PassPoint NCLEX Practice Exam

The nurse is teaching dietary interventions to the parents of a child with an elevated blood lead level (EBLL). The nurse recognizes the need for more teaching when the parent makes which statement?

"Adequate intake of vitamin A helps keep lead out of fatty tissues." Explanation: Vitamin A is not known to play a significant role in preventing EBLL. Calcium intake inhibits lead absorption. Children with EBLL levels often are anemic. While this relationship is not well understood, iron supplementation has been shown to improve developmental outcomes. Vitamin C improves iron absorption. Increased vitamin intake is associated with decrease EBLL levels.

A nurse is conducting a group session for parents of toddlers recently diagnosed with autism. Which parent statement indicates a need for additional teaching?

"Children with autism may be overwhelmed by rules and structure." Explanation: Children with autism spectrum disorder tend to function best with clear rules, routine and daily structure. Children with autism may develop normally until 18 to 24 months old at which time their development may be stifled or they may regress. Many people with autism have difficulty with muscle tone and coordination, which can affect their ability to reach developmental milestones. Children with autism often have sensory dysfunction and are extremely sensitive to sounds, smells, textures, and tastes.

The nurse is assessing a 17-year-old client with a seizure disorder. Driving privileges were suspended for failure to comply with anti-epileptic medications. The parents express concern because the client is withdrawn, not completing schoolwork, and spends increased time sleeping. Which is the nurse's best response?

"Further evaluation is needed for a mood disorder." Explanation: Adolescence is a time when clients may spend more time sleeping and when changes in mood occur. However, abnormal changes include withdrawal from friends and favorite activities and difficulty completing tasks. The client should be evaluated for a mood disorder, such as situational depression. Assessment for substance abuse and the risk for self-harm will be included in the overall assessment for mood disorder. Asking for the parents' opinion of the risk for self-harm is less important and effective than assessing the adolescent for an actual plan for self-harm. The parents can and should have firm behavioral guidelines for a chronically ill child, but this parenting skill will not assist the client in overcoming the behaviors that are exhibited.

A client with severe osteoarthritis and decreased mobility is moved to an assisted living facility. The nurse notices that the client smells of alcohol, is slurring words, and has six wine bottles in the trash. The client tells the nurse, "Those are my other pain medicines." Which statements by the nurse are appropriate? Select all that apply.

"I didn't realize that your pain was not being managed with your current medication." "It's important for me to know how many bottles of wine you drank this week." "I'm worried about the amount of wine you are drinking and its effects on your balance." "I'm calling your health care provider (HCP) to have all of us to talk about better pain control without the wine." Explanation: Acknowledging the client's concern about pain and expressing the nurse's concern about the client's condition are important to help the client open up and gain further assessment of pain in this client. Awareness of the amount of wine consumption in a week will be helpful to guide which kind of detoxification will be needed. Notifying the healthcare provider about the situation and arranging for a joint conference are important for the client's safety and recovery.How the client is getting the wine is least important because there are so many possibilities such a weekly shopping trips in the facility van or having friends or family bring it in.

The nurse is providing discharge instructions for a client with cirrhosis. Which statement best indicates that the client has understood the teaching?

"I should avoid constipation to decrease chances of bleeding." Explanation: Clients with cirrhosis should be instructed to avoid constipation and straining at stool to prevent hemorrhage. The client with cirrhosis has bleeding tendencies because of the liver's inability to produce clotting factors. A low-protein and high-carbohydrate diet is recommended. Clients with cirrhosis should not take acetaminophen, which is potentially hepatotoxic. Aspirin also should be avoided if esophageal varices are present. Cirrhosis is a chronic disease.

The nurse is providing client education during the rehabilitation phase of a burn injury. Which statement by the client indicates that more instruction is required?

"I will report any skin discoloration to the primary healthcare provider immediately." Explanation: Skin discoloration is expected for months after a burn injury so there is no need to notify the primary healthcare provider. Clients recovering from burn injuries should massage scars with lotions and creams to minimize permanent scarring. Taking pain medications 30 minutes prior to wound care procedures can reduce pain. It is recommended that clients with burn injuries use mild soap and water when bathing.

The nurse is providing health teaching to the mother of a toddler who requires oral medication administration after discharge. Which of the following statements indicate to the nurse that the mother understands the instructions? Select all that apply.

"I will store the medications out of the reach of our children." "I will have the poison control center number close to the phone." "I will mix the medication with fruit puree to make it taste better." "I will carefully read the medication insert from the pharmacy." Explanation: Storing medication out of the reach of children helps prevent accidental overdose. It is important to have the poison control number in case of accidental ingestion of medication. Mixing the medication to improve taste helps ensure that the child will take the medication. Reading the pharmacy insert will provide necessary information about the medication. Passing the medication off as candy may prompt the child to try to access it and potentially result in self-inflicted poisoning or poisoning of other children.

The nurse has been able to draw the daily blood specimen from a client's Hickman catheter only after requesting that the client raise the arms and cough. The client asks the nurse why this is necessary. The nurse should tell the client:

"The catheter may be lodged against a blood vessel wall." Explanation: The ability to obtain a blood specimen only after the client raises the arms and coughs usually indicates that the catheter is lodged against a vessel wall.The nurse would suspect a fibrin sheath or a pinched or kinked catheter if blood could not be aspirated.The catheter itself will not collapse with pressure.

A client with chronic obstructive pulmonary disease (COPD) is receiving theophylline. What should the nurse include in the client's teaching concerning the side effects of theophylline? Select all that apply.

"Theophylline can cause insomnia." "Theophylline can cause palpitations." "Theophylline can cause nausea." Explanation: Side effects of theophylline include anxiety, restlessness, insomnia, palpitations, nausea, vomiting, anorexia. Confusion and constipation are not one of theophylline's side effects.

The client has a history of migraine headaches and has tried various drug therapies without success. The healthcare provider has decided to start the client on ergotamine tartrate. Which information should the nurse teach the client about ergotamine tartrate? Select all that apply.

"You should report numbness and tingling in your fingers or toes." "Take medication as soon as you feel a migraine starting." "Make sure your blood pressure is measured routinely." Explanation: Information the nurse should teach includes starting the medication as soon after the onset of a migraine attack as possible, having his/her blood pressure checked routinely, and reporting numbness and tingling in fingers/toes. Additionally the nurse should explain that the client should not increase the dosage without consulting the healthcare provider first. Photophobia is usually secondary to migraine, and doubling the dosage will cause more adverse effects from the drug.

A client presents to the family clinic to speak with the nurse about her diagnosis of diabetes mellitus and difficulty getting pregnant. How should the nurse respond to this client?

"You should see maternal-fetal medicine." Explanation: This client is considered high-risk. While the obstetrician may have expertise in medical problems such as diabetes mellitus, the best referral would be to maternal-fetal medicine. Family nurse practitioners and certified midwives do not have the expertise needed to handle high-risk cases.

A young woman will receive 6 months of chemotherapy for cervical cancer. She is a single parent of two young children and can no longer work. The nurse contacts a social worker to help plan continuing care. The client states, "I feel overwhelmed. How can the social worker help me?" Which responses by the nurse about the role of the social worker are appropriate? Select all that apply.

-"The social worker is a part of a multidisciplinary team that helps plan care for clients with cancer." -"The social worker can assist in locating resources and programs to assist you during your treatment." -"Based on your financial situation and need to care for your children, the social worker can help you identify needed resources at this time." -"Your entire family will be included in the treatment plan. Your needs and those of your children will be assessed and determined so that referrals can be made to appropriate resources." Explanation: The social worker is part of the comprehensive, holistic health care team. Because the client is now unemployed and is a single parent, the social worker can provide information about sources of financial support. The needs of the client and the family members are included in the treatment plan. The social worker cannot authorize temporary funds.

A client presents to the emergency department (ED) with reports of a "skipped beat" in their chest. The health care provider diagnoses premature ventricular contractions (PVCs) and orders quinidine sulfate. What should the nurse include in the client's teaching concerning the administration of quinidine sulfate? Select all that apply.

-"You should take quinidine sulfate with food." -"You should report palpitations and breathlessness when taking quinidine sulfate." -"You should avoid alcohol when taking quinidine sulfate." -"You should take your blood pressure reading before taking quinidine sulfate." Explanation: Quinidine is an antidysrhythmic, and client teaching will include monitoring heart rate and respiratory status. The client should take this medication with food to avoid adverse GI reactions. Drinking grapefruit juice decreases the absorption of quinidine sulfate. Like most medications, quinidine sulfate should not be taken with alcohol.

