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A client has undergone surgical resection for lung cancer. Which of the following nursing interventions will promote adaptation and rehabilitation? a) Teaching tracheostomy care. b) Planning a progressive activity regimen with the client. c) Planning a vigorous exercise program. d) Arranging a visit from a member of the American Cancer Society Lost Chord Club (Canadian Lung Cancer Society). rationale:A progressive activity regimen may be prescribed to increase pulmonary function after surgical lung resection. Rehabilitation should include walking and some stair climbing as tolerated. Vigorous exercise is usually not recommended initially. Joining the Lost Chord Club (Canadian Lung Cancer Society) and learning tracheostomy care are appropriate for the client who has undergone a laryngectomy.

An HIV-positive client discovers that his name is published in a report on HIV care prepared by his nurse. He strongly opposes this and files a lawsuit against the nurse. Which of the following offenses has this nurse committed? a) Invasion of privacy. b) Defamation. c) Unintentional tort. d) Negligence of duty. rationale: The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.

Sudoriferous glands secrete which type of substance? a) Cerumen b) Oil c) Hormones d) Sweat rationale: Sudoriferous glands are long, coiled tubes that secrete sweat through a duct on the body's surface. Sebaceous glands secrete oil (sebum). Endocrine glands secrete hormones. Together, ceruminous and sebaceous glands secrete cerumen.

The absence of which of the following behaviors in an 18-month-old child would cause the nurse to be concerned? a) Copying a circle. b) Playing with pull toys. c) Playing tag with other children. d) Building a tower of eight blocks. rationale: Playing with pull toys is a typical task of a normally developed 18-month-old child. Inability of the toddler to do so would be a concern. Copying a circle is a behavior typical of a 3-year-old child. Playing tag with other children requires cooperative play and the ability to follow rules; this behavior develops at about age 5 years. Building a tower of eight or more blocks is typical behavior of a 3-year-old child.

The rapid response team has been called to manage an unwitnessed cardiac arrest in a client's hospital room. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is: a) 8 to 10 minutes. b) 1 to 2 minutes. c) 12 to 15 minutes. d) 4 to 6 minutes.

calcium gluconate

reversal for mag sulfate

A hospitalized infant, age 10 months, begins to choke while eating and quickly becomes unconscious. A foreign object isn't visible in the infant's airway, but respirations are absent and the pulse is 50 beats/minute and thready. The nurse attempts rescue breathing, but the ventilations are unsuccessful. What should the nurse do next? a) Deliver five chest thrusts. b) Perform chest compressions. c) Deliver five abdominal thrusts. d) Deliver five back blows. rationale: If rescue breathing is unsuccessful in a child younger than age 1, and the heart rate is less than 60, the nurse should perform chest compressions followed by rescue breathing. The chest compressions will possibly expel the object from the obstructed airway. Once the infant becomes unresponsive, the nurse should not deliver back blows or chest thrusts. The nurse shouldn't use abdominal thrusts for a child younger than age 1 because they can injure the abdominal organs.

Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which of the following eye problems most likely to be associated with diabetes mellitus? a) Cataracts. b) Retinopathy. c) Glaucoma. d) Astigmatism. rationale: The major cause of blindness in people with diabetes mellitus is diabetic retinopathy. Corneal problems, cataracts, refractive changes, glaucoma, and extraocular muscle changes are also noted, but retinopathy is the most common problem. Cataracts increase in frequency in clients with diabetes, but retinopathy is the most common problem. Astigmatism has not been associated with diabetes mellitus. Clients with diabetes mellitus may be more prone to glaucoma, but retinopathy is the most common eye disorder.

A neonate weighing 1870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 has received sodium bicarbonate intravenously. The drug has been effective if the neonate: a) Does not become edematous. b) Is not dehydrated. c) Develops respiratory alkalosis. d) Does not go into metabolic acidosis. rationale: Metabolic acidosis results from the metabolic changes associated with cold stress. End products of metabolism increase the acidity of the blood, evidenced by a pH of 7.11. Therefore, sodium bicarbonate, which is a buffer base, is often used. Diuretics, not sodium bicarbonate, would be used to combat edema. Intravenous fluids would be used to treat dehydration. Respiratory alkalosis results from excessive carbon dioxide loss, a condition that would be unusual in this neonate. Additionally, because sodium bicarbonate is a base, administering it to client with alkalosis would only further exacerbate the alkalotic condition.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Spasticity of all four extremities b) Positive Babinski's reflex along with spastic extremities c) Hyperreflexia along with spastic extremities d) Absence of reflexes along with flaccid extremities rationale: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities

A nurse is assessing a client with bone cancer pain. Which of the following components of a thorough pain assessment is most significant for this client? a) Aggravating factors. b) Cause. c) Intensity. d) Location. rationale: Intensity is indicative of the severity of pain and is important for evaluating the efficacy of pain management. The cause and location of the pain cannot be managed but the intensity of the pain can be controlled. The nurse and client can collaborate to reduce aggravating factors; however, the goal will ultimately be to reduce the intensity of the pain.

Graves' disease, or hyperthyroidism, is a hypermetabolic state that's associated with rapid, bounding pulses; heat intolerance; tremors; and nervousness. Bradycardia and constipation are signs and symptoms of hypothyroidism.

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find: a) jaundice and vomiting. b) severe abdominal pain with direct palpation or rebound tenderness. c) rectal bleeding and a change in bowel habits. d) tenderness and pain in the right upper abdominal quadrant. rationale: Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

Sodium polystyrene sulfonate is prescribed for a client following crush injury. The drug is effective if: a) The ECG is showing tall peaked T waves. b) There is muscle weakness on physical examination. c) The pulse is weak and irregular. d) The serum potassium is 4.0 meq/liter (4/0 mmol/l). rationale: Following crush injury, serum potassium rises to high levels. Sodium polystyrene sulfonate is a potassium-binding resin. The resin combines with potassium in the colon and is then eliminated. Serum potassium levels should return to normal. Normal serum potassium values are between 3.5 and 5.2 meq/liter (3.5 to 5.2 mmol/l). Weak, irregular pulse and tall peaked T waves on ECG are signs of hyperkalemia, and muscle weakness is a sign of hypokalemia.

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? a) Place the client on a sheepskin, and monitor for increasing edema. b) Monitor patient blood pressure. c) Encourage activity as tolerated. d) Provide a high-protein, fluid-monitored diet. rationale: Blood pressure control is a priority assessment in clients with poststreptococcal glomerulonephritis. The blood pressure can be increased for up to 6 weeks after treatment. The nurse must provide a low-protein diet during the acute phase. The nurse must also closely monitor the client's fluid intake and output. Clients should be placed on bed rest to control hypertension and workload on the kidney. Although providing comfort measures (such as placing the client on a sheepskin) are important, this action isn't a priority

When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be: a) "I'm sorry. I was busy with another client." b) "My name is Mary and I'm your nurse for today." c) "You seem upset this morning." d) "You've had your light on for 20 minutes?"

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. The intended outcome of this diet is to: a) Prevent the development of ketosis. b) Reduce demands on the liver. c) Help maintain urine acidity. d) Act as a diuretic. rationale: High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: a) rapid, deep breaths with abrupt pauses between each breath. b) rapid, deep breaths and irregular breathing without pauses. c) shallow breaths with an increased respiratory rate. d) progressively deeper breaths followed by shallower breaths with apneic periods. rationale: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? a) Encourage a high-calorie, high-protein diet. b) Encourage foods high in vitamin B. c) Limit salt intake to 2 g per day. d) Restrict fluids to 1,500 ml per day. rationale: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

The nurse is administering bolus gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fistula (TEF). To prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube the nurse should: a) allow a small amount of formula to enter the stomach before pouring more formula into the syringe barrel. b) unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel. c) maintain a continuous flow of formula down the side of the syringe barrel once the clamp is opened. d) pour all of the formula to be administered into the syringe barrel after opening the clamp. rationale: The best way to prevent air from entering the stomach when performing a bolus feeding on an infant through a gastrostomy tube is to open the clamp after all the formula has been placed in the syringe barrel. Doing so prevents air from mixing with the formula and thus being introduced into the stomach. Pouring all the formula into the barrel after opening the clamp, maintaining a continuous flow of formula down the side of the barrel after unclamping the tube, and allowing a small amount of formula to enter the stomach before adding more formula to the barrel permit air to enter the stomach

A client is admitted to the emergency department after an industrial accident involving organophosphate insecticides. Physical exam reveals anxiety, wheezing, increased salivation, sweating, lacrimation, and diarrhea. What is the nurse's best action? a) Administer alprazolam b) Administer pyridostigmine c) Administer atropine d) Administer albuterol rationale: Pyridostigmine inhibits acetylcholinesterase (AChE), reversing the neuromuscular blockade produced by anticholinergic poisoning or poisoning by irreversible cholinesterase inhibitors such as organophosphates insecticides. Administration of the other drugs such as alprazolam and albuterol will only treat the client symptomatically and not resolve the underlying condition. Atropine, an anticholinergic drug, will make the anticholinergic poisoning worse and cause the client's condition to further deteriorate.

