids, protein, sodium and potassium. Although antibiotics may be indicated if a bacterial infection is still present, this is not the priority action.

A 3 year-old child is brought to the pediatric clinic after experiencing the sudden onset of irritability, thick muffled voice, croaking on inspiration and skin that's hot to the touch. The child sits leaning forward, tongue protruding, drooling and has suprasternal retractions What should the nurse do first? A. Notify the health care provider of the child's status B. Collect a sputum specimen C. Examine the child's throat D. Prepare the child for x-ray of upper airways

A These findings suggest epiglottitis, which is a medical emergency. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate medical attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete obstruction.

A nurse is to administer a liquid medication to a 9 month-old infant. Which method is appropriate? A. Administer the medication with a syringe next to the tongue B. Hold the child upright and administer the medicine by spoon C. Mix the medication with the infant's formula in the bottle D. Allow the infant to drink the liquid from a medicine cup

A Using a needleless syringe to slowly give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.

A nurse is teaching parents about the treatment plan for a 2 week-old infant with tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report which finding? A. Changes in level of consciousness B. Feeding problems C. Poor weight gain D. Fatigue with crying

A While parents should report any of these findings, they need to call 911 immediately if the level of consciousness decreases, or the infant becomes unresponsive. This indicates anoxia, which may lead to death, and is a medical emergency. The structural defects associated with tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages. The other findings can indicate the development of heart failure in an infant.

A 17 year-old client is newly admitted to the emergency department with a spinal cord injury, suspected to be at the level of the 2nd cervical vertebrae. A nurse's priority assessment should be which of the following? A. Muscle weakness B. Respiratory function C. Bladder control D. Response to stimuli

B A spinal injury at the C-2 level results in quadriplegia with impairment of neural control of respiration. While the client will experience all of the problems identified, the respiratory function is the highest priority (A-B-Cs). This client will need intubation and long-term mechanical ventilatory support.

An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? A. Very low-calorie diets often have severe and irreversible side effects. B. Very low-calorie diets are intended for short-term use only. C. Very low-calorie diets are adequate if balanced with fruits and vegetables. D. Very low-calorie diets are appropriate for long-term weight management.

B A very low-calorie diet (VLCD), less than 1,000 calories a day, is a short-term weight loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5 pounds per week. Anyone considering this type of diet should be under the care and supervision of a health care provider (HCP). VLCDs are generally considered safe and common side effects, such as fatigue, constipation or diarrhea, are usually minor and improve within a few weeks. The best way to maintain weight loss though, is through a combination of behavioral therapy, exercise and more modest caloric restrictions of around 1,200 calories per day. Every diet should contain fruits and vegetables, but those foods are low in calories and would not make a VLCD more balanced.

The nurse works in a pediatric hospital. Which action should be planned in the care of an 18 month-old child? A. Engage the child in games with other children B. Encourage the child to feed self with finger foods C. Hold and cuddle the child frequently D. Allow the child to walk independently on the nursing unit

B According to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living that allow toddlers to assert their budding sense of control.

A nurse is caring for a child receiving albuterol inhaled for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation by the nurse is correct? A. "The medication is given to reduce the secretions that block the airways." B. "Proventil will relax the smooth muscles in the airways." C. "The respiratory center in the brain that controls respirations will be stimulated." D. "It will decrease the swelling in the airways."

B Albuterol (a short acting beta-adrenergic agonist) is the drug of choice to treat asthma. It is used to prevent and treat wheezing, difficulty breathing and chest tightness. It works by relaxing and opening the airways to make breathing easier (which is why it is categorized as a bronchodilator). Albuterol comes as a tablet, syrup an extended-release tablet; it can also be inhaled by mouth using a nebulizer.

A 40 year-old male, with a history of intravenous drug use, is seen in the emergency department with severe myalgia and a petechial rash. The initial diagnosis is infective endocarditis (IE). Which approach would be the priority to help confirm the diagnosis? A. Chest x-ray B. Two sets of blood cultures C. Echocardiogram D. Complete blood count and coagulation panel

B All options are expected components of any workup of suspected IE. The key to making a diagnosis is blood cultures; at least two sets (usually more) of blood cultures must be collected (with separate venipunctures). Echocardiography can help detect IE for clients with a nondiagnostic blood culture result (usually seen with fungal infections). A chest x-ray can detect embolic abscesses. A variety of other baseline blood tests are also ordered, such as a CBC, BUN, electrolytes, creatinine, glucose and coagulation panel.

A newly promoted nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach? A. Use simple questions requiring "yes" and "no" answers to gain definitive information B. Obtain an interview guide from human resources (HR) for consistency in interviewing each candidate C. Vary the interview style for each candidate to learn different techniques D. Ask personal information of applicants to ensure they can meet job demands

B An interview guide used for each candidate enables the nurse manager to be more objective in decision making. The nurse manager should use resources available in the agency before the manager attempts to develop one from scratch. Certain personal questions are prohibited, and HR can identify these for novice managers.

The nurse is caring for a client with Parkinson's disease. Which finding indicates that the client might be experiencing an adverse side effect from the dopamine-enhancing drugs? A. Urinary retention B. Hallucinations C. Kidney failure D. Hypertensive urgency

B Carbidopa-levodopa-entacapone is the treatment of choice for clients with Parkinson's disease. Common side effects include dyskinesia, confusion and dizziness. Serious side effects include hallucinations, paranoia and agitation. Hallucinations may be relieved by decreasing the dose of levodopa, but this may decrease the effect of the drug on the motor symptoms of Parkinson's disease.

The nurse is caring for a post myocardial infarction client in the intensive care unit. It is noted that urinary output has dropped from 60-70 mL per hour to 20 mL per hour. This change is most likely due to which of the following issues? A. Dehydration B. Decreased cardiac output C. Renal failure D. Diminished blood volume

B Cardiac output and urinary output are directly correlated. Poor cardiac output causes decreased renal perfusion, and therefore a decrease in urine output. The nurse should suspect that a drop in cardiac output has occurred if the urinary output drops. As a consequence, renal function will be compromised and a rise in creatinine will be seen within the next 24 hours. Electrolytes that are excreted renaly, such as potassium, should also be monitored with decreasing renal function.

A client visits a community clinic for the treatment of recurrent pelvic inflammatory disease (PID). The nurse should plan to teach this client with the knowledge that this condition most frequently follows which type of infection? A. Syphillis B. Chlamydia C. Trichomoniasis D. Herpes simplex 2

B Chlamydia and gonorrhea infections are the most frequent cause of pelvic inflammatory disease. A complication of recurrent infection is the obstruction and scarring of the fallopian tubes, resulting in infertility. These sexually transmitted infections often have subtle findings; therefore they are often not diagnosed early in their course, before more widespread infection and complications occur. This also prevents appropriate detection and treatment before transmission to others during sexual activity.