What should be included in the plan of care for clients receiving intravenous immunoglobulin (IVIG)? Select all that apply.

-Assess vital signs before, during, and after treatment. -Pre-medicate with acetaminophen and diphenhydramine 30 minutes before infusion. -Stop the infusion at the first sign of a reaction. Explanation: Vital signs should be assessed at the beginning, during, and after treatment with IVIG. It is appropriate to pre-medicate clients receiving IVIG with acetaminophen and diphenhydramine 30 minutes before treatment. The infusion of IVIG should be stopped at the first sign of a reaction. The infusion should be administered at no more than 3 mL/min (not 3 mL/hr). Reports of tickle or lump in the throat can be a sign of a dangerous reaction called laryngospasm.

A 12-year-old African-American client has experienced significant blood loss and may require a blood transfusion. The child's mother, father, and sisters are currently present at the child's bedside in the emergency department. How should the nurse direct questions and teaching about the client's condition and treatment?

-Assess who is the dominant member of the family and then address that person. Explanation: While African-American families are often matriarchal, this fact does not mean that the nurse should not assess the structure and roles of the family on an individual basis. This assessment is preferable to acting on a generalization, even if it is a generalization that may be accurate for many families who are culturally similar.

A nurse is caring for a pregnant client taking an iron supplement. Which instruction(s) should the nurse include when teaching the client about ferrous sulfate tablets? Select all that apply.

-Avoid taking the supplement with milk. -Avoid taking the supplement with antacids. -Avoid chewing the extended-release form of the drug. Explanation: Because food delays absorption, the nurse should instruct the client to take the supplement between meals to increase absorption. The client may take the supplement with a food high in vitamin C such as orange juice. It should not be taken with milk or antacids. The nurse should also tell the client not to crush or chew extended-release forms of the drug. Black stool is a side effect of iron supplementation; there is no need to contact the health care provider.

A client with a sacral pressure ulcer is limited to 2 hours of chair sitting two times per day. The client is scheduled for physical therapy three times per day and dressing changes two times per day. How can the nurse best adhere to this client's care? Select all that apply.

-Coordinate physical therapy to meal times such as breakfast and dinner, and the third session at the bedside. -Coordinate with the wound care nurse to schedule dressing changes once during the day and again at night. -Collaborate with the client, physical therapy, and wound care nurse to establish the best schedule for this client. Explanation: The nurse should attempt to coordinate physical therapy with getting the client out of bed for breakfast and dinner. The nurse should then request bedside physical therapy for the third session until the client has no activity limitations. Coordinating activities optimizes the client's ability to participate in physical therapy because the client can go to the physical therapy department for therapy. Coordination with the wound care nurse during the time the client is in bed will establish the best schedule for this client. Including the client as the center of care will promote more effective motivation and adherence to the schedule.

A nurse is documenting an admission assessment in the electronic healthcare record. What actions are a breach in confidentiality? Select all that apply.

-The nurse leaves the works station without signing off. -The nurse shares a password with a QMAP to help with documenting vital signs. -The nurse allows a nursing student to access a client's electronic plan of care. Explanation: The nurse needs to protect medical records by signing off when not using the computer. The nurse should never share a password or allow anyone to access information with the nurse's name. Documenting suspected abuse and providing a physician worklist are not breaches in confidentiality.

A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply.

-activity intolerance related to inadequate oxygenation -anxiety related to breathlessness -ineffective breathing pattern related to hypoxia -risk for decreased cardiac output related to failure of the left ventricle Explanation: When planning care, the nurse would select nursing diagnoses that anticipate pulmonary compromise secondary to reduction of air, blood, and gas exchange because these are ensuing complications that can develop from a pulmonary embolism, particularly in a client with a history of heart failure. The prudent nurse would analyze the client's condition and anticipate the need for safe, supportive nursing interventions related to the client's activity intolerance, anxiety, ineffective breathing, and risk for decreased oxygen output. The client history does not indicate that this client has difficulty sleeping, and although nutrition is important to consider, it is not a priority.

The nurse at a long-term care facility is caring for a client who has just died. At the bedside is the older adult spouse. Which nursing actions are appropriate at this time? Select all that apply.

-allowing facility staff to express their sympathy to the spouse -using therapeutic communication to support expression of feelings -assisting the spouse with the acceptance of the reality of the loss Explanation: The loss of a spouse is one of life's most difficult times. After a death, it is appropriate to have others who have cared for the client express their sympathy to the loved ones. This can be a comforting act. By using therapeutic communication, the nurse supports the expression of feelings assisting in the acceptance of the loss. Both are therapeutic for the spouse. Talking about common interests does not decrease the stress or fact that there has been a death. After a client has just died, it is inappropriate to suggest that the spouse make final arrangements or set a time limit for visitation with the deceased.

The nurse is the leader of a team caring for clients with gastrointestinal (GI) disorders on a medical-surgical unit. Which tasks will the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

-assisting with perineal care after episodes of diarrhea; receiving total parenteral nutrition through a central line -collecting vital signs on a client with acute pancreatitis and increased white blood cell count -cleansing the nares around a client's nasogastric tube; receiving IV fluids and is NPO -transporting a client with acute cholecystitis off the unit for a procedure; stable Explanation: The UAP's scope of practice includes measuring vital signs, performing hygienic care, and transporting. The licensed nurse should remove the dressing, perform a wound assessment, clean the area, and redress because these tasks will need the education and assessment skills of the licensed nurse.

The nurse is preparing to interpret an ECG rhythm strip. Place the following steps for ECG rhythm analysis from first to last, in chronological order. All options must be used.

1. Determine the rate and rhythm. 2. Analyze the P waves. 3. Measure the PR interval. 4. Measure the QRS duration. 5. Interpret the rhythm. Explanation: ECG rhythm strip analysis requires a systematic approach using a five-step method. First, determine the rate and rhythm of both the atria and the ventricles. Then, analyze the P waves for consistency. Next, measure the PR interval and then the QRS duration. Finally, you can interpret the rhythm with all of the information that has been collected. If the nurse has answered all five steps within normal limits, the client is in sinus rhythm. The greater number of questions that the nurse notes inconsistent with normal limits, the greater the abnormal conduction through the heart.

A nurse is assigned five clients on the medical-surgical floor. Place in order which client the nurse will assess during the first assessment round starting with who the nurse should see first. All options must be used.

1. a client with a recorded episode of hypoxia earlier in the day 2. a client with dementia requiring wrist restraints to secure medical equipment 3. a client admitted with leg cellulitis needing an initial intravenous antibiotic 4. a client requesting medication teaching with an insulin dose in one hour 5. a client awaiting transport to another hospital in two hours Explanation: The nurse will first assess the client with a recorded episode of hypoxia earlier in the day because of the respiratory compromise concern. Then the client with dementia requiring wrist restraints to secure medical equipment to be sure the client is safe. The client admitted with leg cellulitis needing an initial intravenous antibiotic will be assessed next to begin the antibiotic therapy. The client requesting medication teaching with insulin dose in one hour and lastly the client awaiting transport to another hospital in two hours can be seen at the end of the initial round.

The nurse performs a developmental assessment of a 3-year-old child who is suspected to be developmentally delayed. The child can stack a total of four blocks and cannot kick a ball. At what developmental age level would the nurse document the child to be based on these findings?

18 months Explanation: Developmentally, an 18-month-old should be able to stack 4 cubes, put things in slots, and remove socks and shoes. An 18-month-old cannot usually kick a ball. Therefore, this child is appropriately assessed as having a developmental age of 18 months. A 24-month-old should be able to stack 6 to 7 cubes, turn knobs, kick a ball, and run; this child cannot stack more than four cubes or kick a ball. A 36-month-old should be able to stack 9 to 10 cubes, undress self, hold a pencil in the writing position, and run easily.

A nurse has an order to start magnesium sulfate on a preterm labor client. The order reads: administer a 4-g bolus over 15 minutes. The nurse has 50 g of magnesium sulfate mixed in 1000 mL of lactated Ringers on hand. How will the nurse set the pump rate to deliver the 4-g bolus? Record your answer using a whole number.

320 Explanation: (60 minutes)/(1 hour) × (4 g)/(15 minutes) × 1000 mL/50 g = 240,000/750 = 320 mL/hour

The public health nurse is facilitating a cancer screening in-service for colorectal cancer. Which clients present the fewest risk factors for colon cancer? Select all that apply.