A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report which adverse effect? a) pedal edema b) irregular heartbeat c) decreased pulse rate d) constipation rationale: Irregular heartbeats should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored? a) White blood cell (WBC) count b) Alkaline phosphatase c) Sodium level d) Blood urea nitrogen (BUN) rationale: BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function.

A nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first? a) Administer pain medications. b) Control the environment by turning the lights off and decreasing stimulation for the client. c) Position the client on the left side. d) Check the client's bladder for distention. rationale: The client is experiencing autonomic dysreflexia, which is a medical emergency. The nurse should immediately evaluate the client for bladder distention and be prepared to catheterize the client. Positioning the client on the left side, reducing environmental stimuli, and administering pain medications are not used to treat autonomic dysreflexia.

A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and: a) folic acid. b) iron. c) vitamin D. d) potassium.

A nurse is reviewing a care plan for an infant undergoing phototherapy under blue florescent lights in an isolette for hyperbilirubinemia. Which intervention should the nurse remove from the care plan? a) Obtaining frequent serum bilirubin levels b) Shielding the infant's eyes with an opaque mask to prevent exposure to the light c) Repositioning the infant frequently to expose all body surfaces d) Performing frequent visual assessment of jaundice

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? a) Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess b) Maintaining the client in a quiet environment c) Keeping the client in one position to decrease bleeding d) Positioning the client to prevent airway obstruction

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take? a) Question the physician about the order. b) Administer the medication as ordered. c) Discontinue the medication. d) Inform the client that he should discuss his MI with the physician. rationale: Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: a) potassium. b) sodium. c) phosphorus. d) magnesium.

A primigravida in active labor has been diagnosed with chorioamnionitis. After explaining this condition to the client, the nurse determines that the client understands the instructions when she says: a) "If left untreated, my baby might be born with an infection." b) "My infection is the cause of my hypertonic labor pattern." c) "My baby's heart rate is slow because of my infection." d) "Women who are overweight are more likely to get this infection." rationale: Chorioamnionitis is a serious intrapartum infection that may result in fetal tachycardia and a hypotonic labor pattern. If left untreated, infected amniotic fluid in the fetal lungs may result in an infection, such as pneumonia, during the neonatal period. Typically chorioamnionitis results in fetal tachycardia, not bradycardia. Chorioamnionitis usually results in a maternal fever and tachycardia. It is not associated with either hypotonic or hypertonic labor patterns. No relationship is known between being overweight and development of chorioamnionitis.

The parent of an infant with a cleft lip and palate asks the nurse when the infant's cleft palate will be repaired. The nurse responds by stating that the first repair of a cleft palate is usually done at which of the following times? a) After the child learns to drink from a cup. b) Before the development of speech. c) Before the eruption of teeth. d) When the child weighs approximately 10 kg (22 lb). rationale: The optimal time for cleft palate repair depends on many factors. However, it is best done before speech develops and the child learns faulty speech habits as a result of the defect, usually before 12 to 15 months of age. Tooth eruption usually begins at about 6 months of age. The child should weigh about 10 kg (22 lb) at 6 months, but the important consideration is to schedule surgery before speech patterns begin to develop. An infant may learn to start drinking from a cup as early as 6 to 7 months of age, possibly up to the first birthday

A 39-year-old multiparous client at 39 weeks' gestation diagnosed with class II heart disease is admitted to the hospital in active labor. Which of the following should the nurse assess first after admission to the birthing area? a) Time of last food and fluid intake. b) Fetal position and station. c) Ability to follow directions. d) Contraction frequency and intensity. rationale: When admitting a multigravid client to the birthing area, the nurse needs to obtain information about the frequency, intensity, and duration of labor contractions, the time when the labor began, whether the membranes have ruptured, and the client's estimated childbirth date. From this information, the nurse gets a quick overview of the client's status and can then proceed to plan effective care. Although the time when the client last had food or fluids is important, this information can be obtained later because it is less influential in determining the initial plans for care. Although information about the fetal position is important, this information is less influential in determining the initial plans for care. The client's ability to follow directions is important but this information can be obtained later because it plays a less influential role in initial plans for care.

A 4-year-old child continues to come to the nurses' station after being told children are not allowed there. What behavior is the child exhibiting? a) Aggressive behavior. b) Attention-seeking behavior. c) Resistive behavior. d) Exaggerated stress behavior.

A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? a) "The radioactive iodine reduces uptake of thyroxine and thereby improves your condition." b) "The radioactive iodine destroys thyroid tissue so that thyroid hormones are no longer produced." c) "The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy." d) "The radioactive iodine lowers the levels of thyroid hormones by slowing your body's production of them." rationale: Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. RAI is commonly recommended for clients with Graves' disease, especially the elderly. The treatment results in a "medical thyroidectomy." RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI.

A client, approximately 11 weeks pregnant, and her husband are seen in the antepartal clinic. The client's husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse interprets these findings as suggesting that the client's husband is experiencing which complication? a) pica b) mittelschmerz c) Couvade syndrome d) ptyalism rationale: Couvade syndrome refers to the situation in which the expectant father experiences some of the discomforts of pregnancy along with the pregnant woman as a means of identifying with the pregnancy. Ptyalism is the term for excessive salivation. Mittelschmerz is the lower abdominal discomfort felt by some women during ovulation. Pica refers to an oral craving for substances such as clay or starch that some pregnant clients experience

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of: a) organ meats. b) fresh fish. c) citrus fruits. d) green vegetables rationale: Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

A father asks the nurse how he would know if his child had developed mononucleosis. The nurse explains that in addition to fatigue, which symptom would be most common? a) enlarged lymph glands b) a blush-like generalized skin rash c) persistent nonproductive cough d) liver tenderness rationale: Mononucleosis usually has an insidious onset, with fatigue and the inability to maintain usual activity levels as the most common symptoms. The lymph nodes are typically enlarged, and the spleen also may be enlarged. Fever and a sore throat often accompany mononucleosis. A persistent nonproductive cough can follow an upper respiratory tract infection. A blush-like generalized skin rash is more characteristic of rubella.

A nursery nurse just received the shift report. Which neonate should the nurse assess first? a) Twelve-hour-old term neonate who is small for gestational age b) Six-day-old neonate in an isolette, whose gestational age assessment places him at 36 weeks' gestation c) Four-hour-old term neonate with jaundice d) Two-day-old term neonate in an open bassinette rationale: The nurse should assess the four-hour-old neonate with jaundice. When jaundice occurs within the first 24 hours of life, it typically indicates a life-threatening disorder, such as sepsis, hemolytic disease of the neonate, Rh incompatibility, or ABO incompatibility. Physiological jaundice, which commonly occurs later, is a benign condition. A 2-day-old term neonate in an open bassinette doesn't require immediate assessment by the nurse. A 6-day-old neonate whose gestational age is 36 weeks is a normal preterm neonate who doesn't require immediate assessment by the nurse. A 12-hour-old term neonate who is small for gestational age doesn't require immediate assessment by the nurse.

A postmenopausal client is scheduled for a bone-density scan. The nurse should instruct the client to: a) Remove all metal objects on the day of the scan. b) Consume foods and beverages with a high content of calcium for 2 days before the test. c) Report any significant pain to the physician at least 2 days before the test. d) Ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. rationale: Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis

A staffing agency is sending a licensed practical nurse (LPN) to cover a shift for a pediatric nurse who called out sick. The unit's nurse-manager isn't familiar with the LPN's clinical background or comfort level with pediatric clients. The nurse-manager should assign the LPN to: a) a 9-year-old child with Legg-Calve'-Perthes disease. b) a 10-year-old child who had a tonsillectomy that morning. c) an 8-year-old child admitted that morning with suspected Reye's syndrome. d) a 9-year-old child receiving subcutaneous insulin for treatment of diabetes mellitus.

