PassPoint NCLEX Practice Exam
A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation?
Immediate isolation in a private room is required . Explanation: The incubation period for varicella (chickenpox) is 2 to 3 weeks, usually 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of a breakout. A person is infectious from 1 day before eruption of lesions to 6 days after the vesicles have formed crusts.
A client with ascites had a paracentesis. Which post-procedure intervention should the nurse implement?
Monitor the client's temperature. Explanation: Infection is a complication of paracentesis. The nurse needs to monitor temperature and observe for classic signs of infection. The client does not need to remain NPO, or void post-procedure. The question does not state where the catheter was placed; positioning is not a concern.
A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle accident. What would be the nurse's priority assessment?
Pulse oximetry readings Explanation: After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the C4 level, so assessment of adequate oxygenation and ventilation is necessary. Although the other options are important, observation for respiratory failure is the priority.
Which hospitalized client is at risk to develop parotitis?
an 80-year-old client who has poor oral hygiene and is dehydrated Explanation: Parotitis is inflammation of the parotid gland. Although any of the clients listed could develop parotitis, given the data provided, the one most likely to develop parotitis is the elderly client who is dehydrated with poor oral hygiene. Any client who experiences poor oral hygiene is at risk for developing parotitis. To help prevent parotitis, it is essential for the nurse to ensure the client receives oral hygiene at regular intervals and has an adequate fluid intake.
A nurse is caring for a client with bipolar disorder. The care plan for a client in a manic state would include:
listening attentively to the client's requests with a neutral attitude, and avoiding power struggles. Explanation: The nurse should listen to the client's requests, express willingness to seriously consider each request. The nurse should encourage the client to take short daytime naps because of so much energy expended. High-calorie finger foods should be offered to supplement the diet if the client can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice.
A primigravid client in early labor tells the nurse that she was exposed to rubella at about 14 weeks' gestation. After birth, the nurse should assess the neonate for which complication?
cardiac disorders Explanation: Pregnant women who become infected with the rubella virus early in pregnancy risk having a neonate born with rubella syndrome. The symptoms include thrombocytopenia, cataracts, cardiac disorders, deafness, microcephaly, and motor and cognitive impairment. The most extensive neonatal effects occur when the mother is exposed during the first 2 to 6 weeks and up to 12 weeks' gestation, when critical organs are forming. Bulging fontanels are associated with increased intracranial pressure and meningitis, which can occur as the result of a b-hemolytic streptococcal infection.
An older adult client was prescribed lorazepam 1 mg three times a day to help calm her anxiety after her husband's death. The next day, the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. Which finding would the nurse suspect as the cause of the mother's behavior, and what action would she suggest?
The client is experiencing a paradoxical reaction to the lorazepam and should stop the new medication immediately. Explanation: Paradoxical responses to benzodiazepines are more common in children and the older adult than other age groups and generally occur at the beginning of treatment. Grief and depression in the older adult is more likely to result in fatigue and withdrawal than hyperactivity and agitation. Treatment with a sleeping medication chemically related to the benzodiazepines is likely to result in an increase rather than decrease in agitation symptoms in older adult clients. A medication interaction is possible, but it less likely because most pharmacies screen for drug interactions when filling prescriptions.
A client is admitted with an eating disorder. Which client response should the nurse address first?
"I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.
A nurse caring for a client in labor notes that her blood pressure (BP) rises during contractions. Which should be the nurse's next action?
Continue to monitor BP. Explanation: During contractions, blood flow to the intervillous spaces changes, compromising fetal blood supply. Increased BP is expected during pain and contractions but it should return to precontraction levels, ensuring adequate blood flow to the fetus.
When discussing the use of a fluticasone and salmeterol inhaler with the parent of a child diagnosed with asthma, the nurse should teach the parent that the medication will be most effective if it is administered at which time?
twice daily Explanation: Fluticasone and salmeterol is a combination drug used as a prophylactic agent to help prevent bronchial asthma attacks. The fluticasone is an inhaled corticosteroid that reduces inflammation. The salmeterol is a long-acting beta agonist (LABA) that reduces bronchospasms. The drug must be taken on a consistent basis, twice a day, over a long period of time to be effective.