60-year-old female who follows a diet low in fat and high in fiber 80-year-old male with a history of prostatitis Explanation: Although the 60-year-old female is older than age 40 years, she follows an appropriate diet for avoiding colorectal cancer and does not have other common risk factors. The 80-year-old male with prostatitis could be at risk for prostate cancer; however his age reduces his risk. The other clients all have a high risk, due to a history of breast cancer, ulcerative colitis, and a family history of colon cancer--all of which greatly increase the risk for colon cancer.

Pedophilia is diagnosed by the presence of specifically defined behaviors and characteristics. Which statements regarding pedophilia are correct? Select all that apply.

A person with pedophilia has strong sexual attraction to prepubescent children. A person with pedophilia is very attentive to a child's needs in order to win the child's trust. A person with pedophilia must be age 16 or at least 5 years older than the child. Explanation: Pedophilia is a disorder characterized by a strong sexual attraction to prepubescent children that generally begins to manifest itself in adolescence, not early adulthood. By definition, the pedophile must be age 16 or older, or at least 5 years older than the child. The pedophile generally is attentive to the needs of children in order to gain their trust, loyalty, and attention. Female, not male, children are more commonly the focus of attention.

Which client(s) is likely to be suffering a maturational loss? Select all that apply.

A preschool-aged only child whose mother just had a baby A parent whose youngest child just left for college Explanation: Maturational loss is experienced as a result of natural development processes, such as the loss a parent experiences when sending a child to kindergarten or college, or the loss a first child experiences when a sibling is born. The child who lost his or her toys in a house fire is experiencing an actual loss, physical loss, psychological loss and situational loss. This loss is not part of the normal developmental process, so it would not be a maturational loss. The older adult client who had a foot amputated would be experiencing physical, psychological, and actual loss. Again, this is not part of the normal development process, so it would not be a maturational loss. The young adult client who got divorced would be experiencing psychological and perceived losses, but this would not be a maturational loss. Divorce, amputations, and house fires are not part of the expected development process, and are not maturational losses.

When assessing a client withdrawing from alcohol, the nurse notes that the client is anxious, experiencing nausea, is restless, and has a tremor when both arms are extended. What should the nurse should do next?

Administer a benzodiazepine as prescribed. Explanation: The client is exhibiting signs and symptoms of withdrawal, and the nurse should administer the benzodiazepine to manage the anxiety, nausea, and restlessness and to prevent seizures. After administering the medication, the nurse will continue to assess the client and ensure the client is in a quiet environment. There is no need to transfer this client to the psychiatric unit based on the information provided.

While assessing a 2-month-old infant's airway, the nurse finds that the infant is not breathing. After two unsuccessful attempts to establish an airway, which should the nurse do next?

Administer five back blows. Explanation: The nurse should clear the airway with back blows first followed by chest thrusts. After two attempts to establish an airway, the nurse can assume the airway is blocked. The nurse cannot attempt to ventilate the infant with a handheld resuscitation bag until the airway is patent.

A client is to be started on a daily furosemide dosage. Which instructions would be included in the teaching plan? Select all that apply.

Advise the client to reduce dietary sodium intake. Advise the client to alert the healthcare provider if any visible edema occurs. Instruct the client to take the medication on a regular schedule each day. Explanation: Furosemide is a loop diuretic. Client teaching focuses on actions related to the fluid gradient and electrolyte balance. Reducing dietary sodium intake will help increase the effectiveness of diuretic medication and may allow smaller doses to be ordered. Diuretics are commonly prescribed to control fluid accumulation in the body; therefore, the presence of edema may indicate the need for the health care provider to adjust the therapy. Compliance is very important with diuretics. In order to effectively monitor therapy, the nurse would encourage the client to take the medication exactly as prescribed and on a regular routine. Salt substitutes are not recommended because they contain potassium instead of sodium and may cause serious cardiovascular effects. Diuretics cause an increased urine output, which may interfere with the client's sleep if taken in the evening. It is most commonly suggested to take a daily dosage in the morning.

A nurse is assessing a young adult with a temperature of 103°F (39.4°C), a sore throat, and swollen lymph glands. No adventitious breath sounds or cardiac disorders are noted. To complete an assessment for a potential Epstein-Barr viral infection, which quadrant of the abdomen would the nurse would be particularly careful to palpate?

An Epstein-Barr infection is a common viral infection. Symptoms include a fever, sore throat, and swollen lymph glands. Additionally, a swollen liver or spleen may develop. Assessment of the liver and spleen is essential. The spleen is located in the left upper quadrant of the abdomen. It is posterior and slightly inferior to the stomach. The nurse would stop palpating immediately if the nurse feels the spleen because compression can cause rupture.

The nurse removed the client's name band because the client's arm was edematous. The client has an intravenous infusion in the other arm. What are the nurse's options for replacing the client's name band? Select all that apply.

Apply the name band on the client's leg. Apply the name band loosely on the client's arm with the intravenous infusion. Explanation: The nurse may apply the name band on the client's leg and apply the name band loosely to the arm with the intravenous infusion. The nurse should refrain from taping the name band on the client's bed so that the client is wearing the name band. The nurse does not want to occlude circulation by placing a larger name band on the edematous arm. The client needs to have a name band, and the nurse should not rely on the client to identify their name and date of birth without a name band.

The nurse is using a needleless port to administer an intravenous medication (view the figure). Which is the correct technique with this system? Select all that apply.

Aspirate the line and flush with saline. Use a separate syringe to administer the medication. Explanation: Prior to administering the medication, the nurse should use a separate saline-filled syringe to verify that the infusion system is still positioned in the client's vein, and then flush the line with saline. The nurse should then, using the syringe with the medication, administer the medication. It is not necessary to remove the tape prior to injecting the medication. It is not necessary to change gloves when changing syringes. The syringe should be disposed of in a labeled, puncture-proof and leakproof container.

Oral methylprednisolone was recently started for a 10-year-old client with asthma. The client begins to vomit and reports that the stomach hurts. Which nursing intervention is appropriate?

Call the health care provider to change the medication form to I.V. Explanation: Nausea and GI upset are adverse effects of methylprednisolone. The treatment of asthma requires treatment of the inflammation that is a hallmark of the disease. If the child cannot tolerate oral corticosteroids, an I.V. dose is warranted.

An older adult has hearing loss and a sensation of fullness in both ears. The nurse should examine the ears for:

Cerumen (ear wax) commonly gets impacted in older clients in the external canal. Otalgia is the "fullness" sensation or pain that an older client may experience when the cerumen becomes impacted. External otitis is an inflammation of the outer ear and would not explain the symptoms the client is experiencing. A bony growth (exostosis) arises from the surface of a bone and would not explain the symptoms the client is experiencing.

A nurse is caring for a 14-year-old client who was admitted with cellulitis and has been ordered warm compresses. The nurse delegates the treatment to the unlicensed assistive personnel (UAP). The compress causes a first-degree burn to the area. Which actions should the nurse initiate? Select all that apply.

Complete an incident report regarding the event. Notify the healthcare provider of the injury. Explanation: Based on the rules of delegation, this should have been delegated to a licensed practical/vocational nurse, not the UAP. The nurse is accountable for the action. The nurse needs to complete an incident report and notify the healthcare provider. Ice is not applied to burn wounds, because it increases cellular injury. An incident report should mention all personnel involved—not just the UAP—and objectively describe their actions.

The nurse is providing care for a client who immigrated three months ago. The nurse observes that the client is reluctant to make eye contact when responding to the nurse's questions. What is the nurse's best response?

Consider the norms around nonverbal communication in the client's culture. Explanation: Norms around verbal and nonverbal communication vary widely among cultures; the nurse should be aware of and accommodate these differences whenever possible. It is not normally necessary or possible for clients to receive care from nurses of a similar culture. Mimicking the client's avoidance of eye contact may not put the client at ease. Avoidance of eye contact is not suggestive of a more significant culture-bound syndrome.

When taking a client's vital signs on the first postoperative day, the unlicensed assistive personnel (UAP) reports to the nurse that the oral temperature is 100° F (37.8° C). After encouraging the client to use the incentive spirometer, the nurse should delegate which activity to the UAP?

Continue to monitor the client's temperature. Explanation: Temperature variation in the postoperative period provides valuable information about a client's status. Fever may occur at any time during the postoperative period. A mild elevation (up to 100.4° F [38° C]) during the first 48 hours usually reflects the surgical stress response. After the first 48 hours, a moderate to marked elevation (higher than 99.9° F [37° C]) is usually caused by infection. It is not appropriate to do any of the other options to lower a client's temperature at this time.