An elderly client is constipated and tells the nuse that this has not happened before. The best response for the nurse to make is which of the following? a) "The new onset of constipation may be a sign of a more serious problem." b) "You need to eat more fiber." c) "Constipation is an expected problem at your age." d) "You need to drink more water." rationale: The new onset of constipation may be a sign of a tumor from colon cancer. Constipation is not an expected change of aging. Increased fiber and fluid intake is helpful with constipation, but in this case the client needs to be seen by a health care provider to rule out colon cancer.

During dialysis, the client has disequilibrium syndrome. The nurse should first? a) Reassure the client that the symptoms are normal. b) Administer oxygen per nasal cannula. c) Slow the rate of dialysis. d) Place the client in Trendelenburg's position. rationale: If disequilibrium syndrome occurs during dialysis, the most appropriate intervention is to slow the rate of dialysis. The syndrome is believed to result from too-rapid removal of urea and excess electrolytes from the blood; this causes transient cerebral edema, which produces the symptoms. Administration of oxygen and position changes do not affect the symptoms. It would not be appropriate to reassure the client that the symptoms are normal.

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem? a) Climb the steps early in the day. b) Take a nitroglycerin tablet before climbing the stairs. c) Lie down after climbing the stairs. d) Rest for at least an hour before climbing the stairs. rationale: Nitroglycerin may be used prophylactically before stressful physical activities such as stair-climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

In a client with burns on the legs, which nursing intervention helps prevent contractures? a) Hyperextending the client's palms b) Applying knee splints c) Elevating the foot of the bed d) Performing shoulder range-of-motion exercises rationale: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find: a) tenderness and pain in the right upper abdominal quadrant. b) severe abdominal pain with direct palpation or rebound tenderness. c) jaundice and vomiting. d) rectal bleeding and a change in bowel habits. rationale: Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first? a) A 60-year-old client experiencing nausea and vomiting b) A 20-year-old client with a blood glucose level of 70 mg/dl c) A 55-year-old complaining of chest pressure d) An 80-year-old client with a blood glucose level of 350 mg/dl rationale: The nurse should assess the client with chest pressure first because he might be experiencing a myocardial infarction. The blood glucose levels in 20-year-old client and 80-year-old client are abnormal, but not life threatening; therefore, these clients don't require immediate attention. After assessing the client with chest pressure, the nurse should assess the client experiencing nausea and vomiting.

The client has been prescribed lisinopril to treat hypertension. The nurse should assess the client for which of the following electrolyte imbalances? a) Hypermagnesemia. b) Hypocalcemia. c) Hyponatremia. d) Hyperkalemia. rationale: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. Hyperkalemia can be a side effect of ACE inhibitors. Because of this side effect, ACE inhibitors should not be administered with potassium-sparing diuretics.

The nurse should assess a client with Addison's disease for: a) weight gain. b) muscle spasms. c) lethargy. d) hunger. rationale: Although many of the disease signs and symptoms are vague and nonspecific, most clients experience lethargy and depression as early symptoms. Other early signs and symptoms include mood changes, emotional lability, irritability, weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency.

The nurse teaches a female client who has cystitis methods to relieve her discomfort until the antibiotic takes effect. Which response by the client would indicate that she understands the nurse's instructions? a) "I will place ice packs on my perineum." b) "I will void every 5 to 6 hours." c) "I will drink a cup of warm tea every hour." d) "I will take hot tub baths."

Which change does a nurse demonstrate when she helps a young mother adjust to the birth of her child? a) Maturational b) Physiologic c) Unplanned d) Situational rationale: Adjustment to the birth of a child is an example of a situational change, which arises from interaction between individuals and their environment. Because pregnancy is a 9-month process, the change isn't unplanned. Adjustment to maturational change refers to maturation associated with puberty. Physiologic change refers to events associated with aging and menopause.

Which finding would be most important in an 8-month-old infant admitted with severe diarrhea? a) pale yellow urine b) normal skin elasticity c) depressed anterior fontanel d) absent bowel sounds rationale: An infant with severe diarrhea will experience some degree of dehydration. In an 8-month-old child, the anterior fontanel has not closed. Therefore, a depressed anterior fontanel would be an important finding. Additionally, the infant would exhibit dry mucous membranes, lethargy, hyperactive bowel sounds, dark urine, and sunken eyeballs. Skin turgor would be decreased or delayed (e.g., slow to return when pinched). Bowel sounds every 5 seconds would not be considered abnormal for an infant.

Which of the following would be standard nursing care for a client with cervical cancer who has an internal radium implant in place? a) Provide perineal care twice daily. b) Offer the bedpan every 2 hours. c) Offer a low-residue diet. d) Check the position of the applicator hourly. rationale: Bowel movements can be difficult with the radium applicator in place. The purpose of the low-residue diet is to decrease bowel movements. The bowel is cleaned before therapy, and the woman is maintained on a low-residue diet during treatment to prevent bowel distention and defecation. To prevent dislodgment of the applicator, the client is maintained on strict bed rest and allowed only to turn from side to side. Perineal care is omitted during radium implant therapy, although any vaginal discharge should be reported to the physician. It is rare for the applicator to extrude, so this does not need to be checked every hour.

A child is admitted to the hospital with a febrile seizure. The nurse should: a) Place the child in isolation. b) Place a padded tongue blade at the bedside. c) Keep the room temperature low and bedclothes to a minimum. d) Keep the child supine. rationale: One nursing goal for a child with febrile seizures is to maintain the child's temperature at a level low enough to prevent recurrence of seizures. Decreasing the environmental temperature and removing excess clothing and blankets will help decrease the child's temperature. There is no reason to keep the child supine; a side-lying position would be acceptable and help decrease intracranial pressure. A febrile seizure, though, results from abnormal electrical activity in the brain due to elevated body temperature. Isolation precautions are not necessary unless the child has a condition that warrants such an isolation. Using a tongue blade to separate the teeth in the upper jaw from the lower jaw in an attempt to prevent the child from biting the tongue has proven to be ineffective and may result in broken teeth.

A child with newly diagnosed osteomyelitis has nausea and vomiting. The parent wishes to give the child ginger cookies to help control the nausea. The nurse should tell the parent: a) "I will need to get a prescription." b) "Your child needs medication for the vomiting." c) "We discourage the use of home remedies in children." d) "You can try them and see how he does." rationale: Some clients find ginger cookies or "snaps" help relieve nausea. Ginger, in small doses such as would be found in the cookies, has few side effects. There is no reason that the parent should not try this dietary intervention; however, the nurse must monitor the client's response. If the child has a diet as tolerated prescription, there is no need for an additional prescription. Ultimately, the child may need an antiemetic medication, but dietary strategies are often successful in treating vomiting related to osteomyelitis. Making a universal statement disregarding home remedies is not a client-centered approach.

A client had a total abdominal hysterectomy 10 hours ago. Knowing that sepsis is a potential complication of the surgery, the nurse will monitor for which early assessment change? a) Urine output of 20 ml/hour b) Difficulty breathing c) Temperature of 101.8° F (38.8° C) d) Abrupt change in mental status rationale: Sepsis is a potentially life-threatening complication of an infection. Sepsis occurs when chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body. This inflammation can trigger a cascade of changes that can damage multiple organ systems, causing them to fail. To be diagnosed with sepsis, a person must exhibit at least two of the following symptoms: fever above 101.3° F (38.5° C) or below 95° F (35° C); heart rate higher than 90 beats/minute; respiratory rate higher than 20 breaths/minute; probable or confirmed infection. The diagnosis will be upgraded to severe sepsis if also exhibiting at least one of the following signs and symptoms, which indicate an organ may be failing: significantly decreased urine output, abrupt change in mental status, decrease in platelet count, difficulty breathing, abnormal heart pumping function, abdominal pain.

A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action? a) Start I.V. oxytocin infusion as ordered. b) Prepare for cesarean birth. c) Reposition the client. d) Administer amnioinfusion. rationale: Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean birth. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion, but only serve as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress.