A healthcare provider prescribes meperidine 0.8 mg/kg every 4 hours PRN for a school-age child weighing 66 lb (30 kg). How many milligrams of meperidine will the nurse calculate as the potential maximum dose of meperidine the child could receive in 24 hours? Record your response as a whole number.
144 Explanation: First, calculate how many mg the child will get with each dose: 0.8mg x 30 kg = 24 mg/dose. The child can receive up to 6 doses per 24 hours (24h divided by frequency of q4h = 6 doses). Finally multiply the mg in each dose by the number of doses in 24 hours: 6 x 24 = 144 mg per 24 hours if given at the maximum amount prescribed.
A child received a local anesthetic before a cardiac catheterization. Following the procedure, the child has a pressure dressing on the right extremity and an IV line in place. He is slightly drowsy. What should the nurse do first?
Compare the color in the right and left legs. Explanation: Comparing the involved and uninvolved extremities in terms of color, temperature, pedal pulses, and capillary filling time is the highest priority following a cardiac catheterization to ensure adequate circulation to the involved extremity. Vital signs, including blood pressure, are checked as often as every 15 minutes after the procedure to detect arrhythmias and hypotension. The priority following a cardiac catheterization is assessing the circulatory status. Because the child received local anesthesia, the gag reflex would be normal. However, fluids should be encouraged after the procedure because the dye used during the catheterization procedure causes osmotic diuresis. Pulses, especially those below the catheterization site, are checked for equality and symmetry. Checking the temperature is only one aspect of assessing the circulatory status of the extremities. Additionally, the involved and uninvolved extremities must be compared to identify any differences that could indicate a compromise in circulation of the involved extremity.
A client who is likely to become a candidate for dialysis treatment tells the nurse, "I must talk to my family." Recognizing the cultural preferences and beliefs of the client, what question must the nurse first answer before disclosing health care information?
Who is responsible for making client treatment decisions? Explanation: In some cultures, the family takes the responsibility for health care decisions and for protecting the client from experiencing the burden of knowing about serious health care problems. The nurse must determine who is responsible for making the health care decisions in order to disclose information to that person or group of people. The number of family members involved is not as important as the nurse knowing who the decision makers are. The appropriate information is all known treatment options. Later the discussion of the family's role in sharing the health information and treatment decision-making process with the client needs to occur.
In discussing home care with a client after transurethral resection of the prostate (TURP), what should the nurse tell the male client about dribbling of urine after this surgery? Dribbling of urine:
can persist for several months. Explanation: Dribbling of urine can occur for several months after TURP. The client should be informed that this is expected and is not an abnormal sign. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temporary incontinence. The client should be reassured that continence will return in a few months and will not be a chronic problem. Dribbling is not a sign of healing, but is related to the trauma of surgery.
A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?
early decelerations Explanation: A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they are called early decelerations. Early decelerations result from head compression during normal labor and do not indicate fetal distress. Prolonged decelerations, also known as reflex bradycardia, are decreases in the FHR that last 60 to 90 seconds. These decelerations occur in response to sudden vagal stimulation. Prolonged decelerations may indicate fetal distress. Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends. Accelerations are transient rises in the FHR that are normally caused by fetal movements and uterine contractions.
The son of an older adult reports that his father just "stares off into space" more and more in the last several months but then eagerly smiles and nods once the son can get his attention. What further assessments should the nurse make?
hearing loss Explanation: Blank looks, decreased attention span, positioning of the head toward sound, and smiling/nodding in agreement once attention is gained are all behaviors that indicate hearing loss in adults. It is common to confuse sensory deficits for a change in cognitive status. The nurse should focus assessments of sensory function on considering any pathophysiology of existing or new-onset deficits and consider all client factors that might contribute to deficits.
A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?
"Increase your carbohydrate intake." Explanation: A client with CRF requires extra carbohydrates to prevent protein catabolism. In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided.