The client is diagnosed with emphysema. What information should the nurse emphasize when teaching this client about nutritional needs? A. Perform exercise after respiratory therapy to enhance appetite B. Use oxygen during meals to improve gas exchange C. Increase intake of dairy products to soothe the throat D. Eat foods high in sodium to increase sputum liquefaction

B Clients diagnosed with emphysema breathe easier when using oxygen while eating. This facilitates the digestion of the food as well as keeping the oxygen available for the rest of the body. Dairy and other mucous-producing foods, as well as gas-producing foods, should be avoided. Reducing salt intake is also recommended.

The nurse is teaching a client about precautions while taking warfarin. The client should be instructed to avoid which type of over-the-counter medication? A. Laxatives containing magnesium salts B. Non-steroidal anti-inflammatory drugs (NSAIDs) C. Histamine blockers D. Cough medicines with guaifenesin

B Clients should be warned not to take aspirin and other NSAIDs while taking warfarin. The combination may increase the response to warfarin and increase the risk of bleeding. If the health care provider prescribes the two medications together, the client will need to have bleeding times checked more frequently.

A client has received the first dose of fluphenazine two hours ago. The client suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other action should a nurse implement? A. Immediately place the client in a seclusion room B. Have respiratory support equipment available C. Administer PRN dose of an antipsychotic medication intramuscularly D. Assess the client for anxiety and agitation

B Clients who receive neuroleptic medication and experience torticollis and involuntary muscle movement are demonstrating side effects that could lead to respiratory failure.

A nurse is reviewing the medication administration record (MAR) for a 72 year-old client scheduled to have a cardioversion. Prior to the procedure, the nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A. Diltiazem (Cardizem) B. Digoxin (Lanoxin) C. Nitroglycerin ointment D. Metoprolol (Toprol XL)

B Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation during and after cardioversion. The other medications do not increase ventricular irritability.

The nurse is preparing to administer morning medications. Prior to administering diltiazem, what action should the nurse perform first? A. Assess lung sounds B. Measure blood pressure C. Measure urine output D. Auscultate the abdomen for bowel sounds

B Diltiazem is a calcium channel blocker that causes systemic vasodilation and lowers the heart rate. It is used to treat hypertension. It can also be used to control angina and some heart rhythm disorders. The nurse should measure the client's blood pressure before administering this medication.

A nurse is caring for a 75 year-old client who is in heart failure. Which finding suggests that digoxin (Lanoxin) levels should be checked? A. Constipation B. Extreme fatigue C. Increased appetite D. Intense itching

B Extreme fatigue and weakness are common and early signs of digoxin toxicity, which would be confirmed by a high blood serum level of digoxin. Digoxin is toxic at 2.0 mEq/L.

A nurse prepares to administer eye drops to a 6 year-old child. Which of these descriptions describes the correct method for the instillation of eye drops? A. Directly on the anterior surface of the eyeball B. In the conjunctival sac as the lower lid is pulled down C. Under the upper lid as it is pulled upward D. In the corner where the lids meet

B Eye drops should be placed in the sac between the eye and the lower lid. This sac is formed by pulling the lower lid down.

The health care team is planning discharge for a 90 year-old client diagnosed with musculoskeletal weakness. Which intervention would be the priority to help prevent falls in the home? A. Begin therapy for muscle strengthening and balance B. Place night lights in the bedroom and bathroom C. Wear eyeglasses and hearing aid D. Take calcium and vitamin D supplements

B Family members and the client should understand the simple actions they can take to help prevent falls in the home. More falls occur in the bedroom than in any other location; a simple environmental change would be to add night lights in the bedroom and bathroom. Muscle strengthening and balance exercises, taking calcium and wearing glasses may be all indicated for this client, but using night lights is an immediate and effective action to help prevent falls.

A client in the emergency room is given 100 mg meperidine hydrochloride (Demerol) and 50 mg hydroxyzine hydrochloride (Vistaril) IM for pain related to a fractured lower right leg. One hour later, the client reports the "pain is getting worse." The nurse should recognize that the client may be developing which complication? A. Thromboembolitic complications B. Acute compartment syndrome C. Fatty embolism D. Osteomyelitis

B Increasing pain that is not relieved by narcotic analgesics is a possible sign of compartment syndrome after a bone fracture. It requires immediate action by the nurse to prevent permanent muscle damage. Thromboembolic complications, such as deep vein thrombosis and pulmonary embolism, are not characterized by increasing pain at the site of injury. Both pulmonary embolism and fat embolism are associated with sudden changes in respiratory status. Osteomyelitis is a bone infection that could occur some time after the initial injury, typically around 48 to 72 hours later.

A client is admitted with a diagnosis of acute bacterial endocarditis. Which finding would alert the nurse to a complication of this condition? A. Macular rash B. Pain and pallor in one foot C. Hemorrhage D. Heart murmur

B Large, soft, rapidly developing vegetations grow on the heart valves in bacterial endocarditis. These vegetations may break off and travel through the blood stream, lodging in small vessels and resulting in necrosis of the tissue distal to the embolus. Pain and pallor are findings in acute embolic arterial occlusion of an extremity, necessitating rapid intervention to restore circulation and save the foot. Other findings would include pulselessness, parasthesia, paralysis and poikilothermia (coldness), known as the 6 Ps of ischemia. Heart murmur is a common finding in endocarditis, and clients with murmurs caused by valve damage are at highest risk of developing endocarditis.

A nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A. May drink as much milk as desired B. Should be limited to three to four cups of milk daily C. Will benefit from fat-free cow's milk D. Can have milk mixed with other foods

B More than 32 ounces of milk a day considerably limits the intake of solid foods with results of a deficiency of dietary iron, as well as other nutrients.

A nurse is caring for a client with heart failure. Which finding requires the nurse's immediate attention? A. Crackles in lungs B. Pulse oximetry of 85% C. Diaphoresis D. Nocturia

B Oxygen saturation of 88% or less indicates hypoxemia and requires the nurse's immediate attention.

A preterm newborn develops nasal flaring, cyanosis and diminished unilateral breath sounds. The health care provider's diagnosis is a spontaneous pneumothorax. Which procedure should a nurse prepare for first? A. Cardiopulmonary resuscitation B. Insertion of a chest tube C. Humidified oxygen therapy using face mask D. Assisted ventilation

B Premature infants, infants on mechanical ventilators or who have lung diseases (such as respiratory distress syndrome) are at risk for pneumothorax. If a newborn's breathing is labored or if the level of oxygen in the blood declines, the air must be removed rapidly from the chest cavity by inserting a chest tube. Asymptomatic pneumothorax can be treated by placing the infant in a 100% oxygen hood; oxygen will enter the stomach when a face mask is used.

The nurse is caring for a client admitted to the acute care setting with a diagnosis of Guillain-Barré. While reviewing the client's chart, which of the following orders would the nurse question? A. Schedule surgery for a tracheostomy B. Administer pyridostigmine (Mestinon) C. Physical therapy and occupational therapy consults D. Obtain vital signs prior to plasmapheresis

B Pyridostigmine (Mestinon) is an anticholinesterase/cholinesterase inhibitor medication used to treat myasthenia gravis. All the other options are treatments for Guillain-Barré. Plasmapheresis is a blood purification procedure used to treat autoimmune diseases; it reduces the severity and duration of the Guillain-Barré episode. During the acute phase of the disease, the client may be totally paralyzed and may need to be placed on a respirator. Once recovery begins and the client recovers limb control, physical therapy is ordered.