A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? a) Explaining that other clients are complaining about the client's body odor b) Accepting these fears and allowing the client to take a sponge bath c) Asking a security officer to assist in giving the client a shower d) Dismantling the showerhead and showing the client that there is nothing in it rationale: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him

A client is admitted to a psychiatric unit after a suicide attempt. The client is withdrawn, has poor hygiene, and appears underweight. What is the priority for a nurse in keeping a therapeutic milieu for this client? a) Manage the client's spiritual needs. b) Give the client structure and support until the client is able to function. c) Encourage the client to participate in group therapy sessions. d) Validate a client's worth and respect for life. rationale: The nurse's priority for a client who has just entered the milieu of the psychiatric unit is to provide a client with safety and security. As the client progresses and displays less destructive behavior, the nurse will encourage the client to participate in group therapy. Validation is part of the actions of a nurse to establish the therapeutic milieu. The nurse will begin validation by giving the client respect and showing the client worth through the nurse's actions. Management of the client's spiritual needs is continuous within the therapeutic milieu; however, the client's physical environment and physical needs are the priority.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? a) "You are not allowed anything by mouth so that your pancreas can rest." b) "Activity is important, so you will be scheduled for physical therapy." c) "I will be starting antibiotic therapy once the blood cultures are obtained." d) "I can offer you ibuprofen for pain with a small sip of water." rationale: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management, fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A client with allergic rhinitis asks the nurse what to do to decrease the rhinorrhea. Which of the following instructions would be appropriate for the nurse to give the client? a) "Use your nasal decongestant spray regularly to help clear your nasal passages." b) "Ask the doctor for antibiotics. Antibiotics will help decrease the secretion." c) "It is important to increase your activity. A daily brisk walk will help promote drainage." d) "Keep a diary of when your symptoms occur. This can help you identify what precipitates your attacks." rationale: It is important for clients with allergic rhinitis to determine the precipitating factors so that they can be avoided. Keeping a diary can help identify these triggers. Nasal decongestant sprays should not be used regularly because they can cause a rebound effect. Antibiotics are not appropriate for allergic rhinitis because an infection is not present. Increasing activity will not control the client's symptoms; in fact, walking outdoors may increase them if the client is allergic to pollen

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? a) They prevent the entrance of microorganisms and minimize wound discomfort. b) They debride the wound and promote healing by secondary intention. c) They protect the wound from mechanical trauma and promote healing. d) They contain exudate and provide a moist wound environment. rationale: 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

A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first? a) Start the intravenous infusion. b) Initiate fetal and contraction monitoring. c) Administer betamethasone. d) Obtain the urine specimen. rationale: The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other orders. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if ordered.

A nurse is assessing a post-surgical client who has been receiving nasogastric suctioning for 3 days. The client is restless, confused, and has generalized edema. What is the nurse's best intervention? a) Infuse 100 ml bolus of 3% saline if serum sodium decreases to less than 128 mEq/L. b) Administer IV morphine sulfate 4 mg every 2 hours PRN. c) Stop the infusion of 5% dextrose in water (D5W) at 100 mL/hr. d) Administer IV metoclopramide 10 mg every 6 hours PRN for nausea. rationale: yponatremia is decrease in serum Na concentration < 136 mEq/L caused by an excess of water relative to solute. Because the client's gastric suction has been depleting electrolytes, the client is displaying signs of fluid volume overload and hyponatremia. Clinical manifestations are primarily neurologic due to an osmotic shift of water into brain cells causing edema. They include headache, confusion, and stupor. D5W becomes hypotonic as it is metabolized and could worsen fluid volume overload. The action of the nurse should be to recognize the symptoms and stop the D5W IV infusion. Once completed, the IV solution should be changed to a solution that includes electrolyte (sodium) replacement. The client is not in acute pain therefore morphine should not be given. Metoclopramide is given for a client who has nausea and vomiting.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. Which of the following is an expected outcome of these exercises? a) Deep breathing expands the alveoli and increases the lung surface available for ventilation. b) Deep breathing increases blood flow to the lungs to allow them to recover from the trauma of surgery. c) Deep breathing elevates the diaphragm, which enlarges the thorax and increases the lung surface available for gas exchange. d) Deep breathing controls the rate of air flow to the remaining lobe so that it will not become hyperinflated. rationale: Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon.

An elderly client on steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should: a) Continue to monitor the client's blood glucose values. b) Contact the dietician to request that one additional serving of protein be added to each meal. c) Contact the physician and recommend that the doses of insulin be evaluated. d) Restrict ambulation so there will be less of a chance for hypoglycemia. rationale: One of the risk factors for hypoglycemia is decreased insulin clearance, such as with impaired kidney function, renal failure, or both. Another risk factor for hypoglycemia is increased glucose use, when there is too much activity or exercise without enough food. Protein is digested slower than carbohydrate, but with chronic kidney disease, it is more difficult for the kidneys to rid the body of metabolic waste products. The nurse should continue to monitor glucose in the blood to prevent the client from continuing to experience hypoglycemia.

During the first few weeks after a cholecystectomy, the client should follow a diet that includes: a) A decreased intake of fruits, vegetables, whole grains, and nuts, to minimize pressure within the small intestine. b) Ingestion of pancreatic enzymes with meals to replace the normal enzyme secretion that has been surgically altered. c) A limited intake of fat distributed throughout the day so there is not an excessive amount in the intestine at any one time. d) At least four servings daily of meat, cheese, and peanut butter to increase protein intake that aids incisional healing. rationale: Bile flows almost continuously into the intestine for the first few weeks after gallbladder removal. Limiting the amount of fat in the intestine at any one time ensures that adequate bile will be available to facilitate digestion. There is no need to eliminate high-fiber foods, and doing so would tend to increase (rather than decrease) pressure within the large intestine (not the small intestine). Eating large amounts of meat, cheese, and peanut butter would be undesirable because these foods are often high in fat. Removing the gallbladder does not decrease pancreatic secretions.

Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice? a) A low transverse incision contraindicates the possibility for VBAC. b) VBAC is not possible, because the neonate was large for gestational age. c) VBAC may be possible if the client has not had a classic uterine incision. d) A history of rapid labor is a necessary criterion for VBAC. rationale: VBAC can be attempted if the client has not had a classic uterine incision. This type of incision carries a danger of uterine rupture. A health care provider (HCP) must be available, and a cesarean birth must be possible within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication because the client has a greater possibility for uterine rupture. Estimated fetal weight greater than 4,000 g by itself is not a contraindication if the mother is not diabetic.

The community psychiatric nurse conducts a weekly education group for clients in a senior citizen day program. The nurse suspects that one of the clients with cognitive impairment is experiencing abuse in the home where she lives with a middle-aged child. The client has suspicious bruises on her body and tells the nurse she often falls at home. What would be the priority care plan for this client by the nurse? a) Alert the physician. b) Encourage the installation of railings and raised toilet seats in the home. c) Wait a few weeks to assess whether there are additional bruises. d) Make an immediate appointment to visit the home to assess the situation. rationale: Older adults are at high risk for abuse and violence in the home, particularly when there is cognitive impairment. The first step for the nurse is to assess the client's home environment. To disregard the injuries by simply encouraging hand railings does not allow for a sufficient assessment of the situation/causation. Alerting the physician will not be effective without a fuller assessment. Waiting a few weeks could be considered negligent behavior of the nurse. There is enough evidence to suggest that the nurse should visit the home soon.

The nurse talks to an adolescent about how she can tell her friends about her new diagnosis of diabetes. Which of the following behaviors by the adolescent indicates that the adolescent has responded positively to the discussion? a) She says, "I'll try to tell my friends, but they'll probably quit hanging out with me." b) She introduces the nurse to her friends as "the one who taught me all about my diabetes." c) She asks her friends what they think about someone who has a lifelong illness. d) She asks the nurse for material on diabetes for a school paper. rationale: The ability to talk about her diabetes indicates that the adolescent feels good enough about herself to share her problem with her peers. Asking for reference material does not specifically indicate that the client's self-esteem has improved or that she has accepted her diagnosis. Saying that her friends will probably desert her if she tells them about the illness indicates that the adolescent still needs to work on her self-esteem and her feelings about the disease. Asking her friends what they think of someone with a lifelong illness would not indicate that the nurse's interventions targeted toward improving self-esteem have been successful. Rather, this statement demonstrates the adolescent's uncertainty about herself.