A client with an intravenous line in place states having pain at the insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions would the nurse take? Select all that apply.

Discontinue the infusion at the affected site. Apply warm soaks to the intravenous site. Document the assessment, nursing actions taken, and the client's response. Explanation: Redness, warmth, pain, and a hard, cordlike vein at the intravenous catheter insertion site suggest that the client has phlebitis. The nurse would discontinue the intravenous infusion and insert a new catheter proximal to or above the discontinued site or in the other arm. Applying warm soaks to the site reduces inflammation. The nurse would document the assessment of the intravenous. site, the actions taken, and client's response to the situation. Slowing the infusion rate would not reduce the phlebitis. Restarting the infusion at a site distal to the phlebitis may contribute to the inflammation. Skin mottling is not a symptom of phlebitis; it is associated with poor circulation.

The nurse is preparing a client with sickle cell anemia for discharge. What information should the nurse include in the teaching plan? Select all that apply.

Drink plenty of fluids when outside in hot weather. Avoid being in high altitudes. Know that pregnancy with sickle cell disease increases the risk of a crisis. Explanation: The nurse should teach the client to drink plenty of fluids when outside in hot weather to avoid becoming dehydrated. The client should avoid being in high altitudes, such as mountains above 5,000 feet (1,524 m), where the lower availability of oxygen could precipitate a sickle cell crisis. The nurse should alert young women with sickle cell anemia that pregnancy increases the risk of a crisis. People who are homozygous for HbS have sickle cell anemia; the heterozygous form is the sickle cell carrier trait. A client with sickle cell anemia may fly on commercial airlines; the airplane is pressurized and has an adequate oxygen level.

The nurse has admitted a client who identifies as being orthodox Jewish. When planning a diet that meets the client's nutritional needs within the confines of religious restrictions, the nurse should take what actions? Select all that apply.

Encourage the client's family to bring in foods for the client as they wish, unless contraindicated. Ensure that the client's meals contain no pork. Explanation: Judaism prohibits the consumption of pork. Special precautions are involved in the preparation of dairy products, but there is no blanket prohibition on dairy. It is unnecessary to delegate the client's nutritional planning to an individual who shares the same religion or to deliver supper trays before sundown each day. As with all clients, bringing in outside food is encouraged unless there are particular reasons why this is unsafe.

On the second postoperative day after an abdominal hysterectomy, the client develops a temperature of 100.4°F (38°C). What should the nurse do first?

Ensure that the client takes at least 10 deep breaths every hour. Explanation: Elevated temperature on the second postoperative day is suggestive of a respiratory tract infection. Respiratory infections most often occur during the first 48 hours after surgery. The nurse should encourage the client to take deep breaths frequently. The nurse should also monitor the client's vital signs and report significant changes to the surgeon. Signs of infection, if present in the wound or urinary tract, are likely to occur later in the postoperative period. There is no indication that the IV catheter is the source of infection.

A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which diseases can be transmitted by a designated donor? Select all that apply.

Epstein-Barr virus human immunodeficiency virus (HIV) cytomegalovirus (CMV) Explanation: Using designated donors does not decrease the risk of contracting infectious diseases, such as the Epstein-Barr virus, HIV, or CMV. Hepatitis A is transmitted by the oral-fecal route, not the blood route; however, hepatitis B and C can be contracted from a designated donor. Malaria is transmitted by mosquitoes.

A client experienced an overdose of heroin. Providers administered naloxone along with CPR, but did not have success. How can the nurse best meet the needs of the family members? Select all that apply.

Find a private room to discuss the client's condition. Be prepared to have ancillary staff available such as pastoral care and social work. Allow for viewing of the body. Explanation: The nurse is responsible for caring for the client and client's family. The lead or charge nurse can be helpful in clarifying questions, but the nurse should be involved with the family. The nurse should allow the family to decide on postmortem care. The nurse should prepare the client but should not be involved in funeral arrangements.

A client reports a pain level of 8 on a scale of 0 to 10. Which is the best intervention?

Further assess the pain. Explanation: The client's pain should be further assessed before administration of pain medication. The healthcare provider may need to be notified after the assessment, and pain medication administration may be needed. Alternative methods of pain relief, such as distraction and imagery, should not be the first choice of pain relief when the pain is an 8.

The nurse-manager of the pediatric unit notices that vital signs are frequently not being documented on children returning from surgery. Which approach will be most effective for the unit manager to use to improve documentation?

Have a group of staff nurses review the established standards of care for postoperative clients. Explanation: According to principles of total quality management (TQM)—a proactive, participative approach to improving all aspects of client care—the nurse-manager would have a group of staff members review the established client care standards and make suggestions.Talking to the staff members individually will not promote a participative group approach to setting standards.Having a meeting may pinpoint issues; however, using a small group that will first review the standards and make recommendations will empower the nurses to change. In TQM, participative, action-oriented approaches, not blame or punishment, are used to improve care.

The nurse is preparing to care for a postoperative thyroidectomy client who has just returned to the unit after surgery. What are the most important nursing interventions for this client? Select all that apply.

Have an emergency tracheotomy set on hand. Check behind the neck for bleeding. Monitor voice quality regularly. Observe for sudden increase in temperature, respiratory distress, and tetany. Explanation: Postoperative thyroidectomy clients may need humidified oxygen and should be placed in the semi-Fowler's position. Vital signs will need to be monitored for any changes, and the client should be observed for bleeding behind the neck under the dressing. It is important to observe for signs of respiratory distress and to have tracheotomy equipment on hand. Monitor voice quality for injury to vocal chords. If the client develops postoperative thyroid storm/crisis, the temperature could rise as high as 106° F (41.1° C), and tetany may develop if the parathyroid glands were injured or removed.

A client is scheduled for amniocentesis. What priority intervention should the nurse implement?

Have the client void. Explanation: Before amniocentesis, the client should empty the bladder which reduces the risk of bladder perforation. This client doesn't need to drink fluids or fast before amniocentesis. A client would be placed in a supine position for an amniocentesis.

The nurse is instructing a client following right-knee replacement on how to use crutches. Which instructions are included? Select all that apply.

Have your elbows bent when holding the crutch handles. Place crutches 1 foot in front of you. Pivot on your left leg. Swing your left leg forward. Explanation: It is very important to instruct a client to safely use crutches. Additional damage to the injured knee may result with improper crutch use. When using crutches, instruct the client to "place the crutches about 1 foot (0.3 meters) in front of your feet, slightly wider apart than your body. Next, lean on the handles of your crutches (not armpit) and move your body forward. Use the crutches for support. Do not step forward on the weak leg. Finish the step by swinging your left leg forward. Repeat steps to move forward. Turn by pivoting on the strong left leg, not the right leg. The armpits should not support your body weight."

A female client diagnosed with lung cancer is to have a left lower lobectomy. The nurse should assess the client for which factor that increases the client's risk of developing postoperative pulmonary complications?

Height is 5 feet, 7 inches (170.2 cm) and weight is 110 lb (49.9 kg). Explanation: Risk factors for postoperative pulmonary complications include malnourishment, which is indicated by this client's height and weight. It is thought that emotional responses can affect overall health; however, not verbalizing one's feelings is not a contributing factor in postoperative pulmonary complications. The client's current activity level and age do not place her at increased risk for complications.

The nurse is developing a teaching plan for the client with hepatitis A. What should the nurse tell the client to do?

Increase carbohydrates and protein in the diet. Explanation: A low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss. Activity should be modified and adequate rest obtained to promote recovery. Social isolation should be avoided, and education on preventing transmission should be provided; the client does not need to sleep in a separate room.

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?

Intradermal drugs diffuse more slowly. Explanation: Drugs administered intradermally (injected between the skin layers, just below the surface stratum corneum) diffuse slowly into the local microcapillary system. Slow diffusion is necessary during diagnostic allergy testing because rapidly introducing an allergen could cause a life-threatening allergic reaction in a sensitive client. The ease of administration and client comfort are not principles taken into account when using intradermal injections for allergy testing.

Which statements would be an example of a focused nursing response to meet a client's needs? Select all that apply.

Involvement in a plan of care to identify priority needs Working to arrange for discharge and follow up with the public health unit for daily heparin injections Letting the client decide which nursing measures are most important and implementing these measures Explanation: The three correct choices all directly involve the client in decision-making and participation in the care. Explaining the rationale for nursing measures and insisting the client meets the demands of the nursing unit is incorrect as it is never appropriate to insist that a client meets demands. Allowing the family to decide which nursing measures should be implemented is also incorrect as the client is not involved in the decision-making.