The perioperative nurse must place the anesthetized client into the lithotomy position for a cystoscopic procedure. What is the safest technique for moving the client into this position? A. Gently externally rotate the hips and flex the knees one at a time before placing in padded stirrup B. Ask for assistance to raise both legs simultaneously, then to flex both knees and place legs in padded stirrups C. First raise one leg, flex the knee and place leg in a padded stirrup; repeat with other leg D. Abduct the legs and then flex the knee of one leg before placing in padded stirrup; repeat with other leg

B Raising both legs simultaneously and flexing the knee prevents excessive stretching and potential nerve damage.

A client who is recovering from addiction to alcohol asks a nurse, "Will it be OK for me to just drink at special family gatherings?" Which response by the nurse is appropriate? A. "At your next Alcoholic Anonymous meeting discuss the possibility of limited drinking with your sponsor." B. "In the recovery phase, as well as for the rest of your life, you cannot return to drinking without starting the addiction process over." C. "At this phase you have to be very careful not to lose control. Therefore, confine your drinking only to family gatherings." D. "Since you are in recovery, you need to get in touch with your feelings. Do you want a drink?"

B Recovery from alcohol, as well as recovery from other substance addictions, requires total abstinence from the desired substance. To take one drink or one puff on a cigarette has a high potential for the return to addictive behaviors.

The nurse is preparing a client for a myelogram scheduled at 9 am. Which statement made by a client indicates a contraindication for this test? A. "I think I may be allergic to shellfish." B. "I took my regular dose of warfarin last night." C. "I suffer from claustrophobia and hate loud noises." D. "I had a severe headache after a spinal tap last year."

B Relative contraindications to myelography include history of an adverse reaction to the iodinated contrast media; an allergy to shellfish is no longer considered a contraindication. Clients who are on anticoagulant therapy such as warfarin (Coumadin) are supposed to discontinue these drugs prior to undergoing myelography for about 48 hours before and 24 hours after the myelogram. A headache after a spinal tap is often caused by lack of fluids after the procedure. Claustrophobia and an aversion to loud noises would be an issue for someone undergoing a MRI.

The nurse caring for a 9 year-old child realizes a medication error has occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? A. Risk for fluid volume deficit related to morphine overdose B. Ineffective breathing patterns related to central nervous system depression C. Altered nutrition related to inability to control nausea and vomiting D. Decreased gastrointestinal mobility related to mucosal irritation

B Respiratory depression is a life-threatening risk in a narcotic overdose.

First-time parents bring their 5 day-old infant to the pediatrician's office with concern about the infant's breathing pattern. A nurse assesses the infant and finds the breath sounds are clear with equal chest expansion. Respiratory rate is 38 to 42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings? A. The pediatrician must examine the baby B. This breathing pattern is normal C. A future referral may be indicated D. Emergency equipment should be available

B Respiratory rates in a newborn, which is the initial four weeks of life, is 30 to 60 breaths/minute. Periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the parents that this is an expected finding and is known as "periodic breathing" and occurs as the newborn lungs and brain become more coordinated.

A nurse prepares to care for a 4 year-old child newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay attention to the function of which area of the body? A. The leg bones B. The muscles C. The kidneys D. The cerebellum

B Rhabdomyosarcoma is the most common children's soft tissue sarcoma. It originates in striated (skeletal) muscles and can be found anywhere in the body. The clue is in the middle of the word "myo," which typically means muscle.

The nurse is caring for a client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which item should prompt questions about the safety of this medication? A. Diagnosis of vascular disease B. Prescribed monoamine oxidase (MAO) inhibitor C. History of obesity D. Reported frequent use of antacids

B SSRIs, including fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro) and others, should not be taken concurrently with monoamine oxidase inhibitors (MAOIs) because serious, life-threatening reactions may occur with this combination of drugs. Common MAOIs include: isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), and selegiline (Eldepryl, Zelapar).

A nurse is going over medication instructions with a client who is taking digoxin. The nurse should reinforce to the client to report which of these side effects? A. Rash, dyspnea, edema B. Nausea, vomiting, fatigue C. Hunger, dizziness, diaphoresis D. Polyuria, thirst, dry skin

B Side effects of digoxin toxicity include fatigue, nausea, vomiting, anorexia, and bradycardia. Digoxin inhibits the sodium potassium ATPase, which makes more calcium available for contractile proteins and this results in an increased cardiac output.

The home care nurse is teaching the client about managing heart disease at home. What lifestyle change will promote comfort and potentially help prevent a medical crisis and unwanted hospitalization? A. Record and monitor daily weight B. Rest in an armchair instead of lying in bed C. Relax and contract leg muscles D. Participate in a progressive exercise routine

B Some people with heart failure may need bed rest, but the client's upper body should be elevated. For most clients, resting in an armchair is better than lying in bed because this decreases cardiac workload and facilitates breathing. Exercise may not be appropriate for all people with heart failure, but strength training, for example, can be useful to keep muscles from deteriorating. Monitoring and recording daily weight and relaxing and contracting leg muscles are important lifestyle changes, but they don't directly promote comfort.

Upon admission to an intensive care unit, a client diagnosed with an acute myocardial infarction is ordered oxygen per nasal cannula. The nurse should care for the client with the knowledge that the major reason for the oxygen order in this situation is for what purpose? A. To decrease the risk for cyanosis B. To increase the oxygen delivered to the myocardium C. To saturate the red blood cells with oxygen D. To relieve or prevent dyspnea

B The border tissues around the injured myocardium are ischemic. Oxygen administration will help to prevent or relieve dyspnea and cyanosis associated with the condition. However, the major purpose is to increase the oxygen concentration in the damaged myocardial tissue.

The nurse is teaching the client how to properly use a dry powder capsule inhaler. How should the nurse instruct the client to use this type of inhaler? A. Shake the inhaler before putting it in the mouth B. Seal the lips tightly around the mouthpiece and inhale rapidly and deeply C. Rinse the mouthpiece in hot soapy water after using D. Breathe in the medicine slowly and deeply breathe for about three to five seconds

B The client should breathe in quickly and deeply for up to 10 seconds when using a dry powder capsule inhaler. The client should not shake this type of inhaler. The mouthpiece can be rinsed with warm water but without soap or detergent.

A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse should expect the client to have which of the following findings? A. Scrotal discoloration B. Heaviness in the affected testicle C. Inability to achieve erection D. Sustained painful erection

B The feeling of heaviness in the scrotum is related to testicular cancer. Sexual performance and related issues are not affected at this time.