What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine?
"Morphine decreases the heart's need for oxygen and also makes your heart not work as hard." Explanation: When given to treat acute MI, morphine eliminates pain, reduces preload and afterload, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. Morphine does not increase myocardial contractility, raise blood pressure, or increase preload or afterload.
An anxious client is admitted for treatment of an exacerbation of irritable bowel disease. The client asks the nurse if biofeedback will help after reading about biofeedback online. What is the best response by the nurse?
"Biofeedback will help reduce stress." Explanation: The nurse should acknowledge that biofeedback is an evidence-based treatment for stress reduction and commend the client for reading and asking about the modality. It is considerate to ask the availability of this device and respectful to ask for more information as needed. It is demeaning to insist that biofeedback does not work, is not a serious treatment, or is not indicated for the client's condition. The nurse should not tell the client that a medication for relaxation is needed.
While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response?
"I'm sorry, I can't disclose client information." Explanation: The nurse is bound by the rules of confidentiality and can't reveal any information about a client or treatment, and should state this fact to the neighbor. Suggesting that the neighbor call the client is inappropriate because the nurse is inadvertently disclosing information and acknowledging the client's presence at the clinic. Saying that the client is stable and doing well is a blatant violation of the client's right to absolute confidentiality.
A 67-year-old client will be discharged to home with imipramine. Which information would be most important for the nurse to include when instructing the client and spouse about the medication?
Avoid alcohol. Explanation: Alcohol potentiates the central nervous system depression that can occur with imipramine, leading to increased sedation, confusion, and disorientation and consequently placing the client at risk for injury. Therefore, instructing the client and spouse about avoiding alcohol is most important.
A client is receiving the cell cycle-nonspecific alkylating agent thiotepa, 60 mg weekly for 4 weeks by bladder instillation as part of chemotherapy regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects?
It interferes with DNA replication and RNA transcription. Explanation: Thiotepa interferes with DNA replication and RNA transcription. It doesn't destroy the cell membrane.
The nurse is planning a presentation about ovarian cancer to a group of women. Which topic should receive priority attention in the lesson plan?
Ovarian cancer signs and symptoms are often vague until late in development. Explanation: Ovarian cancer is rarely diagnosed early. Methods for mass screening and early detection have not been successful. Signs and symptoms are often vague until late in development. Ovarian cancer should be considered in any woman older than 40 years of age who has vague abdominal and/or pelvic discomfort or enlargement, a sense of bloating, or flatulence. Enlargement of the abdomen due to the accumulation of fluid is the most common sign.
Which scenario below complies with the HIPAA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations?
The healthcare team is discussing a client's care during a formal care conference. Explanation: To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates the HIPAA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations. Looking up laboratory results for a neighbor is a violation of those acts, as is discussing a client's condition with one's spouse.
The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism?
Wear a face mask and shield when in close contact with the client. Explanation: RSV infection necessitates droplet precautions, including the use of a facemask and shield. Goggles are not normally included in droplet precautions. It is important to educate family members and visitors about the need for hand hygiene, but the similarities and differences between the two different methods of performing hand hygiene are not a priority. Antiviral medications such as ribavirin are not commonly used, and they do not directly prevent the spread of the infection.
Which outcome would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?
absence of any seizure activity during the first 48 hours Explanation: The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.
A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. The client reports shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side. Explanation: In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade.
A nurse is helping a client move up in the bed. Which action maintains good body mechanics?
having the client help as much as possible Explanation: When moving up in bed, the client's assistance will reduce strain on the nurse. The nurse may have to adjust the bed to a higher position, so it isn't possible to always keep the bed in a low position. However, the low position is preferred unless the client's medical condition contraindicates it. With folded arms, the client can't help pull or push up in the bed.
After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate?
holding the infant semi-upright during feedings Explanation: Holding the infant semi-upright during feedings is appropriate because it helps prevent aspiration. The Logan bow must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on the abdomen could lead to disruption of the suture line if the infant rubs the face.