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

It helps prevent early airway collapse. Explanation: Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

Five hours after birth, a newborn baby is observed for episodes of rapid respirations, gagging, and regurgitation of mucus. Which intervention should the nurse do first?

Keep the infant warm. Explanation: The newborn usually shows a predictable pattern of behavior during the first several hours after birth, characterized by two periods of reactivity. The first period is 30 minutes after birth. The second period occurs around 4 to 6 hours of life. During the second period, the newborn is awake and alert; the heart and respiratory rates increase; production of respiratory and gastric mucus increases; and the newborn responds by gagging, choking, and regurgitating if the newborn swallows milk incorrectly. Keeping the infant warm is a priority during reactivity, placing the infant prone and stimulating the infant to cry will not change this physiologic condition, and a prone position could place the airway at risk. Reactivity is not due to formula or breast milk intolerance.

Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?

Lying on the abdomen with the head turned to the side. Explanation: Immediately after a surgical repair of a cleft palate, the child is placed on the abdomen with the head turned to the side to lessen the chance of aspiration by allowing secretions to drain out. Positioning the child on the back places the child at risk for aspiration should any regurgitation or vomiting occur, even in low Fowler's position with the head to the side or in reverse Trendelenburg position with the head tilted forward.

A toddler is admitted to the pediatric unit. Based on the progress notes below, what developmentally appropriate intervention will the nurse perform? 2/10 1000 History and Physical Tab14-month-old male with croup admitted at 1400. Temperature: 100.5oF (38.1oC), Heart rate: 126 bpm, regular, no murmur. Resp. rate 28. Lungs bilaterally clear. Frequent barky cough. Weight: 22.4 lb (10.2 kg). Height: 31.1 in (79 cm). Head circumference: 18.5 in (47 cm). Child is crying but easily consoled by the nurse. Smiles when he hears mom's voice in the hallway. Able to pass blocks back and forth between hands, but then drops them. Verbalizes "mama," "dada," but no other words. Mother states child is read to daily and likes to turn pages. Anterior fontanel closed. Eyes dull. Unable to assess ears due to child's lack of cooperation. Abdomen soft, flat. Standing in crib.

Notify the healthcare provider of the child's responses. Explanation: The child is showing some signs of delayed development, and the healthcare provider needs to be alerted to the delays. By 14 months, the child should be able to put blocks in a cup. Passing blocks back and forth and saying "dada" and "mama" are typically seen in 9-month-old infants. Not cooperating with an ear exam, dull eyes, and crying could be due to the illness. The anterior fontanel closes between 12 and 18 months of age.

The nurse completes an incident report after discovering and assessing a client sitting on the floor beside the bed. Which actions should the nurse take after completing the incident report? Select all that apply.

Notify the physician. Notify the nursing supervisor. Send a copy of the report to the risk management department. Document the client's condition. Explanation: Sending a report to risk management is necessary because incident reports are part of an agency's risk management program and are used for internal purposes, such as identifying trends and strategies to prevent situations from occurring again. Notifying the physician and nursing supervisor is necessary to ensure patient safety. A summary note of the client's condition and care provided would be appropriate, but it is not necessary to note that an incident report was completed. Such a note in the client record will lead to the incident report being discoverable in a court of law.

The nurse is transferring an immobilized client. What is the best way for the nurse to maintain safety? Select all that apply.

Place the feet apart to increase the stability of the body. Ask for assistance from another staff member. Explanation: Placing the feet apart creates a wider base of support and brings the center of gravity closer to the ground. This improves stability. Asking for assistance will also reduce the risk of injury for the nurse. The other choices all place the nurse at risk for back injury.

A client is admitted to the post-anesthesia care unit following a left hip replacement. The initial nursing assessment is: temperature, 96.6° F (35.9° C); pulse, 90 bpm; respiration rate, 14 breaths/min; and blood pressure, 128/80 mm Hg. The client only responds with moaning when spoken to. What should the nurse do first?

Position the client on the right side. Explanation: During the immediate post-anesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions; because of the type of surgery, the client should be positioned on the right side. Removing the oral airway and observing the surgical dressing is appropriate, but other actions should be implemented before these. Respiratory depression can occur in a client after a procedure requiring sedation. If the client cannot be aroused, the sedation drugs can be reversed by administering a sedation reversal agent, but this client's respiratory rate is 14, and the client is moaning, indicating expected recovery from anesthetics.

Which statement best identifies the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client?

Pregnant adolescents are at high risk for pregnancy-induced hypertension. Explanation: Prenatal care is commonly the most critical factor influencing pregnancy outcome. This is especially true for adolescents, because the most significant medical complication in pregnant adolescents is pregnancy-induced hypertension. Continued prenatal care helps to allow for early detection and prompt intervention should the complication arise. Other risks for adolescents include low-birth-weight infant, preterm labor, iron-deficiency anemia, and cephalopelvic disproportion. Gestational diabetes can occur with any pregnancy regardless of the age of the mother. Generally, all first-time mothers need instruction related to discomforts. Adolescent mothers have better nutrition when they attend group classes and are subject to peer pressure. No evidence demonstrates that most adolescents lack support systems. Fathers may abandon mothers at any time during the pregnancy; other fathers, regardless of age, are supportive throughout the pregnancy.

A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in discharge teaching? Select all that apply.

Provide humidity at home. Learn how to suction. Have communication rehabilitation with a speech pathologist Attend a smoking cessation program. Explanation: Home care for a client with a total laryngectomy should include a high-humidity environment, laryngectomy tube care and suctioning, speech rehabilitation, and smoking cessation. The client is not restricted to a bland diet.

A client experiencing alcohol withdrawal wakes up and screams, "There is something crawling under my skin! Help me!" What should the nurse do in order of priority from first to last? All options must be used.

Remind the client that this is a withdrawal symptom and that these symptoms will be treated. Take the client's vital signs. Assess the client for other withdrawal symptoms. Administer a dose of lorazepam depending on the severity of the withdrawal symptoms. Chart the details of the episode in the medical record. Explanation: After the nurse reminds the client about this withdrawal symptom, the nurse should take the client's vital signs and then assess for other symptoms, such as visual and auditory disturbances, tremors, anxiety, nausea, and excess perspiration. The elevation of the vital signs also helps to determine the amount of lorazepam needed to control the withdrawal symptoms. The nurse should then chart the details of the episode and outcomes of the interventions.

The nurse is auscultating S1 and S2 in a client. Identify the area where the nurse should hear S1 the loudest.

S1 is loudest at the mitral area which is the 5th intercostal space, midclavicular line.

A healthcare facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietitian, and nurse involved in the client's care are required to collate all information for easy access. Which style do you think the agency is following to record the client details?

SOAP charting Explanation: In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

The client is scheduled to receive phenytoin through a nasogastric tube and has a tube-feeding supplement running continuously. The head of the bed is elevated to 30 degrees. Prior to administering the medication, what should the nurse do?

Stop the tube feeding for 1 hour before and hold the tube feeding for 1 hour after giving phenytoin. Explanation: In order for phenytoin to be properly absorbed and provide maximum benefit to the client, nutritional supplements must be stopped before and after delivery. The head of the bed is elevated 30 degrees since this client has a tube feeding infusing; it is not necessary to elevate the bed any further. Blood levels are usually drawn before giving a dose of phenytoin, not after. It is not necessary to flush with such a large amount of water (150 mL) before and after administering phenytoin.

A client experiencing a manic episode has been talking loudly, pacing the unit, and trying to draw other clients into debates about the value of self-determination. Arrange in order the steps a nurse should take to help calm this client. All options must be used.

Take client to a quiet area, such as his or her room, to decrease stimuli. Use oral medication to decrease anxiety and increase appropriate social interaction. Talk with the client about the anxiety and stress the client is feeling. Teach the client coping strategies to deal with stressors. Explanation: None of the other interventions will be successful unless the stimuli that fuel the client's mania are removed or decreased. Once the client is in a quieter setting, oral medication will help calm the client so he or she can be calmer. Once the medication has taken effect, the nurse can help the client explore the client's feelings and problem. Finally, teaching coping techniques can be effective to address client problems after he or she has become calmer.

A client with terminal cancer has an advance directive stipulating that there will be no invasive treatments once the client loses consciousness. The client has been unresponsive for 12 hours, and the family is concerned about dehydration and starvation. A family member asks, "Can't we use a feeding tube? Eating and drinking are not medical treatments." Which action will the nurse take first in response to the family's concerns?