The nurse is assessing a client with myasthenia gravis who has a dose of pyridostigmine (Mestinon) ordered for 7 am. Prior to giving the medication the nurse observes and notes diplopia, dysphagia and a weak cough. The client has ordered breakfast for 8 am. Which of the following actions should the nurse take first? A. Give the client edrophonium chloride (Tensilon) B. Administer the pryidostigmine as soon as possible C. Hold the medication and notify the health care provider D. Assess for lower extremity weakness

B The findings indicate the need for the medication to be administered promptly to decrease the symptoms of muscle weakness and facilitate the client's ability to eat breakfast. Lower extremity weakness is expected in this diagnosis and is not relevant to the situation. Holding the medication would only be an option if a cholinergic crisis is suspected. Edrophonium chloride (Tensilon) is typically administered for diagnostic purposes, not for treatment.

A nurse walks into a client's room and finds the client lying still and silent on the floor. What should the nurse do next? A. Determine if anyone saw the client fall B. Establish that the client is unresponsive C. Assess the client's airway D. Call for help

B The first step in CPR is to establish responsiveness. The nurse would then call for help and check the victim's pulse (for at least five seconds, but not more than 10 seconds). If there is no pulse, the nurse would perform chest compressions. Remember, after determining unresponsiveness and pulselessness, the steps are: C-A-B: C = compressions, A = airway, and B = breathing.

During a staff meeting, the nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse's contribution and begins to find objections to the suggestion. The nurse manager's best response is which one of these approaches? A. "Let's move on to a new action that deals with the problem." B. "Let's move to the 'what if...' as related to these objections and explore ideas related to this situation." C. "Very well thought out. Your analytic skills and interest are incredible." D. "I think you need to reserve judgment until after all suggestions are offered."

B The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Exploration of the nurse's objections would encourage the generation of new ideas.

The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is most appropriate? A. Place the child in a supine position B. Observe swallowing patterns C. Allow the child to drink through a straw D. Offer ice cream every two hours

B The nurse should observe for increased frequency of swallowing, which would signal hemorrhage.

The nurse prepares to give a 1 year-old child an intramuscular injection. At what site should the nurse administer the injection? A. Ventrogluteal B. Vastus lateralis C. Dorso gluteal D. Deltoid

B The preferred site for an injection for an infant is the vastus lateralis muscle, which lies along the lateral aspect of the thigh. This site is able to tolerate larger volumes, and it is not located near any nerves or blood vessels.

The nurse reviews a new order: infuse 1000 mL D5W with 100 mEq KCl intravenously at a rate of 50 mL/hour. What action should the nurse take? A. Verify the information in the order and prepare to administer the IV solution B. Contact the prescriber and point out a concern about the amount of KCl ordered C. Ask another nurse for a second opinion about the order before checking the client's labs D. Ask another nurse to observe adding 100 mEq KCl to the IV solution

B There is no indication if the IV solution is for peripheral or central administration, but the maximum concentration of KCl via a peripherial line is usually 10 mEq/100 mL; the usual infusion rate is 10 mEq per hour. The nurse should contact the prescriber to verify the amount of KCl in the order; the nurse should not ask another nurse for assistance. Prior to calling the prescriber, the nurse should obtain the latest lab results for potassium. Since KCl is a high alert medication, having two independent checks is recommended (but only after the ordered amount is verified.) If infused too rapidly or in too high a dose, KCl can cause arrhythmias and cardiac arrest.

The nurse should understand an adolescent's need for autonomy. Which intervention demonstrates the nurse's sensitivity? A. Explores feelings of resentment to identify causes for behaviors B. Provides opportunity to discuss concerns without the presence of any parent C. Allows young siblings to visit the client whenever they want to D. Alertness for the adolescent's feelings about body image

B This intervention provides the teen with the opportunity to have control and encourages decision making through talking with a neutral person. Body image has no connection to the asked question. The other two options introduce new content into the situation of visiting of siblings and resentment feelings and are unlikely to be the correct answer.

At 40-weeks gestation, a client in active labor is admitted to the labor and delivery unit. Based on the trend in cervical examination findings listed in the table below, what does the nurse anticipate for this birth? Timeline 8 am Dilation: 4 centimeters Effacement: 30% 9 am Dilation: 7 centimeters Effacement: 60% 10 am Dilation: 9 centimeters Effacement: 90% A. Maternal episiotomy B. Fetal hypoxia C. Neonatal APGAR score of 9 at one minute D. Maternal happiness and anticipation

B This labor is precipitous, which is defined as active labor lasting less than three hours. Because the contractions are coming rapidly, with little time in between contractions, there is a risk of fetal hypoxia. Maternal episiotomy is incorrect because there is little time for this (lacerations would be anticipated). Due to the potential for fetal hypoxia, the APGAR score would be lower than 9. Extremely rapid delivery can be anxiety-provoking for the client (and partner). When the actual birth event is not what is expected, other reactions may include hostility, fear and disappointment.

The parents of a newborn male with hypospadias want their child circumcised. Which of the following statements made by the nurse would provide the best information to the parents? A. "There is no medical indication for performing a circumcision on any child." B. "Circumcision is delayed so the foreskin can be used for the surgical repair." C. "This procedure is contraindicated because of the permanent defect." D. "The procedure should be performed as soon as the newborn is stable."

B With the birth of a healthy baby boy, parents need to decide what is best for their son, based on their religious, cultural and personal preferences. However, even if only mild hypospadias is suspected, a circumcision is not done in order to save the foreskin for surgical repair if needed.

A client who lives in a long-term care (LTC) facility (nursing home) is placed on contact precautions when drainage from a wound tests positive for methicillin-resistant Staphylococcus aureus (MRSA). What interventions should the nurse include in the care of the client? (Select all that apply.) A. Plan to transfer the client to the hospital. B. Move the client to an available private room. C. Educate the client on good personal and hand hygiene. D. Monitor staff compliance with using required personal protective equipment (PPE). E. Notify the client's family that no visitors are allowed until the infection is cured. F. Collaborate with the facility infection preventionist on treatment for the wound.

B,C,D,E Recommendations are very straightforward for the placement of clients with MRSA colonization and infection in a hospital—a private room is preferred. Recommendations for placement in an LTC facility are not as clear cut. Some guidance on the use of contact precautions in an LTC facility is given in the CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007.Make decisions regarding client placement on a case-by-case basis, balancing infection risks to other clients in the facility, the presence of risk factors that increase the likelihood of transmission and the potential adverse psychological impact on the infected or colonized client.When single-client rooms are available, assign priority for these rooms to clients with known or suspected multi-drug resistant organism (MDRO) colonization or infection. Give highest priority to those clients who have conditions that may facilitate transmission, such as uncontained secretions or excretions and lack of compliance with personal and hand hygiene due to cognitive deficits.An LTC infection preventionist should collaborate on the care plan of all clients with wounds in the facility and monitor any infections they might have.It is not necessary to transfer the client to a hospital or limiting the client's visitors at this time. On the contrary, limiting visitors would constitute interference with the client's rights and dignity.