In assessing an adolescent client at an outpatient clinic, the nurse is able to recognize that depression in adolescents is often what?
often masked by aggressive behaviors Explanation: Depression in adolescents is often masked by anger or aggressive behaviors. Symptoms are usually different from adults in that adolescent exhibit intense mood swings.
The nurse is planning care for a client scheduled for treatment with cytotoxic medications. What is important for the nurse to include in the plan of care to combat the most common side effects of cytotoxic medications?
Administer an antiemetic. Explanation: Antiemetics, antihistamines, and certain steroids treat nausea and vomiting, which is a common adverse effect of cytotoxic medications. Cytotoxic medications may cause neutropenia, so it would be appropriate to implement neutropenic precautions, not contact precautions. Clients often require appetite enhancers to stimulate appetite after receiving cytotoxic medications. Teaching the client about the adverse effects of cytotoxic medications is important, but does not combat the adverse effects.
The client was diagnosed with hypertension 7 years ago. In the last 6 months, after diet and exercise, the client's blood pressure has consistently ranged around 160/95. What should the nurse include in the client's teaching about the side effects of clonidine? Select all that apply.
"Clonidine may cause low blood pressure when you stand up." "Clonidine may cause fatigue." "Clonidine may cause dry mouth." Explanation: The nurse should explain that side effects of clonidine include orthostatic hypotension, drowsiness, peripheral edema, fatigue, urinary retention, dry mouth, and constipation. Hematuria and arthralgia are not side effects of clonidine.
A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain?
Administer analgesics around the clock. Explanation: Because assessing pain medication needs in a client with end-stage dementia is difficult, analgesics should be administered around the clock. Clients at this stage of dementia typically can't request oral pain medications when needed. They're also unable to use patient-controlled analgesia devices. Transdermal patches are used to manage chronic pain; not postoperative pain.
The nurse prepares to administer digoxin to a client. For which reason should the nurse question the prescribed dose?
The client has chronic kidney disease (CKD). Explanation: After digoxin is metabolized, the kidneys eliminate remaining digoxin as an unchanged drug. Because of this, a client with CKD should be prescribed a lower dose of digoxin. Because digoxin is not eliminated through the lungs, gastrointestinal tract, or integumentary system, elimination will not be altered if the client has COPD, constipation, or eczema.
A female client who has diagnosis of borderline personality disorder is manipulative and very disruptive on the hospital unit. She is not dangerous to herself or others, but is clearly not making any therapeutic progress. She consistently refuses any medications. The nurse realizes that legally this client has which option?
Refuse treatment. Explanation: A client who has not been deemed a danger to self or others or who has not been declared incompetent retains the right to refuse treatment. Legal protocols need to be followed to initiate treatment against an adult client's wishes, even if the family wishes treatment to occur. Punitive threats of retaliation or loss of privileges are ethically unacceptable in administering treatment.
The nurse is walking past the supply room on the hospital unit and sees smoke coming out from below the door. Opening the door, the nurse sees flames. Identify the correct sequence of the nurse's response. All options must be used.
Remove from the area anyone who is in immediate risk of harm. Activate the fire alarm. Contain the smoke and fire by closing windows, doors, and curtains. Evacuate the area or extinguish the fire, as appropriate to the severity of the fire. Explanation: The response to an actual or suspected fire should follow these steps: R: Rescue the client by removing the client or the source of the fire. A: Activate the alarm. C: Confine the fire. E: Evacuate or extinguish, as appropriate to the fire.
When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which factor for the parents?
confidence in their ability to care for their child Explanation: When teaching the parents of a child with Down syndrome, activities should focus on increasing the parents' confidence in their ability to care for the child. The parents must continue to work daily with their child. Most parents feel affection and a sense of responsibility for their child regardless of the child's limitations. Parents usually understand the child's disability on the cognitive level but have difficulty accepting it on the emotional level. As the parents' confidence in their caring abilities increases, their understanding of the child's disability also increases on all levels.