Teach the family about nutritional and hydration needs at the end of life and risks associated with feeding tubes. Explanation: The priority action in response to the family's concerns is to provide education about the requested intervention of a feeding tube. Neither hydration nor feeding has been shown to prolong life or greatly alter comfort levels, and a feeding tube is an invasive procedure with a number of risks, including increasing client discomfort. Providing this information may help the family come to terms with their loved one's decision to choose nonintervention and move toward acceptance of death. The client's advance directive must be followed, and if the family becomes insistent, the nurse will explain the ethics and legalities to them. However, this is not the first action to take, as it will not help the family cope with the transition. The family may also need to speak to the health care provider, but the nurse should provide the relevant teaching first rather than avoid the question.

The nurse is helping a family plan for the discharge of their child, who will be going home in a spica cast. Which information should be most important for the nurse to consider?

The child's bedroom is on the second floor. Explanation: The child with a hip spica cast who is going home and has a bedroom on the second floor of the home needs to have the bed moved to an area that is more central to family life. Negotiating a flight of steps at least twice a day (on awakening in the morning and before going to bed at night) with a child in a hip spica cast would be difficult and most likely dangerous. Because the child in a hip spica cast will need to use a bedpan or urinal, the bathrooms can be on any floor. Because the family is involved in the discharge, the 16-year-old sister should be taught appropriate care along with the rest of the family. The child can be carried up and down the three steps to the house the few times necessary after discharge.

The home health nurse is completing the admission paperwork for a new client diagnosed with osteomyelitis who will be receiving home service intravenous therapy for the next month. The client is 32 years old and happily married. Which findings will warrant further investigation? Select all that apply.

The client talks repeatedly about the inability to grow old with the spouse. The client spends a great deal of time reflecting back on teen years. Explanation: At age 32, the client is in the middle adult stage of life. The repeated discussions about the lack of a future or death and reflections back on life are not appropriate or expected for this stage of development and should be investigated further. An interest in civic responsibilities and the establishment of hobbies is expected. During this developmental period, the greatest concern typically relates to establishing gainful employment and significant relationships. This is being demonstrated by the client's willingness to discuss family, which includes spouse and children.

A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client?

They debride the wound and promote healing by secondary intention. Explanation: For this client, wet-to-damp dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Dry, sterile dressings protect the wound from mechanical trauma and promote healing. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.

The advanced practice nurse suggests to the client that practicing some yoga positions would address the balance issues that the client mentioned during an appointment. The client makes an appointment with the Women's Health Source Service at the local hospital to see about joining the yoga class. Which information should the nurse include in introducing yoga to this client? Select all that apply.

This gentle exercise improves a person's flexibility. People remark that their endurance level improves. Sometimes people feel their concentration increases. People report this workout results in better coordination. Explanation: Yoga is a complementary mind-body intervention which promotes calmness, concentration, flexibility, balance, endurance, and strength. All people can benefit from yoga routines. A person does not need to be calm and quiet to practice yoga, for yoga assists in relaxing a person.

The nurse is suctioning a client's tracheobronchial tree. Identify the area to which the nurse should advance the catheter.

To suction the tracheobronchial tree, the nurse should insert the catheter deep in the trachea.

Which instructions should be included in the plan of care for a client who had a left femoral-popliteal bypass yesterday? Select all that apply.

Turn frequently, and use pillows to support the incision. Encourage the client to change positions frequently to prevent atelectasis. Place client in supine position, and elevate the leg above heart to prevent edema. Encourage the client to walk short distances to promote circulation. Explanation: Turning frequently promotes circulation, while using pillows for support will prevent stress to the suture line. Short periods of different leg/body positions will not impair postoperative oxygen levels. The client should only be in a knee flexed position when walking and not at rest. Prolonged sitting is discouraged, and it may cause pain and edema. It is not recommended that the leg be placed in a dependent position as this promotes edema. Placing a client in a supine position with the leg elevated above the heart is recommended only if the client develops edema.

The nurse is caring for a client who has a type I second-degree atrioventricular (AV) block. Which ECG rhythm would the nurse expect to see?

Type I second-degree AV block is characterized by a progressively longer PR interval until a QRS complex is dropped (option D). Option A shows a type II second-degree AV block, which has a PR interval that may be prolonged but stays constant until a QRS complex is dropped. Option B shows a third-degree AV block, which has a constant PR interval and a constant interval between the QRS complexes, but there is no apparent relationship between the P waves and the QRS complexes. Option C shows a first-degree AV block, which has a consistent prolonged PR interval. No QRS complexes are dropped.

A nurse is discussing possible risk factors related to surgery with a client. Considering that the client belongs to the Navajo culture, which approach should the nurse adopt to prevent any misunderstandings?

Use a hypothetical third person. Explanation: The nurse should discuss the risk and complications related to surgery using a hypothetical third person. People belonging to Navajo culture view talking about possible risks in an informed consent discussion as ill-intended and even malicious because of their belief that speaking ill causes ill. In these situations, discussing risks and side effects using a hypothetical third person may be appropriate. Having a direct discussion may not be appropriate. Providing written information may not be appropriate because it prevents open communication between the nurse and the client.

The nurse teaches appropriate care measures to the parents of a 5-year-old child who has been given trimethoprim/sulfamethoxazole for a urinary tract infection. What directives should be included in the teaching plan? Select all that apply.

Use a sunscreen. Report any rash. Keep medication out of the sunlight. Keep the child well hydrated. Explanation: The child receiving trimethoprim/sulfamethoxazole should wear sunscreen daily while on the medication, and the medication must be kept out of direct sunlight. (It comes in a dark bottle.) Children with a urinary tract infection should drink lots of fluids to help flush the organisms from the bladder. The medication does need to be taken with milk or food. Trimethoprim/sulfamethoxazole has been associated with Steven-Johnson syndrome, so any rash requires prompt attention.

A nurse has just received a report from the nurse who worked the previous shift. Which child should be assessed first?

a 6-year-old child with acute heart failure on 2 L of oxygen Explanation: Following the ABCs (airway, breathing, and circulation), the nurse should assess the child on oxygen first to make sure the child has the oxygen in place and the pulse oximeter reading is above 94%. The other children should be assessed as soon as possible, but the child on oxygen takes priority.

After undergoing a tetralogy of Fallot repair, a preschool child is transferred to the pediatric floor. Which intervention does the nurse tells the family to expect?

a reduced sodium diet Explanation: Because of the hemodynamic changes that occur with open heart surgery repair, particularly with septal defects, transient congestive heart failure may develop. Therefore, the child's sodium intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate. Typically the child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any postoperative client, therefore isolation is not necessary. The child may be placed in a room with other children who are not contagious. Visitors are not restricted unless the pediatric unit has restrictive visiting policies.

The client who routinely takes sertraline presents to the emergency department reporting muscle rigidity and tremors. The client also states that they had a cough last week that was treated with dextromethorphan. What is the appropriate nursing intervention?

administer intravenous diazepam Explanation: The combination of an anti-depressant and dextromethorphan can increase the serotonin level leading to serotonin syndrome. Diazepam or another benzodiazepine is administered to treat the seizures and anxiety that can result from this condition.

A nurse takes all of these actions when caring for a client with hypothyroidism. Which intervention is the priority?

administering liothyronine Explanation: Liothyronine is triiodothyronine (T3) and is often administered to a client with hypothyroidism. This is the priority to increase thyroid hormone levels. The other interventions would be lower-level priorities.

The nurse-manager is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.

admission to the hospital transfer to the nursing home transfer of a client from surgery to the surgical unit admission to a home health agency from the hospital Explanation: The goal of "medication reconciliation" is to ensure that clients are on the right medication after any transfer, admission, or discharge. It is not necessary to reconcile the medications if the client moves to a different room on the same floor. It is estimated that more than half of medication errors occur during these transitions, and medication reconciliation can reduce errors by 70% or more. The Joint Commission requirements mandate medication reconciliation programs.

The nurse is assessing a client in the third trimester of pregnancy. What assessment findings does the nurse document as expected at this stage? Select all that apply.

ankle edema shortness of breath Explanation: Heartburn, varicose veins, fatigue, leg cramps, ankle edema, and shortness of breath are common during the third trimester and considered normal. The nurse should teach the client how to relieve these minor discomforts and what to report if they become unbearable. Nausea and vomiting should subside by the end of the first trimester; if these persist, the nurse should suspect an undiagnosed problem, such as hyperemesis gravidarum, or emotional factors. Increased vaginal discharge generally occurs during the first trimester and decreases by the end of this trimester. A yellow, curd-like, or malodorous discharge suggests an abnormal vaginal infection and should be reported to the healthcare provider. Hypertension may indicate the development of preeclampsia and is not a normal occurrence for any trimester.