The nurse is caring for an 8-month-old infant who has perinatally acquired Human Immunodeficiency Virus (HIV) infection. Which clinical manifestations should the nurse monitor the infant for? (Select all that apply.) A. Autism B. Failure to thrive C. Developmental delays D. Hepatomegaly E. Recurrent diarrhea F. Kaposi sarcoma

B,D,E The majority of infants with perinatally acquired HIV infection are clinically normal at birth. Common clinical manifestations of HIV infection in children vary and include such signs as lymphadenopathy, hepatosplenomegaly and unexplained diarrhea. Diarrhea may be the result of pathogens or of HIV itself, due to malabsorption of carbohydrate, protein and fat. HIV-infected children often do not grow normally. They may be proportionally smaller in both length and weight for their age.Kaposi sarcoma, one of the hallmarks of adult acquired immunodeficiency syndrome (AIDS), is found in less than 1% of affected children.Autism or developmental delays are not conditions associated with HIV or AIDS.

When evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. Rank in order of priority the interventions the nurse should take (with 1 being the first action). Drag and drop options into the correct order. A. Notify primary health care provider B. Change the woman's position C. Discontinue oxytocin infusion D. Document interventions E. Provide oxygen by face mask F. Administer IV fluids bolus

B,F,E,C,A,D The term intrauterine resuscitation is sometimes used to refer to the interventions initiated when a nonreassuring FHR pattern is noted. These interventions are directed primarily toward improving uterine and intervillous space blood flow. They also increase maternal oxygenation and cardiac output, which will promote fetal well-being. The correct order of actions are: change positions, administer IV fluid bolus, provide oxygen, discontinue oxytocin, and notify the health care provider.

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Present findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are appropriate? A. Increased sodium and fluids B. Increased potassium and protein C. Decreased sodium and potassium D. Decreased carbohydrates and fat

C Children with AGN who have edema, hypertension oliguria, and azotemia have dietary restrictions which are to limit sodium, potassium, fluids and protein.

The nurse has established a psychotherapeutic relationship with a client. The nurse understands that a therapeutic nurse-client interaction occurs when a nurse takes which of these actions? A. Advises the client on ways to resolve problems B. Praises the client for appropriate feelings and behavior C. Assists the client to clarify the meaning of what the client has said D. Interprets the client's covert communication

C Clarification is the facilitation of a therapeutic communication strategy for a nurse-client interaction. Interpretation, changing the focus/subject, giving approval, and advising are non-therapeutic and barriers to communication.

A client is admitted to a voluntary hospital mental health unit with the diagnosis of suicidal ideation. The client has been on the unit for two days and now states, "I demand to be released now!" The appropriate response from the nurse should be which of these statements? A. "You have a right to sign out as soon as we get the health care provider's discharge order." B. "You cannot be released because you are still at risk of being suicidal." C. "Let's discuss your decision to leave and then we can prepare you for discharge." D. "You can be released only if you sign a no suicide contract before you leave."

C Clients who are voluntarily admitted to the hospital have a right to demand and obtain release. By discussing the decision to leave the nurse has an opportunity to suggest or implement interventions other than discharge. The client may just need to talk through thoughts or feelings.

A client who is diagnosed with multiple sclerosis plans to begin an exercise program. What should the nurse be sure to emphasize when discussing this topic with the client? A. Avoid aerobic exercise B. Focus on strength training C. Avoid dehydration D. Dress warmly

C Clients with MS who participate in regular aerobic exercise have better cardiovascular fitness, greater strength, better bowel and bladder function, less fatigue and less depression. But the client must take in adequate fluids before and during exercise periods to prevent dehydration. It is recommended that clients with MS exercise when it is cooler and perform exercise earlier in the day to avoid fatigue.

The nurse admits a 2 year-old child who has had a seizure. Which statement by the child's parent would be important in the determination of the etiology of the seizure? A. "Red meat has been his favorite food lately." B. "In the past week the naps have been getting longer and longer." C. "An ear infection has been present for the past two days." D. "He seems to be constipated."

C Contributing factors to seizures in children include age (more commonly in the first two years), infections associated with febrile seizures (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.

The nurse is reviewing the assessment data of a client suspected of having diabetes insipidus. Which of these findings should the nurse expect after a water deprivation test? A. Increased edema and weight gain B. Decreased serum potassium C. Unchanged urine specific gravity D. Rapid protein excretion

C Diabetes insipidus (DI) is a condition in which the kidneys are unable to conserve water. Symptoms of DI are excessive thirst and excessive urine volume. Even when fluids are restricted, as with the fluid deprivation test, the client continues to excrete large amounts of dilute urine. This finding supports the diagnosis. Normally, urine is more concentrated in situations of reduced fluid intake.

The nurse is caring for a client who is experiencing urinary incontinence. Which of the following teaching points should the nurse reinforce when discussing this health issue with the client? A. Avoid eating foods high in sodium B. Restrict fluids to prevent elimination accidents C. Avoid taking antihistamines D. Hold the urine to increase bladder capacity

C Due to their anticholinergic action on the urinary sphincter and bladder, antihistamines can cause urinary retention, followed by sudden overflow incontinence. Still other antihistamines relax the bladder, which also contributes to incontinence. Avoiding sodium has not been shown to reduce or minimize urinary incontinence. Clients with incontinence should control fluid intake and not drink large amounts of fluids at one time, but they should not restrict fluids. If the bladder becomes over-stretched, the muscle may be permanently damaged and lose its ability to contract.

The nurse assesses a client who has been taking haloperidol for several months. Which adverse effect must be immediately reported to the health care provider? A. Constipation B. Dry, harsh cough C. Tongue thrusting and facial grimacing D. Muscle flaccidity

C Dystonias often involve tongue protrusions and muscle rigidity. Dystonias usually resolve after the medication is discontinued, but the client may require antihistamine and antiparkinsonian therapy. Dystonic movements have the potential of becoming irreversible and must be immediately reported to the health care provider. Some of the more common side effects of haloperidol include nausea, vomiting, diarrhea, dry mouth, nervousness, drowsiness, insomnia, and blurred vision.

The medical record review nurse is reading recorded entries. Which entry on a client's progress notes is the most complete? A. Client expresses anxiety about a low-salt diet B. Demerol 75 mg administered for severe abdominal pain C. Dark green drainage 100 mL from nasogastric tube at 0600 D. Client's urinary output adequate for the past shift

C Entries in client records need to be complete, accurate and factual. Reimbursement from third-party payers is facilitated when records are accurate, reliable and valid. The medication order lacks the route and client's response to the medication. "Anxiety" could be defined more specifically, along with the inclusion of information about the nurse's response. The criteria for "adequate" output needs to be defined.

The nurse is assessing a toddler diagnosed with croup. Which initial finding requires the nurse's immediate attention? A. Coughing up copious secretions B. Lethargy for the past hour C. Respiratory rate of 54 D. Apical pulse of 130

C Findings of impending airway obstruction in croup include increased respiratory rate and pulse; substernal, suprasternal and intercostal retractions; nostril flaring and increased restlessness or agitation. The normal respiratory rate in a 1 to 3 year-old child is 24 to 40, the normal pulse rate is 90 to 150.