The client sustained a tibia fracture and a cast was applied. The client is reporting increasing pain when flexing toes. Which symptoms does the nurse assess as associated with compartment syndrome? Select all that apply.
paresthesia pain pulselessness Explanation: he symptoms associated with compartment syndrome include pain, pallor, paresthesia, pulselessness, and paralysis. Palpitations and petechiae are not included in these symptoms.
A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for?
surgery Explanation: The client should be prepared for surgery because the signs and symptoms indicate bowel perforation. Appendicitis is a common cause of bowel perforation. Because perforation can lead to peritonitis and sepsis, surgery would not be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures are not necessary at this point.
A mother of a hospitalized infant appears anxious and displays anger with the staff. Which response by the nurse is most appropriate?
"You seem upset. Having your child hospitalized must be difficult." Explanation: Acknowledging the mother's feelings and recognizing that it's difficult to cope with a hospitalized child allows the mother to express her feelings. Asking the mother if she wants to talk about her concerns only allows a yes or no response; it does not provide an opportunity for the mother to share or vent. The mother may want to speak to a chaplain, but asking does not address the issue of being fearful and angry. Additionally, that action involves the nurse delegating the problem to someone else without seeking out the root of the problem. Saying "your baby will be better soon" only gives false reassurance and does not address the mother's immediate needs.
After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which action by the nurse is most appropriate?
Enter the information tomorrow stating it is a late entry. Explanation: The nurse should enter the information on the medical record as a late entry with current date and time. The other options are incorrect because the nurse needs to document the care provided. Blank spaces should not be left in the chart and all care must be documented.
A nurse is assigned to a client who is using an insulin pump. The nurse has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?
Request information about nursing responsibilities in caring for a client with a pump. Explanation: Taking the initiative to gain new information relevant to client care as well as expressing a desire to support the unit's needs is an appropriate and professional nursing response. Refusing the assignment is inappropriate because the nurse isn't taking any initiative to learn about the pump. Refusing to care for the client until the nurse receives training is inappropriate; the nurse should gather information and evaluate the client before refusing to provide care. Accepting the assignment doesn't address the issue of lack of knowledge and may put the nurse or the client in jeopardy.
When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point?
at about the level of the client's umbilicus Explanation: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.
A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:
consistently enforcing unit rules and facility policy. Explanation: Firmness and consistency regarding rules are the hallmarks of a care plan for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and client manipulation.
Which observation by the nurse indicates that the mother of a child receiving home IV nafcillin therapy requires further teaching? The mother:
flushes the venous access site with heparin 20 minutes after giving the antibiotic. Explanation: When administering IV antibiotics, heparin or saline should be used to flush the IV line as soon as the infusion is completed so that the line remains patent. Waiting for 20 minutes is too long. Although nafcillin can be given as a slow IV push, it is usually infused over 30 minutes to decrease inflammation of the vein. The infusion should be stopped if there is any question about whether the fluid is entering a vein or subcutaneous tissue, evidenced by hardening or reddening of the site. If the IV access is not allowing infusion of the medication, the mother should call the nurse.
A client is admitted to the neurologic intensive care unit for an intracranial hemorrhage. Which medication prescription should the nurse question for this client?
enoxaparin Explanation: The nurse should question the prescription for enoxaparin for this client. Enoxaparin is a low-molecular weight heparin, and is an anticoagulant, which causes increased bleeding and impaired clotting, and would cause further complications in the client with bleeding in the brain. Famotidine is a common peptic ulcer prevention agent, and is often given to intensive care unit clients to help prevent gastric ulcers due to the stress of hospital admission. Ondansetron is a common antiemetic, and would be appropriate for this client to treat or prevent nausea and vomiting, because vomiting increases intracranial pressure. Morphine is a narcotic pain reliever, and would be an appropriate analgesic medication for the client with an intracranial hemorrhage.
A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. What should the nurse should advise the client to do during the 2-hour car ride?