The nurse is caring for a client experiencing a moderate systemic reaction. What would the nurse see upon assessment? Select all that apply.

anxiety bronchospasm cough wheezing Explanation: Anxiety is a symptom of a moderate systemic reaction. Seizure is a symptom of a severe systemic reaction. Bronchospasm is a symptom of a moderate systemic reaction. Cough is a symptom of a moderate systemic reaction. Cyanosis is a symptom of a severe systemic reaction. Wheezing is a symptom of a moderate systemic reaction.

A nursing student is about to administer an injection to a competent client who is acting out on the hospital unit. The client refuses the injection and the assigned nurse helps the student administer the medication after a physical struggle. What legal compromises did the student nurse engage in with this scenario? Select all that apply.

assault battery intentional tort Explanation: Assault is a threat to have bodily contact without the person's consent such as administering an injection. Battery is an assault that is carried out such as administering the injection. An intentional tort is an act of wrongdoing such as a medication error. Slander is the spoken word of defamation of character and administering the injection was not speaking. False imprisonment is restricting movement without proper consent and did not happen with the injection.

The nurse is caring for a client who is taking haloperidol. The client comes to the nurses' station and states that he feels frightened and his muscles hurt. He is unable to turn his head to look at the nurse, his face is stiff, and he cannot move his tongue very well. Which prescribed PRN medication would be appropriate for the nurse to administer?

benztropine Explanation: The client is experiencing the side effect of dystonia, an extrapyramidal symptoms (EPS). Treatment for EPS is with an anti-parkinson drug class, which includes benztropine. Lorazepam is prescribed for anxiety, which may be appropriate for fear, but it does not resolve the underlying pathophysiological process. Diphenhydramine is an antihistamine commonly used in allergy reactions and may cause sleepiness. Meperidine is a narcotic pain medication that will not resolve the cause of the client pain.

While caring for a post-term multigravida who is being induced with intravenous oxytocin solution, what finding should the nurse interpret as indicative of a possible complication?

convulsions Explanation: Severe water intoxication with convulsions and coma can occur when clients are induced with oxytocin. Other serious adverse effects include hypertension, uterine rupture, tetanic contractions, neonatal jaundice, and postpartum hemorrhage. Generalized edema is not a complication of administering oxytocin. Depression of deep tendon reflexes is a possible complication of magnesium sulfate therapy. Hypertension, rather than hypotension, may be a complication of oxytocin.

A 15-month-old child is recovering from surgery, and the nurse is performing a postoperative pain assessment. The nurse documents what findings as evidence of pain? Select all that apply.

crying increasing heart rate touching the wound dressing Explanation: A behavioral change is one of the most valuable clues to pain. A child who is pain-free likes to play. A child of this age will not use a numeric rating scale for pain. It is typical for a child of this age to throw toys, and engagement in play is not a sign of pain. An increased heart rate may indicate increased pain. Touching the area is also an indicator that there is pain.

The nurse has administered meperidine to a client in labor. Which change in the fetal heart rate tracing would the nurse expect to occur as a result of the meperidine administration?

decreased fetal heart rate variability Explanation: Possible fetal adverse reactions include moderate central nervous system depression and decreased fetal heart rate variability. Bradycardia, late decelerations, and increased fetal movement don't occur as a result of meperidine administration.

A client is admitted to the psychiatric unit with acute onset of schizophrenia. The physician orders the phenothiazine chlorpromazine, 100 mg by mouth four times per day. Before administering the drug, a nurse reviews the client's medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects?

droperidol Explanation: When administered with any phenothiazine, droperidol may increase the risk of extrapyramidal effects. Guanethidine, lithium carbonate, and alcohol do not increase the risk of extrapyramidal effects.

A nine-year-old child has been diagnosed with cancer and is scheduled for chemotherapy. The parents ask the nurse how they should explain the side effect of hair loss to the child. What is the nurse's best response?

explain that, as hair thins, keeping it clean and short may camouflage partial baldness Explanation: The nurse must prepare the parents and child for possible hair loss. Cutting the hair short lessens the impact of seeing large quantities of hair on bed linens and clothing. Sometimes, keeping the hair in a short full style can make a wig unnecessary. Hair usually regrows in six months, depending on the treatment protocol. The child should be encouraged to pick out a wig similar to their own hair color and style before the hair falls out to ease the adjustment to hair loss. Hair loss during a second treatment with the same medication is usually less severe.

A client who has been taking hydrocodone with acetaminophen at home for 6 weeks following a fractured tibia is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/min and shallow. What do these findings indicate?

habituation effect of the long-term drug use Explanation: Hypotension and depressed respirations are signs of high levels of ingestion of hydrocodone, and the client may be developing a habit of taking this drug for a prolonged period. Expected common adverse effects of hydrocodone and acetaminophen would include drowsiness, confusion, blurred vision, and constipation. Hemorrhage from gastrointestinal irritation is not associated with this drug. Hypersensitivity reactions would be manifested by pruritus and rashes.

A client with impaired cardiac functioning is having abdominal surgery. Sodium thiopental is being used during anesthesia induction. What should the nurse monitor the client for during the surgery?

hypotension Explanation: Sodium pentothal, a short-acting barbiturate, can cause hypotension, which may be especially problematic for the client with impaired cardiac functioning. Sodium pentothal does not cause bradycardia, complete muscle relaxation, hypertension, or tachypnea.

When preparing to administer a drug dose to a client, the nurse examines the drug label. The nurse understands that the U.S. Food, Drug, and Cosmetic Act and Canada's Food and Drug Act and Cosmetic Regulations require that drug labels include which information? Select all that apply.

manufacturer's lot number expiration date Quantities and proportions of active ingredients Explanation: A drug label must list the active ingredients and their quantities and proportions, as well as directions for use, lot number, and expiration date. The laws do not require that the chemical compound be listed and it is not necessary for the label to provide general disease information.

The nurse visits the home of a client with a newly applied leg cast. On which area should the nurse focus when assessing this client's neurovascular functioning? Select all that apply.

motion sensation capillary refill Explanation: The neurovascular assessment includes assessment of motion, sensation, and peripheral circulation. Muscle tone and body temperature are not a part of the neurovascular assessment after the application of an immobilization device such as a cast.

A parent brings a child to the health care provider's office for evaluation of chronic stomach pain. The parent states that the pain seems to go away when the child is kept home from school. The health care provider diagnoses school phobia. Which other behaviors or symptoms may the child exhibit? Select all that apply.

nausea headaches dizziness Explanation: Children with school phobia commonly complain of vague symptoms, such as stomachaches, nausea, headaches, and dizziness, to avoid going to school. These symptoms typically do not occur on weekends. A careful history must be taken to identify a pattern of school avoidance. Weight loss and specific areas of pain are more likely to have a physiological cause and are uncommon in children with school phobia.

A physician orders laboratory tests to confirm hyperthyroidism in a client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

no increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test Explanation: In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

A parent describes that she is trying to get her toddler to eat well but meal times with have become increasingly frustrating. Which behavior would the nurse suggest that the parent modify to make meals a more pleasant experience?

offering several healthy choices Explanation: It is best to keep choices simple for young children. Too many choices increase the likelihood of creating a picky eater. Meal times should be kept short to align with a toddler's attention span. Distraction, especially television, should be minimized so the child can focus on eating. Small portions are less overwhelming for small children.

A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who is caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the dressing when? Select all that apply.

per hospital policy when the dressing is becoming loose when the dressing is soiled when the site is reddened Explanation: Research demonstrates that central lines are a large infection risk for clients. The dressing must be clean, dry, and intact to be effective. Sterile dressing change is indicated when the dressing does not meet this criteria; otherwise it is changed per hospital policy.

A 13-year-old client is dying of cancer. When providing care for this client, the nurse should incorporate the developmental tasks for this age. According to Erikson's developmental model, the child normally is expected to be working on which psychosocial issue?

personal values Explanation: According to Erikson, a child of 13 years is normally seeking to meet the need to develop personal identity. Personal values are a component of this identity. Developing a conscience is a component of achieving initiative during the preschool years. Developing a sense of competence is a component of achieving industry in the school-age years. Developing a lifetime vocation is a component of achieving generativity in adulthood.