A nurse is caring for a client who is diagnosed with clinical depression and is receiving a monoamine oxidase inhibitor (MAOI). When providing instructions about precautions with this medication, which point should the nurse stress to the client? A. Avoid walking without assistance B. Take frequent naps C. Avoid chocolate and cheese D. Take the medication with milk

C Foods high in tryptophan, tyramine, and caffeine, such as chocolate, wine and cheese may precipitate a hypertensive crisis.

A woman is hospitalized for treatment of pregnancy induced hypertension (PIH) in the third trimester. She is now receiving magnesium sulfate intravenously. The nurse understands that this medication is used mainly for what purpose? A. Increase uterine blood flow B. Decrease the respiratory rate C. Prevent preeclamptic seizures D. Maintain normal blood pressure

C Magnesium sulfate is a central nervous system depressant. While it has many systemic effects, it is used in the client with pregnancy induced hypertension (PIH) to prevent seizures.

A client is admitted to the coronary care unit (CCU) after experiencing a myocardial infarction. Which nursing diagnosis should be the priority? A. Risk for altered elimination: constipation B. Risk for complication: dysrhythmias C. Pain related to cardiac ischemia D. Anxiety related to pain

C Pain in myocardial infarction is related to tissue ischemia of the cardiac muscle, potentially indicating ongoing heart damage, such as extension of the infarction. Any cardiac pain/discomfort should be treated as a priority. Relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system with an outcome of potential increased preload and afterload, which further increases myocardial demands.

A client has been admitted with lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and reports being "too sick to return to work." The client is diagnosed with somatoform disorder. In formulating a plan of care, what must the nurse consider about the client's behavior? A. It is manipulation to avoid work responsibilities B. It could be modified through reality therapy C. It is controlled by the subconscious mind D. The client may respond to psychoeducational strategies

C Persons with somatoform disorder do not intend to feign illness. Their complaints are not under their conscious control. Showing intention to use feigned physical complaints to accomplish some goal is called "malingering" or a factitious disorder.

The nurse is in the process of admitting a client to an acute inpatient psychiatric unit. Which approach by the nurse will result in the most useful information? A. Observe the client's nonverbal behaviors carefully B. Allow clients to talk about whatever they want C. Elicit the client's description of experiences, thoughts and behaviors D. Adhere to preplanned interview goals and structure

C Psychiatric nurses must gather assessment data on admission that is accurate and comprehensive. Active listening to focused discussions about behaviors, feelings and insights will assist the nurse to develop and implement a personalized plan of care.

The nurse is planning care for a client with pneumococcal pneumonia. Which intervention would be most effective in promoting the clearance of respiratory secretions? A. Administer pain medications B. Maintain bed rest with bathroom privileges C. Increase in oral fluid intake to 3000 mL per day D. Administration of cough suppressants

C Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions.

A client is admitted to the hospital with findings of liver failure with ascites. A health care provider orders spironolactone. What is the pharmacological effect of this medication? A. Combines safely with antihypertensives B. Depletes potassium reserves C. Promotes sodium and chloride excretion D. Increases aldosterone levels

C Spironolactone (Aldactone) promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. It has no effect on ammonia levels.

The client is a 15 year-old female diagnosed with anorexia nervosa. During the admission process, the nurse finds a container of assorted pills in a drawer in the client's room. The client tells the nurse, "They are antacids for stomach pains." Which of these statements made by the nurse would be the best response? A. "Are you taking pills to change your weight?" B. "These pills don't look like antacids." C. "Tell me about the week prior to you being admitted." D. "Some teenagers use pills to lose weight."

C This is an open-ended, nonjudgmental statement that allows for further discussion. The topic is non-threatening and will give the nurse insight into the client's view of events leading up to admission. It is the only option that is client-centered; the other options focus on the pills. The nurse can eventually ask about the pills (and remove them from the drawer.)

A client has returned to the unit after having a renal biopsy. Which of these nursing interventions is appropriate? A. Change the dressing every eight hours B. Maintain client on NPO status for 24 hours C. Monitor vital signs more frequently D. Ambulate the client four hours after procedure

C The potential complication after this procedure is active bleeding from the site of the biopsy. Monitoring vital signs is critical to detect early indications of active bleeding. The other options are incorrect. There is no reason to ambulate every four hours or withhold food and fluids for a day.

The clinic nurse is caring for a 15 month-old child with a first episode of otitis media. Which intervention should the nurse include in the instructions to the child's parents? A. Explain that the child should complete the full five days of antibiotics B. Describe the tympanocentesis to detect persistent infections C. Emphasize the importance of a return visit after completion of antibiotics D. Provide them with handout describing care of myringotomy tubes

C The usual treatment for otitis media is oral antibiotics for 10 to 14 days. The child should be examined again after completion of the full course of antibiotics to assess for persistent infection or middle ear effusion.

Several clients all have the findings of a board-like abdomen. Which client would the nurse suggest the health care provider examine first? A. A teenager with a history of falling off a bicycle without hitting the handle bars B. A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week C. An older adult client who stated, "The awful pain in my right side suddenly stopped about three hours ago." D. A pregnant woman of eight weeks newly diagnosed with an ectopic pregnancy

C This client has the highest risk for hypovolemic and septic shock because the appendix has most likely ruptured, based on the history that over three hours ago the pain suddenly stopped. Older adult clients have less functional reserve for the body to cope with shock and infection. The others are at risk for shock also. However, given that these clients fall into younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper left abdomen, which often results in a ruptured spleen.

A client exhibits delusional behaviors and refuses to eat because of a belief that the food is poisoned. What should be the initial response by the nurse? A. "You're safe here. I won't let anyone poison you." B. "Why do you think the food is poisoned?" C. "You think that someone wants to poison you?" D. "These feelings are a symptom of your illness."

C This response acknowledges perception of the client's comment through a reflective question. This reflective question presents an opportunity for discussion, clarification of meaning and expressing doubt. It also provides for verification of the nurse's perceptions and the client's communication.

A client has undergone a cardiac catheterization procedure. Which complication should the nurse monitor for in the initial 24 hours after the procedure? A. Dizziness B. Angina at rest C. Thrombus formation D. Lowered blood pressure (BP)

C Thrombus formation in the coronary arteries is a potential problem in the initial 24 hours after a cardiac catheterization. A lowered BP may exist with hemorrhage of the insertion site, which is at highest risk within the first 12 hours after the procedure if a local plug is not used.

The nurse is caring for a client with cancer who is two days postop following the surgical creation of an ileostomy. Which of these interventions would be the most important for the nurse to implement? A. Providing emotional support B. Addressing concerns about body image C. Assessing the stoma D. Teaching the care and management of the pouch

C While all of these interventions would be appropriate, assessing the health and functioning of the stoma is the most important intervention at present to ensure stoma health and to monitor for possible complications. As the stoma starts to function, the nurse would empty the pouch, explaining the procedure to the client. Teaching is necessary to facilitate acceptance of the ostomy and to help promote self-care; self-care is vital to independence and self-esteem. Body image is often a concern following this type of surgery. Information about support groups, such as those found online, can be helpful.