To help minimize calcium loss from a hospitalized client's bones, the nurse should: a) provide supplemental feedings between meals. b) reposition the client every 2 hours. c) encourage the client to walk in the hall. d) provide the client dairy products at frequent intervals. rationale: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

A 2-month-old infant is brought to the clinic by his mother. His abdomen is distended, and he has been vomiting forcefully and with increasing frequency over the past 2 weeks. On examination, the nurse notes signs of dehydration and a palpable mass to the right of the umbilicus. Peristaltic waves are visible, moving from left to right. The nurse should suspect which condition? a) Colic b) Failure to thrive c) Pyloric stenosis d) Intussusception rationale: Abdominal distention, forceful vomiting, dehydration, a palpable mass, and visible peristaltic waves are classic symptoms of pyloric stenosis caused by hypertrophy of the circular pylorus muscle. Abdominal masses and abnormal peristalsis aren't necessarily related to colic or failure to thrive. Intussusception is usually characterized by acute onset and severe abdominal pain

A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an IV of D5 NS + 20 meq KCL/L running at 60 mL/h. Vital signs are a temperature of 100.4° F (38° C), heart rate of 120 bpm, respiratory rate of 28 breaths/min, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for: a) IV lorazepam. b) rectal acetaminophen. c) IV fosphenytoin. d) rectal diazepam. rationale: IV lorazepam is the benzodiazepine of choice for treating prolonged seizure activity. IV benzodiazepines act to potentiate the action of the gamma-aminobutyric acid (GABA) neurotransmitter; stopping seizure activity. If an IV is not available, rectal diazepam is the benzodiazepine of choice. The child does have a low-grade fever; however, this is likely caused by the excessive motor activity. The primary goal for the child is to stop the seizure in order to reduce neurologic damage. Benzodiazepines are used for the initial treatment of prolonged seizures. Once the seizure has ended, a loading dose of fosphenytoin or phenobarbital is given.

A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? a) "I'll ask the physician about giving the baby an immunization shot." b) "I don't have to worry because I've had the measles." c) "I told my husband to give my son aspirin for his fever." d) "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son." rationale: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella

A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which of the following clients? a) Middle-aged client who had a kidney transplant 3 days ago b) Elderly client just admitted for an acute stroke c) Client who had an ileal conduit 3 days ago d) Middle-aged stable client with bladder cancer awaiting surgery rationale: The charge nurse should assign the new nurse to the middle-aged client newly diagnosed with bladder cancer awaiting surgery, as this client has a condition common to the genitourinary floor and is of low acuity and stable. The charge nurse should assign the agency nurse to the client who had an ileo conduit. Their conditions have lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient

A client comes to the emergency department with severe back pain. The client states he has taken several pain pills he had at home but cannot remember how many he has taken and provides the nurse with an empty bottle of acetaminophen with codeine. Which laboratory value should the nurse address? a) Sodium (Na+) of 145 mEq/L and potassium (K+) of 5.5 mEq/L b) Serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 c) Blood urea nitrogen (BUN) of 22 mg/dL and serum creatinine of 1.35 mg/dL d) Creatine phosphokinase (CPK) of 21 U/L rationale: Hepatic necrosis is the most serious toxic effect of an acute overdose of acetaminophen. The nurse should monitor the liver enzymes and INR level. Renal failure is not a consideration since the lab values are within normal limits. Total CPK would not need to be monitored, if the level is high, it usually means there has been injury or stress to muscle tissue, the heart, or the brain. The CPK level is within normal limits. Both the Na+ and K+ levels are also within normal limits

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an: a) antihypertensive. b) antibiotic. c) anticoagulant. d) anticonvulsant. rationale: During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses don't routinely give antibiotics during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.

A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis? a) Hypoactive bowel sounds b) Weakness and atrophy of the arm muscles c) Severe lower back pain d) Sensory deficits in one arm rationale: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet — usually unilaterally. A herniated disk also may cause sensory and motor loss (such as footdrop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.

A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy for colon cancer. This tube will most likely be removed when the client demonstrates: a) passage of mucus from the rectum. b) passage of flatus and feces from the colostomy. c) absence of stomach drainage for 24 hours. d) absence of nausea and vomiting. rationale: sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned.

A client has been diagnosed with hypothyroidism. Which statement by the client would demonstrate appropriate teaching by the nurse? a) "I should stop taking the prescribed daily aspirin." b) "I will increase daily caloric consumption." c) "I will increase fiber and fluids in my diet." d) "I should stop attending group activities." rationale: Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. Group activities have nothing to do with the current issue. A nurse would not change medical prescriptions by telling the client to stop taking the prescribed aspirin. Increasing caloric consumption is not appropriate with hypothyroidism

A client has been diagnosed with right-sided heart failure. The nurse should assess the client further for: a) Intermittent claudication. b) Dyspnea. c) Crackles. d) Dependent edema. rationale: Right-sided heart failure causes venous congestion resulting in such symptoms as peripheral (dependent) edema, splenomegaly, hepatomegaly, and neck vein distention. Intermittent claudication is associated with arterial occlusion. Dyspnea and crackles are associated with pulmonary edema, which occurs in left-sided heart failure.

A client has been prescribed digoxin. Which of the following symptoms should the nurse tell the client to report as a potential indication of digoxin toxicity? a) Visual disturbances. b) Hypertension. c) Shortness of breath. d) Urticaria. rationale: Visual disturbances are a symptom of digoxin toxicity. These disturbances can include double, blurred, or yellow vision. Cardiovascular manifestations of digoxin toxicity include bradycardia, other dysrhythmias, and pulse deficit. Gastrointestinal symptoms include anorexia, nausea, and vomiting.

b, c, e

A client has been recently diagnosed with type 2 diabetes and is taking metformin twice a day, 1000 mg before breakfast and 1000 mg before supper. The client is experiencing diarrhea, nausea, vomiting, abdominal bloating, and anorexia on admission to the hospital. The admission orders include metformin. The nurse should do which of the following? Select all that apply. a) Administer glargine insulin rather than the metformin. b) Inform the client that adverse effects of diarrhea, nausea, and upset stomach gradually subside over time. c) Assess the client's renal function. d) Discontinue the metformin. e) Monitor the client's glucose value prior to each meal. rationale: The nurse may not discontinue a medication without a physician's order and the nurse may not substitute one medication for another. Maximum doses may be better tolerated if given with meals. Before therapy begins and at least annually thereafter, assess the client's renal function; if renal impairment is detected, a different anti-diabetic agent may be indicated. To evaluate the effectiveness of therapy, the client's glucose value must be monitored regularly. The prescriber must be notified if the glucose value increases, despite therapy.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order? a) Ask the client what type of laxative he/she would like to have. b) Give mineral oil because it does not require a physician's order. c) Ask the client if he/she would prefer to have an enema administered. d) Ask the physician to prescribe a specific laxative. rationale: The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug. The other options are incorrect because they put the nurse in the position of prescribing a medication and not following established professional standards for the administration of medication.

A client has urge incontinence. When obtaining the health history, the nurse should ask if the client has: a) inability to empty the bladder. b) involuntary urination with minimal warning. c) frequent dribbling of urine. d) loss of urine when coughing. rationale: A characteristic of urge incontinence is involuntary urination with little or no warning. The inability to empty the bladder is urine retention. Loss of urine when coughing occurs with stress incontinence. Frequent dribbling of urine is common in male clients after some types of prostate surgery or may occur in women after the development of a vesicovaginal or urethrovaginal fistula.

A client in the intensive care unit (ICU) is on a dobutamine drip. During an assessment the client states, "I was feeling better but now my chest is tight and I feel like my heart is skipping." Physical assessment reveals a heart rate of 110 beats per minute and blood pressure of 160/98 mm Hg. What is the nurse's immediate concern for this client? a) The dosage of the dobutamine needs to be increased. b) The client is experiencing an allergic reaction to the dobutamine. c) The client is experiencing an exacerbation of the heart failure. d) The dobutamine may need to be decreased.

A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should: a) Position the client on a firm mattress. b) Encourage the client to raise and lower his leg four times every hour. c) Keep the involved extremity warm with blankets. d) Position the left leg at or below the body's horizontal plane. rationale: Keeping the involved extremity at or below the body's horizontal plane will facilitate tissue perfusion and prevent tissue damage. The nurse should avoid placing the affected extremity on a hard surface, such as a firm mattress, to avoid pressure ulcers. In addition, the involved extremity should be free from heavy overlying bed linens. The nurse should handle the involved extremity in a gentle fashion to prevent friction or pressure. Raising the leg would cause occlusion to the iliac artery, which is contrary to the goal to promote arterial circulation.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has: a) peptic ulcer disease. b) appendicitis. c) cirrhosis. d) cholelithiasis. rationale: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of: a) severe hypotension. b) profound neuromuscular irritability. c) acute gastritis. d) excessive thirst. rationale: Hypoparathyroidism may slow bone resorption, reduce the serum calcium level, and cause profound neuromuscular irritability (as evidenced by tetany). Hypoparathyroidism doesn't alter blood pressure or affect the thirst mechanism, which usually is triggered by fluid volume deficit. Gastritis doesn't cause or result from hypoparathyroidism.