A nurse is caring for a client with esophageal varices. A Sengstaken-Blakemore tube is successfully inserted to control bleeding. The nurse should:

provide the client with an emesis basin to expectorate secretions. Explanation: The Sengstaken-Blakemore tube has a gastric and an esophageal balloon that are inflated to compress bleeding esophageal varices. An inflated esophageal balloon prevents swallowing. Therefore, the nurse should provide the client with tissues and encourage him to spit into the tissues or an emesis basin. If the client cannot manage his secretions, gentle oral suctioning is needed. Oral and nasal care is provided every 1 to 2 hours. Lozenges will increase saliva production, increasing the client's risk of aspiration.A water-soluble lubricant rather than a petroleum-based lubricant is applied to the external nares.The client with a Sengstaken-Blakemore tube cannot swallow.

A school-age child with Down syndrome has an upper respiratory infection (URI). The nurse assesses and finds upper lobe wheezing bilaterally, a respiratory rate of 28 breaths/min, and oxygen saturation of 97% on room air. What are the nurse's priority actions? Select all that apply

providing fluids that the child likes to drink restricting visitation by ill family members ensuring that child is as active as possible Explanation: A child with Down syndrome has deficits in the immune system and increased mucus viscosity, which contribute to URI. Providing fluids the child likes will increase the chance the child will drink the fluid and help with hydration. People who feel unwell should not visit, because the child has deficits in the immune system. However, vaccination should not be performed while the child is actively ill. Increasing activity as much as possible will help to resolve the URI. Oxygen is not required, because the room-air oxygen saturation level is within the acceptable range.

Despite continuous health teaching, a client will use only the left thigh for insulin administration. The nurse is aware this is happening because:

repeatedly using the same site is less painful. Explanation: Repeatedly injecting in the same site causes scar tissue (lipohypertrophy) to form, and little or no pain is felt with subsequent injections. It also decreases insulin absorption. Scarring is more likely to occur with same-site injection than with rotating injection sites, and generally this would not be considered attention-seeking behavior or a control issue.

When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply.

right ventricular hypertrophy ventricular septal defect overriding aorta pulmonary stenosis Explanation: Tetralogy of Fallot involves four defects: right ventricular hypertrophy, ventricular septal defect, overriding aorta, and pulmonary stenosis. Aortic valve stenosis and atrial septal defect are not components associated with this condition.

Which milieu activity should the nurse recommend to a client with acute mania? Select all that apply.

scheduled rest periods relaxation exercises listening to soft music taking a walk Explanation: Scheduled rest periods, relaxation exercises, and listening to soft music are activities that reduce environmental stimuli for the client who is hyperactive, talkative, easily distracted, irritable, and angry. Walking is also beneficial to discharge some of the client's need to be active. Watching television is not therapeutic because it would stimulate the client with acute mania.

A 20-year-old obese primigravida at 40 weeks' gestation is admitted to the birthing center in the first stage of labor with contractions lasting 50 seconds and occurring every 3 to 4 minutes. The client's cervix is dilated 5 cm and is 75% effaced. When assessing the client's emotional status, what should the nurse anticipate the client to exhibit?

seriousness Explanation: Typically, as labor progresses, the client becomes serious and her focus turns inward. Thus, the nurse would expect the client to be exhibiting seriousness. Seriousness, not fear, is more common during the active phase of labor. Early in the first stage of labor (1 to 3 cm) when complications are absent and contractions are still not very strong, the client usually is not very uncomfortable. She is usually excited that the birth day has finally arrived, and she can expect to be happy and eager. As the transition phase approaches, the client is likely to become irritable, tired, and sometimes panicky or fearful.

A laboring client brings a doula with her to the labor room. When working with the doula, which of the following actions can a doula perform with a laboring client? Select all that apply.

serve as a support person and coach during labor function as a resource person in the perinatal time Explanation: The role of the doula in labor and birth is to provide support. Doulas do not assist with the birth process and do not replace the partner. Doulas are not certified to perform vaginal exams or abdominal assessments. Doulas are to provide physical, emotional, and informational support for the woman and her invited supporters, but do not make decisions for clients.

A client who practices the Mormon faith has had abdominal surgery several days ago. The client's bowel function has returned, and the client is now advanced to a full liquid diet. When working with the nutritional staff to ensure that the client's meal trays include the appropriate food choices for the client's prescribed diet, which suggestion would be most appropriate for the nurse to include? Select all that apply.

sherbet cranberry juice strained cream of chicken soup Explanation: Based on the client's faith, the client is required to abstain from the ingestion of caffeinated products such as tea, coffee, and carbonated beverages such as colas. Items such as sherbet, fruit juices, including cranberry juice, and strained cream soups would be appropriate for the client's religious beliefs as well as adhere to the prescribed full liquid diet.

A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. Which fetal heart rate pattern would the nurse find is most concerning?

sinusoidal pattern Explanation: A sinusoidal pattern is an ominous sign that reflects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. Sinusoidal patterns, while rare, are associated with Rh sensitization, fetal hydrops, and anemia. This client will most likely require a cesarean birth to improve the fetal outcome. Variable decelerations, associated with cord compression, and late decelerations, associated with poor placental perfusion, are concerning but may correct with appropriate interventions. Early decelerations are associated with head compression and are considered a normal variation.

A child is diagnosed with pituitary dwarfism. Which pituitary agent will the primary care provider most likely order to treat this condition?

somatotropin Explanation: Somatotropin is used to treat linear growth failure stemming from hormonal deficiency. Synthetic ACTH is used to treat adrenal insufficiency and a variety of other conditions; desmopressin acetate and vasopressin are used to treat diabetes insipidus.

A client with schizophrenia is taking the atypical antipsychotic medication clozapine. Which signs and symptoms indicate the presence of adverse effects associated with this medication? Select all that apply.

sore throat fever Explanation: Sore throat, fever, and sudden onset of other flulike symptoms are signs of agranulocytosis, a condition in which an insufficient number of granulocytes (a type of white blood cell [WBC]) causes the individual to be susceptible to infection. The client's WBC count should be monitored at least weekly throughout the course of treatment. Pill-rolling movements can occur in clients experiencing adverse extrapyramidal effects associated with antipsychotic medication that has been ordered for much longer than a medication, such as clozapine. Polyuria and polydipsia are common adverse effects of lithium therapy. Orthostatic hypotension is an adverse effect of tricyclic antidepressant therapy.

The nurse is caring for a client with gastroesophageal reflux disease (GERD). The nurse knows that breakfast is served for clients at 0800. Which prescribed medication will the nurse administer at 0730?

sucralfate Explanation: Sucralfate coats the stomach protecting the lining from irritation. For this to occur, the medication must be given on an empty stomach. Lansoprazole, cimetidine, and acetaminophen do not have to be given on an empty stomach.

A client with metastatic bone cancer has signed a Do Not Resuscitate (DNR) order specifying comfort care only. Which would be included in the client's plan of care? Select all that apply.

suctioning thick secretions to relieve dyspnea administering oral pain medication every hour Explanation: Because the client has signed a DNR order, only comfort measures should be taken. Insertion of a feeding tube would be inappropriate because it would sustain life. Oral pain medications would be necessary to promote comfort by relieving pain. In most cases, antibiotic therapy and intubation would not be performed if the sole goal of treatment is to maintain comfort and not to cure disease.

Lorazepam is commonly given along with a neuroleptic agent. What is the purpose of administering the drugs together?

to reduce anxiety and potentiate the neuroleptic's sedative action Explanation: Lorazepam, when taken with a neuroleptic such as haloperidol, potentiates the neuroleptic's sedating effect and is used to treat severely agitated clients. Lorazepam wouldn't be given to counteract extrapyramidal effects. Both drugs can cause depression, so they aren't used to treat depression. The drugs' depressant effect would decrease concentration, not increase it.

A mother who is visibly upset carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse's first action should be:

to take the infant and mother back to a treatment room. Explanation: Taking the infant and mother into a treatment room for assessment is appropriate because this action provides privacy and a controlled environment. Taking the infant away from the mother is inappropriate because the mother should be allowed to remain with her child if she wishes. If she does not want to be present, the nurse should find a private area for her. The nurse must assess the child before calling the resuscitation team. Assessing the child in the waiting room is not appropriate.

A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching?

turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation Explanation: The synchronizer switch should be turned "off" when defibrillating. All other answers are correct and do not require further teaching.