When should a nurse initiate discharge planning for a client? A. When the client is informed that a date for discharge has been determined B. Immediately after a client's condition is stabilized on the assigned unit C. Upon admission to a hospital unit or the emergency department D. When the client or family demonstrate readiness to learn self-care modalities

C With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to an emergency department or hospital unit. Thus, is the thought "discharge planning begins on admission."

The nurse is preparing to discharge a client who has suffered full thickness burns to the chest and upper extremities. What home care instructions should the nurse include as part of the discharge education to the client and family? (Select all that apply.) A. "Avoid the use of emollients on affected skin and over scarred areas." B. "Eat five to six small meals that are high-protein, low carbohydrate." C. "Wear protective sleeves over your arms to prevent additional injury." D. "Physical therapy will be arranged if you develop any problems with range of motion." E. "Notify the health care provider if you experience changes in sleep or mood."

C, E Wounds and scarred areas should be covered to prevent injury to the area while it heals. The client should be instructed to use lotions or emollients on scarred skin to prevent it from becoming too dry, which can restrict movement. Hypermetabolism can last up to a year and requires the client to have a balanced diet that is high in both nutritionally dense carbohydrates and protein. Depression and anxiety are common and should be brought to the attention of the health care provider. Physical therapy is a process that starts in the acute care setting and continues for months (and sometimes years) after the initial event.

A 62 year-old male arrives at the emergency department and reports having chest pain. Based on standing orders, which intervention does the nurse expect to be implemented within the first 10 minutes of his arrival in the ED? (Select all that apply.) A. Intravenous thrombolysis B. Supplemental oxygen C. Focused cardiovascular history-taking and physical exam D. 12- lead ECG with continuous monitoring E. Blood draw for cardiac troponin F. Intravenous access

C,D,E,F All clients reporting chest pain should be managed as if the pain were ischemic in origin. Treatment in the ED begins with a focused cardiovascular history-taking and screening for alternative causes of chest pain. IV access will be established, labs drawn for cardiac markers and a 12-lead ECG (with continuous monitoring) will be used to help confirm if it is a MI. Further treatment will depend on whether the chest pain is due to a MI and the type of MI. IV thrombolysis would be used once a ST segment elevation myocardial infarction (STEMI) is confirmed. Pulse oximetry should be performed and supplemental oxygen given only to maintain oxygen saturation above 90%; supplemental oxygen may harm nonhypoxic clients with STEMI.

The nurse assesses several postpartum women. Which of these women is at the highest risk for a puerperal infection? A. Five days postpartum, temperature is 99.6 F (37.6 C) since undergoing cesarean section B. Twelve hours postpartum following vaginal delivery, temperature is 100 (37.7 C) C. Seven days postpartum, temperature is 99 F (37.2 C) since vaginal delivery D. Three days postpartum, temperature is 100.8 (38.2 C) for two days after undergoing cesarean section

D A temperature of 100.4 F (38 C) or higher on two successive days (not counting the first 24 hours after birth) indicates a postpartum infection. Puerperal infections can be due to endometritis, wound and other infections; the risk of endometritis increases after cesarean delivery. The other women are not at risk for infection because their temperatures are within the expected normal findings for the time period.

The nurse is assessing a client who is two days post-surgery and notes new and sudden onset of confusion. There is an order to discharge the client to go home today. What would be the best action for the nurse to take? A. Make a clinic appointment with the primary health provider for follow-up care the next day B. Teach a family member clean dressing change technique and address safety measures in the home C. Collaborate with the dietitian for increasing protein and calcium in the diet D. Collaborate with the health care provider about the change of condition

D Although all the responses may be correct for a post-surgical client, a status change involving confusion must be reported, particularly if it is a new finding. As an advocate for the client, the nurse should protect the client from physical harm and collaborate with the health care provider about a change in the plan for discharge.

A client is receiving nitroglycerin intravenously for unstable angina. What assessment would be a priority for the nurse to monitor for the effects of this medication? A. Respiratory rate B. Cardiac enzymes C. Cardiac rhythm strip analysis D. Blood pressure

D Because an effect of this drug is vasodilation, the client must be monitored for hypotension.

A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse? A. Nulligravida 2, Para 1 B. Primigravida 1, Para 1 C. Para 2, Gravida 1 D. Gravida 2, Para 1

D Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability. Therefore, a woman pregnant with her second child would be described as Gravida 2, Para 1. Primipara refers to a woman who has completed one pregnancy to the period of viability. Multipara refers to a woman who has completed two or more pregnancies to the stage of viability.

A client asks a nurse to explain the basic ideas of homeopathic medicine. Which response would best explain the approach of such remedies? A. Increase bodily energy B. Maintain fluid balance C. Destroy organisms causing disease D. Boost the immune system

D Homeopathic medicine treats clients with minute doses of plant, mineral or animal substances that provide a gentle stimulus to the body's own defenses.

The nurse is caring for a 10 month-old infant diagnosed with iron-deficiency anemia. Based on this diagnosis, which of these findings should the nurse anticipate? A. Poor appetite B. Hemoglobin level of 12 g/dL C. A heart rate between 80 and 130 D. Pale mucosa of the eyelids and lips

D In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild-to-severe tachycardia. The normal heart rate of infants typically ranges from 120 to 180 BPM. The normal hemoglobin range for children is about 11 to 13 gm/dL.

The parents of a school-age child are providing information to the nurse about their child. Which of these concerns would the nurse recognize as a finding that could suggest type 1 diabetes? A. Dehydration B. Being a picky eater C. Weight gain D. Bed-wetting

D In school-aged children, warning signs of type 1 diabetes include: fatigue, frequent urination (also bed-wetting), unusual thirst, extreme hunger, and weight loss. Also, diabetics usually have dry skin. The parents may not initially think anything of the polyphagia or polydipsia, but bed-wetting in a school-age child (who previously did not wet the bed at night) would prompt the parents to seek medical intervention.

At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What is the nurse's best response? A. "Have you tried waking the child to urinate?" B. "This is normal at this time of day." C. "Do you offer fluids at night?" D. "How long has this been occurring?"

D Nighttime control should be present by this age, but may not occur until age 5 years at the latest. Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons. Referral to a specialist may be needed.

A client is receiving nitroprusside intravenously for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor during the administration of this medication? A. Potassium level B. Arterial blood gasses C. Blood urea nitrogen D. Thiocyanate

D Nitroprusside (Nitropress) metabolism involves the production of cyanide (CN), which may be extremely toxic. Cyanide is normally converted to thiocyanate and is eliminated by the kidneys. The risk of thiocyanate toxicity increases in clients with underlying renal insufficiency. Thiocyanate should not be over 1 millimole/liter.

The nurse in the physician's office is assessing a geriatric client who began taking omeprazole a month ago. Which finding indicates the drug has had the desired effect? A. Blood pressure readings are lower B. Feelings of depression are not as severe C. Chronic pain level is markedly decreased D. Heartburn discomfort is lessened

D Omeprazole (Prilosec) is a proton pump inhibitor used to decrease stomach acid and relieve symptoms of gastroesophageal reflux disorder (GERD), such as heartburn. The generic spelling of most of the proton pump inhibitors end with "prazole." Be careful not to confuse omeprazole (Prilosec) with other drugs with similar names but different effects: Prozac (fluxetine is the generic name) is an antidepressant, Prinivil (lisinopril is the generic name) is an antihypertensive, and Percocet (oxycodone and acetaminophen) is a pain medication.