A client is admitted to the hospital with malaise, headache, and cough followed by fever, chills, dyspnea, chest discomfort, myalgia, anorexia, vomiting, and diarrhea. The physician makes the diagnosis of legionellosis (Legionnaires' disease). The client asks, "How did I get this?" Which response by the nurse is the most accurate? a) "As ceiling fans circulate, bacteria are dispersed into the air." b) "You may have swallowed contaminated water." c) "The bacteria thrive in warm water environments and are inhaled from contaminated water droplets." d) "You inhaled the bacteria from secondary smoke."

A client prescribed enalapril reports symptoms of a persistent dry cough. What is the nurse's best action? a) Notify the healthcare provider b) Assess the client's oxygenation status c) Review medication administration with the client d) Administer dextromethorphan rationale: ACE inhibitors can cause a characteristic dry, nonproductive cough that reverses when therapy is stopped. By notifying the healthcare provider the nurse can discuss a change of medication. The other answer choices do not correctly address the cause of the dry cough.

A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that do not precede a beat. What intervention would have the highest priority? a) Call a code. b) Call the primary healthcare provider c) Assess the client's cardiac output. d) Apply a magnet over the pacemaker. rationale: Extra pacemaker spikes that do not precede a beat may indicate failure to capture, in which the pacemaker fires, but the heart does not conduct the beat. The priority nursing intervention would be to assess the client to see if the client is tolerating the failure to capture or if the client has a decrease in cardiac output. Until the nurse knows how the client is tolerating this, it will not be useful to call the primary healthcare provider or call a code. Assessment is the first step in the nursing process, and the nurse should assess the client, not just the rhythm strip. Applying a magnet is not an appropriate action of failure to capture, but for loss of pacing.

A client recently diagnosed with hyperparathyroidism demands to see what the physician has written about him in the chart. What is the nurse's best response? a) "The chart might be difficult to understand. I suggest you review it with your physician." b) "Your chart is hospital property. I'm not allowed to let you see it." c) "Physicians use medical language. It might be difficult for you to understand what he has written." d) "I'll get the chart and set up a time for you to review it with your physician."

A client reports of a headache to an unregulated care provider (UCP). The UCP reports the client's concerns to the nurse, who is busy with other clients. What is the best action by the nurse to address the client's headache? a) Have the UCP perform a thorough assessment of the client. b) Have the UCP inform another nurse that the client needs assistance. c) Ask another nurse to observe the UCP administering the acetaminophen. d) Have the UCP perform a thorough assessment of the client.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a) "Limit the amount of protein in the diet." b) "Clean the tracheostomy tube with alcohol and water." c) "Oral intake of fluids should be limited for 1 week only." d) "Family members should continue to talk to the client."

A client undergoes an arthroscopy at the outpatient clinic. After the procedure, the nurse provides discharge teaching. Which response by the client indicates the need for further teaching? a) "My physician may prescribe pain pills after the procedure." b) "Elevating my leg will reduce swelling after the procedure." c) "I may notice some bruising or swelling in my knee." d) "I should use my heating pad this evening to reduce some of the pain in my knee." rationale: The client requires additional teaching if he states that he'll use a heating pad to reduce pain the evening of the procedure. The client shouldn't use heat at the procedure site during the first 24 hours because doing so may increase localized swelling. Ice is indicated during this time. Elevating the extremity helps reduce swelling. The client may experience some discomfort after the procedure for which the physician may order medication. Bruising and swelling are common after an arthroscopy.

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? a) Increase the suction level. b) Notify the physician. c) Irrigate the tube. d) Reposition the tube. rationale: The nurse should notify the physician because an NG tube that fails to drain during the postoperative period may be clogged, which could increase pressure on the suture site because fluid isn't draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line.

A client with a urinary tract infection is ordered co-trimoxazole. The nurse should provide which medication instruction? a) "Avoid taking antacids during co-trimoxazole therapy." b) "Take the medication with food." c) "Drink at least eight 8-oz (240 mL) glasses of fluid daily." d) "Don't be afraid to go out in the sun." rationale: The nurse should instruct a client receiving a sulfonamide such as co-trimoxazole to drink at least eight 8-oz (240 mL) glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: a) Black, tarry stools. b) Circumoral pallor. c) Yellow sclerae. d) Light amber urine. rationale: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: a) increased blood pressure. b) weight loss. c) increased urine output. d) hematuria. rationale: Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.

A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium because this drug causes: a) Hypotension. b) Tachypnea. c) Complete muscle relaxation. d) Bradycardia. rationale: Thiopental sodium, a short-acting barbiturate, can cause hypotension, which may be especially problematic for the client with impaired cardiac functioning. Thiopental sodium does not cause bradycardia, complete muscle relaxation, hypertension, or tachypnea.

A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? a) Chloride b) Sodium c) Calcium d) Potassium rationale: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium should not restrict their intake of sodium and should drink adequate amounts of fluid each day. Calcium, chloride, and potassium are important for normal body functions but sodium is most important to the absorption of lithium.

A client with thrombocytopenia has just had a bone marrow aspirate performed to monitor for treatment effectiveness. Which of the following nursing interventions take priority? a) Cleaning the puncture site and applying a sterile dressing b) Cleaning the puncture site and applying a pressure dressing c) Monitoring the client's vital signs for signs and symptoms of infection d) Applying pressure to the puncture site for a full 10 minutes rationale: A pressure dressing may be needed, but immediate pressure for a full 10 minutes is necessary to stop bleeding in the case of thrombocytopenia. A bandage is usually applied to the site. Vital signs will be monitored but do not need to be monitored more frequently, nor is infection an immediate priority.

A health care provider (HCP) has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which information should the nurse teach the client about taking valproic acid? a) The extended-release tablet can be crushed if necessary for ease of swallowing. b) Follow-up blood tests are necessary while on this medication. c) Tachycardia and upset stomach are common side effects. d) Consumption of a moderate amount of alcohol is safe if the medication is taken in the morning. rationale: Valproic acid can cause hepatotoxicity, so regular liver function tests are needed. Other side effects include nausea and drowsiness. Extended-release tablets should not be split or crushed; doing so changes their absorption. Alcohol should never be mixed with this medication. There will be medication in the client's body at all times. Nausea and tachycardia are not common side effects of valproic acid.

A male client enters the oncology clinic for an evaluation. The nurse explains that the healthcare provider has ordered a prostate-specific antigen (PSA) test. The client asks the nurse, "How will this test tell if I have prostate cancer?" Which of the following is the nurse's best response? a) "Individuals who have a PSA higher than 10 have a 60-70% chance of having prostate cancer." b) "Individuals with a 2.5 ng/mL PSA and a mother who had breast cancer need to have a biopsy of the prostate gland." c) "If your level is between is between 6 and 8 ng/mL, you have nothing to worry about." d) "The evidence shows that individuals who have levels under 4 ng/mL need yearly follow-up." rationale: Most men have PSA levels under 4 ng/mL, which has traditionally been used as the cutoff for concern about the risk of prostate cancer. Men with prostate cancer often have PSA levels higher than 4. Those with a PSA between 4 and 10 have a 25% chance of having prostate cancer and if the PSA is higher than 10, the risk increases to 67%

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? a) 1,800-calorie ADA b) High-protein c) Low-fat d) Full-liquid rationale: Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites? a) Insulin is absorbed more rapidly at abdominal injection sites than at other sites. b) Insulin is absorbed unpredictably at all injection sites. c) Insulin is absorbed rapidly regardless of the injection site. d) Insulin is absorbed more slowly at abdominal injection sites than at other sites. rationale: Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh. Absorption after injection in the buttocks is less predictable

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: a) thick, coarse skin. b) deposits of adipose tissue in the trunk and dorsocervical area. c) weight gain in arms and legs. d) hypotension. rationale: Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moon face), and dorsocervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities

A nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to prevent: a) abdominal distention. b) diarrhea. c) aspiration. d) gastric ulcers. rationale: Checking tube placement and checking for residual volume protects the client from aspiration, which can cause pneumonia, a potentially life-threatening disorder. The nurse's actions don't prevent gastric ulcers. Although abdominal distention and diarrhea can be associated with tube feeding the nurse's actions don't prevent their occurrence, and neither condition is immediately life-threatening

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal? a) C-reactive protein (CRP) b) Platelet count c) B-type natriuretic peptide (BNP) d) Potassium rationale:The client's symptoms suggest heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml is commonly associated with mild heart failure. As the BNP level increases, the severity of heart failure increases. Potassium levels aren't affected by heart failure. CRP is an indicator of inflammation. It's used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding abnormalities, such as those seen with an abnormal platelet count.