Do ankle pumps. Explanation: Performing active ankle and foot range-of-motion exercises periodically during the ride home will promote muscular contraction and provide support to the venous system. It is the muscular action that facilitates return of the blood from the lower extremities, especially when in the dependent position. Arm circle exercises will not promote circulation in the leg. It is not necessary for the client to elevate the legs as long as the client does not occlude blood flow to the legs and does the leg exercises. It is not necessary to take an ambulance because the client is able to sit in the car safely.
A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do?
Remove all metal objects on the day of the scan. Explanation: Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.
A client has been involuntarily committed to a hospital because he has been assessed as being dangerous to self or others. The client has lost which right?
the right to leave the hospital against medical advice Explanation: An involuntarily admitted client loses the right to leave the hospital until the condition is stable enough that the client no longer poses a danger to self or others. While hospitalized, the client retains all civil rights such as receiving mail, making phone calls, refusing treatment, and also receiving the least restrictive treatment. Should the involuntarily admitted client refuse treatment once admitted, he will be evaluated for the need to receive treatment against wishes in order to decrease the risk for self-harm or harm to others.
The unlicensed nursing assistant is viewing the electronic medical record of an assigned client. When the assistant tries to access notes made by the social worker, an error message appears on the screen that reads, "You are not authorized to view this information." The assistant questions the nurse about this message. What response would the nurse make?
"You are not authorized to view all of the details on the client." Explanation: To protect confidentiality, it is important to control the type of information that personnel in various departments can retrieve. Unlicensed nursing assistants can retrieve information from the medical records, but they cannot view information from the social worker. The reason the assistant wants to view that information is irrelevant. The information technology department does not need to be notified, because there is not a problem with the nursing assistant's log-in information. The nurse should not pull up the data for the assistant, because it is information that the assistant is not authorized to have.
A 62-year-old female client with severe depression and psychotic symptoms is scheduled for electroconvulsive therapy (ECT) tomorrow morning. The client's daughter asks the nurse, "How painful will the treatment be for Mom?" The nurse should respond with which statement?
"Your mother will be asleep during the treatment and will not be in pain." Explanation: The nurse should explain that ECT is a safe treatment and that the client is given an ultrashort-acting anesthetic to induce sleep before ECT and a muscle relaxant to prevent musculoskeletal complications during the convulsion, which typically lasts 30 to 60 seconds to be therapeutic. Atropine is given before ECT to inhibit salivation and respiratory tract secretions and thereby minimize the risk of aspiration. Medication for pain is not necessary and is not given before or during the treatment. Some clients experience a headache after the treatment and may request and be given an analgesic such as acetaminophen. Telling the daughter that the HCP will ensure that the client does not suffer needlessly would not provide accurate information about ECT. This statement also implies that the client will have pain during the treatment, which is untrue.
A homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen?
Arrange for the client to come to a community center each day to receive a meal and medication. Explanation: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for tuberculosis. Providing the client with a daily meal will help ensure the client will come to receive the medication. The client should be provided with a mask to wear to the community center to prevent transmission of TB to others. It is not cost-effective to keep the client hospitalized; the TB medication regimen may last more than a year. A homeless client probably will not have the financial resources to pick up the medication at a pharmacy, so a prescription and/or written instructions will not be an effective way to ensure adherence.
A client with metastatic brain cancer is admitted to the oncology floor. What action will the admitting nurse take regarding an advanced directive for this client?
Inform the client or legal guardian of the right to execute an advance directive. Explanation: All clients have a right to execute an advance directive. The admitting nurse would ensure that the client is aware of that right. The facility's ethics committee can decide on a treatment plan if the client is unable and a health care power of attorney has not been appointed. Facility employees are not required by law to respect an individual's moral rights; however, the health care professional should respect the client's individual rights as part of professional responsibility. While a client may refuse medical treatment via an advanced directive, the nurse would not advise this.
A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause
hyperglycemia. Explanation: Hyperglycemia may occur if TPN is administered too rapidly, exceeding the client's glucose metabolism rate. With hyperglycemia, the renal threshold for glucose reabsorption is exceeded and osmotic diuresis occurs, leading to dehydration and electrolyte depletion. Although air embolism may occur during TPN administration, this problem results from faulty catheter placement, not overly rapid administration. TPN may cause diarrhea, not constipation, especially if administered too rapidly. Dumping syndrome results from food moving through the GI tract too quickly; because TPN is given I.V., it can't cause dumping syndrome.