After talking with her partner, a client voluntarily admits herself to the substance abuse unit. The next day the client states to the nurse, "My partner told me to get treatment or we would have to get divorced. I don't believe I really need treatment, but I don't want my partner to leave me." Which response by the nurse would be of assistance to the client? A. "In early recovery it's quite common to have mixed feelings. I didn't know you had been pressured to come." B. "In early recovery it's quite common to have mixed feelings. Unmotivated people can't get well." C. "In early recovery it's quite common to have mixed feelings. Perhaps it would be best to seek treatment on an outpatient basis." D. "In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."

D Only the correct option focuses on the client and the client's problem (alcohol). This is the best response because it gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. The other options are not therapeutic and do not have the client's best interests at heart. The option about being pressured to come might encourage clients to project blame for their behavior on someone else. The option of outpatient care might be a goal for this client, but it is inappropriate to suggest outpatient counseling at this time. To label the client's behavior as "unmotivated" might simply reinforce the client's ambivalence about treatment.

A woman with a 28-week pregnancy is on the way to the emergency department by ambulance with a tentative diagnosis of placenta abruptio. Which action should the nurse take first when the woman arrives? A. Insert urethral catheter with hourly urine outputs B. Start a second IV with an 18 gauge cannula C. Check fetal heart rate every 15 minutes D. Administer oxygen by mask at 100%

D Placenta abruptio is the separation of the placenta from its attachment to the uterus wall. Administration of oxygen in this situation is the priority; it will increase the oxygen in the mother's and the fetus' circulation. This action will minimize complications of hypoxia. Additional treatment includes IV fluids and possibly a blood transfusion, which is why starting a second line with a large gauge needle is required. The fetus will be monitored for signs of distress. Additional treatment depends on the severity of the separation and the location of the separation.

Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice? A. When a family member offers information about a loved one B. When the provider decides the family has a right to know the client's diagnosis C. When a visitor insists that the visitor has been given permission by the client D. When the client threatens self-harm or harm to others

D Privacy and confidentiality of all client information is protected with the exception of the client who threatens self-harm or endangering the public, staff or family. (Tarasoff decision,1974)

A health care provider asks the nurse to assist with the obtaining consent for central line placement. The client is an adult male who is deaf. While the health care provider explains the procedure and risks to the client and a family member, the client and family member text each other using their telephones. What is the nurse's responsibility in this situation? A. Remind the health care provider to ask only one question at a time B. Request the health care provider allow extra time to explain information C. Stand next to the client and verify the information in the texts is accurate D. Interrupt and ask about obtaining interpreter services for the client

D Professional interpreter services are not only needed for clients with limited English proficiency but also for those who are deaf. The client must understand the procedure and risks associated with the procedure in order to give informed consent. If the client does not seem to understand the information, the nurse should interrupt and ask about obtaining interpreter services. Interpreter services for clients who are deaf can be provided through video remote interpreting, closed captioning and even texting. But the client's family should not be relied on to interpret medical information via texting.

A mother of a child with a neural tube defect asks a nurse, "What can I do to decrease the chances of having another baby with a neural tube defect?" What is an appropriate response by the nurse? A. "Multivitamin supplements are recommended during pregnancy." B. "Increased dietary iron improves the health of mother and fetus." C. "A well-balanced diet promotes normal fetal development." D. "Folic acid should be taken before and after conception."

D The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements prior to getting pregnant and during pregnancy. Evidence-based practice validates that increased amounts of folic acid prevents neural tube defects such as spina bifida.

After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond with which statement? A. "He has a lot of problems. You need to have patience with him." B. "I will talk with him and try to figure out what to do or what the problem is." C. "Ignore him and get the rest of your work done. Someone else can care for him the rest of the day." D. "He may be scared and taking it out on you. Let's talk to figure out what to do next."

D This response explains the client's behavior without belittling the UAP's feelings. The UAP is encouraged to contribute to the plan of care to help solve the problem. The other responses are incorrect because they either belittle the UAP or ignore the problem and do not include the UAP in planning of how to deal with the issue.

The parents of a 15 month-old child ask the nurse to explain their child's lab results and how the results show the child has iron-deficiency anemia. The nurse's response should include which statement? A. "Although the results are here, your health care provider needs to talk with you about the details." B. "The blood cells that carry nutrients to the cells are too large and indicate a lack of iron-rich food." C. "There are not enough total blood cells in your child's circulation from not eating enough foods with iron." D. "Your child has fewer red blood cells that carry oxygen and this is called anemia."

D To tell the parents that their child has fewer red blood cells that carry oxygen is a simple and clear explanation of anemia. The results of a complete red blood cell count in clients with iron-deficiency anemia will show decreased red blood cell numbers, a low hemoglobin and microcytic, hypochromic red blood cells. There is no reason to defer answering the question to the health care provider.

The nurse is reinforcing instructions to a 67 year-old client with type 2 diabetes. The client should be instructed to contact the outpatient clinic immediately if which of the following findings are present? A. Nausea with two episodes of vomiting B. Insomnia with daytime fatigue C. Temperature of 99.5 F (37.5 C) with painful urination D. An open, reddened wound on the heel

D When signs of trauma and/or infection occur in their feet, older adult clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death from sepsis may result.

The nurse is assessing a client who has paraplegia. What finding would indicate the probable presence of a fecal impaction? A. Presence of blood in stools B. Continuous rumbling flatulence C. Absence of bowel movements D. Oozing liquid stool

D When the bowel is impacted with hardened feces, there is often a seepage of liquid feces around the obstruction. This is often mistaken for uncontrolled diarrhea. This is a classic finding associated with fecal impaction.

When caring for a postpartum woman experiencing an obstetric hemorrhage associated with uterine atony, the nurse must prioritize interventions. Indicate the correct sequence of actions by dragging and dropping the interventions into the correct order. A. Administer IV fluid bolus B. Establish venous access C. Catheterize the bladder D. Massage the fundus E. Administer oxytocin (Pitocin) F. Prepare the woman for surgical intervention

D,B,A,E,C,F Postpartum hemorrhage following a vaginal delivery is defined as blood loss greater than 500 mL. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. This will express any clots and pieces of the placenta and amniotic sac that remain in the uterus, improving fundal tone. This will constrict the uterine blood vessels in the area where the placenta separated from the uterine wall to help stop the bleeding, and thus is the first priority. Establishing IV access is next so that a fluid bolus can be administered (to increase circulating volume). The IV line also provides a means to deliver oxytocin, which will further improve uterine tone, decreasing bleeding. Bladder distention can compromise normal uterine involution, so the client would be catheterized. Finally, if indicated, the client would be prepared for surgical intervention. Delegation of activities to various members of the team would be the best way to rapidly accomplish these important interventions.