A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: a) can make only minimal vocal noises. b) is coughing vigorously. c) cannot speak due to airway obstruction. d) starts to become cyanotic. rationale: The Heimlich maneuver should be administered only to a victim who cannot make any sounds due to airway obstruction. If the victim can whisper words or cough, some air exchange is occurring and the emergency medical system should be called instead of attempting the Heimlich maneuver. Cyanosis may accompany or follow choking; however, the Heimlich maneuver should only be initiated when the victim cannot speak

A nurse is monitoring a client following the administration of sotalol. Which of the following would be of greatest concern to the nurse? a) 2 lb (.91 kg) weight gain in 2 days b) Heart rate of 58 bpm c) Blood pressure of 102/50 d) Bilateral inspiratory wheezing upon auscultation rationale: Nonselective beta-blocking drugs may cause bradycardia, hypotension, heart block, heart failure, bronchoconstriction, and/or increased airway resistance. Any preexisting respiratory condition such as asthma might be worsened by the concurrent use of these medications. A weight gain of more than 3 lbs (1.36 kg) in 2 days or 5 lbs (2.26 kg) in a week should be reported

A nurse is teaching a client with left leg weakness how to walk with a cane. The nurse should instruct the client to proceed in which manner? a) Hold the cane on the left side, 4" to 6" from the base of his little toe. b) Move the cane and the right leg simultaneously. c) Hold the cane away from the body. d) Hold the cane in the right hand. rationale: To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg, 4" to 6" from the base of the little toe. Therefore, this client should hold the cane in his right hand, close to his body to prevent leaning. He should move the cane and the involved leg (left, in this case) simultaneously and then move the uninvolved leg.

A nurse on the geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine to take "on top of his donepezil." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son: a) "Memantine is more effective than donepezil. Your father will be tapered off the donepezil." b) "Maybe the donepezil alone is not improving his dementia fast enough or well enough." c) "Donepezil has a short half-life, and memantine has a long half-life. They work well together." d) "Memantine and donepezil are commonly used together to slow the progression of dementia."

A nurse takes all of these actions when caring for a client with hypothyroidism. Which of the following interventions is the priority? a) Administering liothyronine b) Assessing for periorbital edema c) Increasing room temperature and providing blankets d) Administering acetaminophen for headache

A nurse working in a blood conservation program is being mentored by a supervising nurse. A client asks for information about iron supplements and epoetin alpa as alternatives to a blood transfusion. Which of the following responses by the nurse causes the supervising nurse to plan a review of professional and ethical standards? a) "Do you have any questions that I can clarify for you?" b) "Tell me how the nurse educator explained the procedure." c) "You should take the unit of blood. It will help you feel better." d) "Do you have all the information you need for informed consent?"

A postpartum primiparous client is having difficulty breastfeeding her infant. The infant latches on to the breast, but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when she states: a) "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk." b) "I can put breast milk on my nipples to heal the sore areas." c) "The baby needs to have as much of the nipple and areola in his mouth as possible to prevent sore and cracked nipples." d) "Feeding the baby for a half-hour on each side will not make my breasts sore." rationale: As much of the mother's nipple and areola as possible need to be in the infant's mouth in order to establish a latch that does not cause nipple cracks or fissures. Having the nipple and the areola deep in the infant's mouth decreases the stress on the end of the nipple, therefore decreasing pain, cracking, and fissures. Breast milk has been found to heal nipples when placed on the nipple at the completion of a feeding. The length of time the baby feeds on each nipple is not a factor as long as the nipple is correctly placed in the infant's mouth.

A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. Which action should the nurse take while administering oxygen in this manner? a) Cover the neonate's scalp with a warm cap. b) Assess the neonate's blood glucose level. c) Humidify the air being delivered. d) Record the neonate's temperature every 3 to 4 minutes. rationale: Whenever oxygen is administered, it should be humidified to prevent drying of the nasal passages and mucous membranes. Because the neonate is under a radiant warmer, a stocking cap is not necessary. Temperature, continuously monitored by a skin probe attached to the radiant warmer, is recorded every 30 to 60 minutes initially. Although the oxygen concentration in the hood requires close monitoring and measurement of blood gases, checking the blood glucose level is not necessary.

After receiving a change-of-shift report at 0700, the nurse should assess which client first? a) A 45-year-old scheduled for a craniotomy in 30 minutes and who needs preoperative teaching b) A 59-year-old with Parkinson's disease who will need a swallowing assessment before breakfast c) a 63-year-old with multiple sclerosis who has an oral temperature of 101.8° F (38.8° C) and flank pain d) A 23-year-old with a migraine headache who has severe nausea associated with retching rationale: Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should been seen first by the nurse. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The client should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon, but do not have needs as urgent as this client.

During a clinic visit, the mother of an infant with hydrocele states that the infant's scrotum is smaller now than when he was born. After teaching the mother about the infant's condition, which statement by the mother indicates that the teaching has been effective? a) "Keeping him quiet and in an infant seat has helped." b) "Massaging his groin area is working." c) "It seems like the fluid is being reabsorbed." d) "I guess keeping his bottom up has helped."

Experimental and epidemiologic evidence suggests that a high-fat diet increases the risk of several cancers. Which of the following cancers is linked to a high-fat diet? a) Colon. b) Lung. c) Ovarian. d) Liver. rationale: Evidence suggests that a high-fat diet increases the risk of several cancers, including breast, colon, and prostate cancers. Ovarian, lung, and liver cancers have not been linked to a high-fat diet.

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? a) Increased pulmonary artery diastolic pressure b) Decreased central venous pressure c) Decreased mean pulmonary artery pressure d) Increase in the cardiac index rationale: Increased pulmonary artery diastolic pressure suggests left-sided heart failure. Central venous pressure increases in heart failure rather than decreases. The cardiac index decreases in heart failure. The mean pulmonary artery pressure increases in heart failure.

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? a) Promoting carbohydrate intake b) Encouraging coughing and deep breathing c) Providing pain-relief measures d) Limiting fluid intake rationale: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? a) Crossing the client's ankles every 2 hours b) Placing hand rolls on the balls of each foot c) Putting slippers on the client's feet d) Attaching braces or splints to each foot and leg rationale: Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's feet can't prevent footdrop because slippers are too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, promoting thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because hand rolls are too soft to support and hold the feet in proper alignment.

The nurse applies which ethical principle when telling the truth to a client about the prognosis? a) Nonmaleficence b) Veracity c) Fidelity d) Beneficence rationale: The ethical principle of veracity is the obligation to tell the truth and not to lie or deceive others. Nonmaleficence is the duty not to inflict harm as well as to prevent and remove harm. Fidelity is promise keeping -- the duty to be faithful to one's commitments. Beneficence is the duty to do good and to actively promote positive acts (eg, goodness, kindness, charity).

The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. To maintain tissue integrity, the primary nursing goal should focus on: a) keeping pressure of bed linens off the area. b) encouraging the client to sit up in a chair four times per day. c) administering prescribed analgesics. d) applying lanolin lotions to the left ankle stasis ulcer. rationale: The nurse should keep bed linens off of the stasis ulcer to decrease the amount of pressure that the linens exert upon the lower extremity and prevent further tissue breakdown. Administering prescribed analgesics would be an intervention for reducing the pain. Applying lanolin lotions to the left ankle ulcer will not promote healing. Encouraging the client to sit up in a chair four times per day is an intervention to promote activity. The nurse would elevate the involved extremity while the client is sitting up to reduce venous stasis and capillary pressure.