A client with ascites is experiencing severe respiratory distress and refuses endotracheal intubation. What should be the nurse's first action?
Determine whether the client is competent to make the decision. Explanation: Informed decision-making requires that the decision be voluntary, that the client have the capacity and competence to understand their decision, and that the client have adequate information on which to base the decision. In this instance, the nurse must determine whether the client is competent to refuse endotracheal intubation because severe respiratory distress leads to hypoxemia, which may impair the client's ability to make the decision. The nurse should inform the physician of the client's decision after determining the client's competency. A DNR form requires a physician's order, and the physician is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights guarantees the client autonomy to make decisions about their care plan, including the right to refuse recommended treatment. As an advocate, the nurse should support the client's decision, which may be in opposition to family members' opinions.
A nurse is preparing to administer diazepam 1 mg I.V. The available dose is diazepam 2 mg/ml vial. After drawing 0.5 ml of medication into a syringe, what is the next action by the nurse?
Ask another nurse to witness 0.5 ml medication waste into the sink. Explanation: Diazepam is a controlled substance. Federal law requires close monitoring of all controlled substances to prevent diversion or misuse. After drawing up the ordered dose, the nurse would ask another nurse to witness the waste of the remaining medication into the sink or other approved waste container per the facility policy. Controlled substances are not placed in the sharps container to prevent diversion. Controlled substances require double-locked storage to prevent diversion and would not be stored in the client's medication drawer. The nurse would complete safety checks and administer the medication after another nurse witnessed waste of the remaining controlled substance.
When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?
encouraging increased fluid intake Explanation: During the first postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C), which suggests infection.
Forty-eight hours after undergoing a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. Assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with a recommendation for:
A computerized tomography scan. Explanation: The infant is exhibiting signs and symptoms of increased intracranial pressure (ICP) caused by a shunt malfunction. A CT scan, shunt series X-ray, and tapping the shunt are performed to diagnose a shunt malfunction. Irritability results from the increased ICP, not postoperative pain. The infant has increased ICP; a fluid bolus will further increase it. The increased ICP is caused by a shunt malfunction and will not be relieved by furosemide. Surgical intervention is necessary to correct a shunt malfunction.
A nurse is caring for a woman receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?
Ensure adequate hydration before the anesthetic is administered. Explanation: Administration of an epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Administering fluids I.V. before the epidural anesthetic is given may prevent hypotension. Ephedrine may be administered after an epidural block if a woman becomes hypotensive and shows evidence of cardiovascular decompensation. However, ephedrine isn't administered to prevent hypotension. Oxygen is administered to a woman who becomes hypotensive, but it won't prevent hypotension. Placing a pregnant woman in the supine position can contribute to hypotension because of uterine pressure on the great vessels.
A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because
the client is going into cardiogenic shock. Explanation: This client's findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as poor blood flow causes lactic acid to accumulate and prevents waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.
A client is admitted to the psychiatric unit accompanied by her husband. She brings six suitcases and three shopping bags. She orders the nurse to carry her bags. Her husband states she has been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client's husband?
the client's fluid and food intake Explanation: Assessing nutritional status is a priority in this situation. Clients with bipolar disorder, manic phase, commonly do not have time to eat or drink because of their state of constant activity and easy distractibility. Altered nutritional status and constant physical activity can lead to malnutrition, weight loss, and physical exhaustion. These states can lead to death if appropriate intervention is not instituted. Financial status is neither important nor something that the nurse can modify. Clients with bipolar disorder, manic phase, have disturbed sleep patterns; however, their hydration and nutritional status are the first priority. A common behavior of clients with bipolar disorder, manic phase, is to exhibit hostility when their personal desires are limited, so it is not necessary to seek this information at this time.