The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is: a) Relief from spasms of the diaphragm. b) Stimulation of the medullary respiratory center. c) Relaxation of smooth muscles in the bronchioles. d) Efficient pulmonary circulation. rationale: Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in the treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does not have an effect on the diaphragm or the medullary respiratory center and does not promote pulmonary circulation

The nurse has asked the patient care assistant (PCA) to ambulate a client with Parkinson's disease. The nurse observes the PCA pulling on the client's arms to get the client to walk forward. The nurse should: a) Give the client a muscle relaxant. b) Explain how to overcome a freezing gait by telling the client to march in place. c) Have the PCA keep a steady pull on the client to promote forward ambulation. d) Assist the PCA with getting the client back in bed. rationale: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bedrest. A muscle relaxant is not indicated

The nurse is administering an I.V. potassium chloride supplement to a client who has heart failure. When developing a plan of care for this client, which of the following should the nurse incorporate? a) Metabolic alkalosis will increase the client's serum potassium levels. b) The client's potassium levels will be unaffected by his potassium-sparing diuretic. c) Hyperkalemia will intensify the action of the client's digoxin preparation. d) The administration of the I.V. potassium chloride should not exceed 10 mEq/hour (10 mmol/L) or a concentration of 40 mEq/L (40 mmol/L). rationale: When administering I.V. potassium chloride, the administration should not exceed 10 mEq/hour (10 mmol/L) or a concentration of 40 mEq/L (40 mmol/L) via a peripheral line. These limits are extremely important to prevent the development of hyperkalemia and the possibility of cardiac dysrhythmias. In some situations, with dangerously low serum potassium levels, the client may need cardiac monitoring and more than 10 mEq (10 mmol/L) of potassium per hour. Potassium-sparing diuretics may lead to hyperkalemia because they affect the kidney's ability to excrete excess potassium. Metabolic alkalosis can cause potassium to shift into the cells, thus decreasing the client's serum potassium levels. Hypokalemia can lead to digoxin toxicity.

The nurse is assigned a client with an nasogastric (NG) tube attached to low intermittent suction. What intervention will the nurse include in the plan of care? a) Instruct the client to position NG tube as needed for comfort b) Assess lung sounds every 24 hours c) Turn off the NG tube suction while auscultating bowel sounds d) Irrigate the NG tube every shift with normal saline rationale: For the nurse to accurately assess the bowel sounds of a client with low intermittent suction, the suction should be turned off or the nurse may confuse the suction with bowel sounds. Lung sounds should be assessed every 4 hours for assessment of aspiration. The NG tube should not be repositioned per the client's comfort as this action can dislodge the position of the tube. Irrigation of the NG tube should be every 4 hours with either water or normal saline.

The nurse is assigned to a client with jaundice and collects the following data: poor appetite, nausea, and two episodes of emesis in the past 2 hours. The client reports having spasms in the stomach area. The nurse should develop a care plan for which of the following health problems first? a) Nausea. b) Poor appetite. c) Abdominal spasms. d) Jaundice. rationale: The nurse should first plan to relieve the nausea and vomiting; if these continue the client is at risk for dehydration and electrolyte imbalance. The client's poor appetite is likely related to the underlying health problem and is not the priority; the nausea does not improve the appetite, and relieving the nausea may allow the client an opportunity to eat and drink. The client has jaundice, but does not report uncomfortable symptoms such as pruritis. The abmonimal spasms may be related to nausea and vomiting and can be assessed again when the nausea and vomiting have stopped.

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? a) Respiratory acidosis b) Hypercalcemia c) Metabolic alkalosis d) Metabolic acidosis rationale: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

The nurse is caring for a client in the medical unit. The nurse receives a physician's order for Hydrocortisone 100 mg I.V. at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse is most correct to understand that this treatment is common in clients with which disease process? a) Hypoparathyroidism. b) Cushing's syndrome. c) Addison's disease. d) Hyperthyroidism. rationale: I.V. hydrocortisone for clients in acute adrenal crisis is the proper treatment for individuals with Addison's disease. Cushing's syndrome is associated with excessive amounts of glucocorticoids. Hyperthyroidism and hypoparathyroidism are not treated with hydrocortisone.

The nurse is caring for a client on the urinary unit. When providing report to the next shift, it is noted that the client has osteopenia and history of renal calculi. Which of the following disorders would the nurse suspect? a) Hypothyroidism b) Hypopituitarism c) Hyperparathyroidism d) Hypoparathyroidism rationale: Hyperparathyroidism is characterized by osteopenia and renal calculi secondary to overproduction of parathyroid hormone. The hallmark symptom of hypoparathyroidism is tetany from hypocalcemia. Hypopituitarism presents with extreme weight loss and atrophy of all endocrine glands. Symptoms of hypothyroidism include hair loss, weight gain, and cold intolerance.

The nurse is caring for a client with end-stage kidney disease. What arterial blood gas results are most closely associated with this disorder? a) pH 7.20, PaCO2 36, HCO3 14- b) pH 7.47, PaCO2 45, HCO3 33- c) pH 7.31, PaCO2 48, HCO3 24- d) pH 7.50, PaCO2 29, HCO3 22- rationale: Metabolic acidosis occurs in ESKD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? a) Metabolic alkalosis b) Respiratory alkalosis c) Metabolic acidosis d) Respiratory acidosis rationale: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).

The nurse is evaluating an infant for auditory ability. Which of the following is the expected response in an infant with normal hearing? a) Stoppage of body movements when sound is introduced. b) Absence of squealing by age 4 months. c) Saying "da-da" by age 5 months. d) Evidence of shy and withdrawn behaviors. rationale: In response to hearing a noise, normally hearing infants blink or startle and stop body movements. Shy and withdrawn behaviors are characteristic of older children with hearing impairment. Squealing occurs in 90% of infants by age 4 months. Most infants can say "da-da" by age 9 months

The nurse is instructing the nursing assistant on how to transfer a male client with left-sided weakness from the bed to a wheelchair. Which statement by the assistant tells the nurse that the assistant has understood the instructions? a) "I will place the wheelchair behind the client." b) "The wheelchair should be placed at the head of the bed." c) "As long as I assist the client, it does not matter where the wheelchair goes." d) "The wheelchair should be placed on the right side of the bed." rationale: When assisting a client with a weakness out of bed, it is important that the client always move toward the stronger side. This allows the client to assist in the move as much as he physically can. In this case, the client will need to move toward his right side to maximize the use of his strong arm and leg. Placing the wheelchair at the head of the bed or behind the client does not allow for a safe transfer of the client. The presence of the assistant does not necessarily ensure safety regardless of the position of the wheelchair.

The nurse is performing a digital rectal examination. Which finding is a key sign for prostate cancer? a) a boggy, tender prostate b) a nonindurated prostate c) a hard prostate, localized or diffuse d) abdominal pain rationale: On digital rectal examination, key signs of prostate cancer are a hard prostate, induration of the prostate, and an irregular, hard nodule. Accompanying symptoms of prostate cancer can include constipation, weight loss, and lymphadenopathy. Abdominal pain usually does not accompany prostate cancer. A boggy, tender prostate is found with infection (e.g., acute or chronic prostatitis).

The nurse is preparing to administer furosemide to a 3-year-old with a heart defect. The nurse verifies the child's identity by checking the arm band and: a) checking the room number. b) asking the child to state her name. c) asking the child to tell her birth date. d) asking the parent the child's name. rationale: Safety standards require the use of two identifiers prior to medication administration. A parent can be used as the second identifier. Many young children will only answer to a nickname that does not coincide with the medical identification band or may answer to any name. It is common for children on a pediatric floor to go into each other's rooms. Small children may not know their birth date

The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? a) Thrombin clotting time, 10 to 15 seconds. b) Partial thromboplastin time, 1.5 to 2.5 times the normal control. c) International Normalized Ratio, 2 to 3 seconds. d) Prothrombin time, 1.5 to 2.5 times the normal control. rationale: The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of warfarin, oral anticoagulation therapy. The thrombin clotting time is used to confirm disseminated intravascular coagulation.

The nurse should assess a client taking chlorpropamide for: a) Oral candidiasis. b) Dumping syndrome. c) Extrapyramidal symptoms. d) Hypoglycemia. rationale: Chlorpropamide is an antidiabetic agent. Clients should be observed for signs and symptoms of hypoglycemia. Other common side effects include anorexia, nausea, vomiting, and heartburn. The drug does not cause dumping syndrome. Extrapyramidal symptoms are not caused by chlorpropamide, and it does not cause oral candidiasis.

When a client is placed in balanced skeletal traction, which of the following nursing actions would be appropriate? a) Ensuring that the traction weights hang freely from the bed at all times. b) Increasing the traction weight gradually as the client's tolerance increases. c) Removing the weights briefly as necessary to reposition the client in bed. d) Applying and removing the traction weights at regular intervals throughout the day. rationale: In balanced skeletal traction, the appropriate pressures and counter pressures are applied to the fracture site, with the traction weights hanging freely at all times. The amount of traction weight used is determined by radiography and the alignment of the fracture. These weights are in place continuously and should never be lifted, reduced, or eliminated.

When caring for a child who has been receiving long-term steroid therapy, the nurse should assess the child for: a) Development of truncal obesity. b) Loss of weight from baseline. c) Usual behavior and temperament. d) Demonstration of a growth spurt. rationale: One of the side effects of steroid therapy is fat deposition on the trunk and face, producing classic Cushingoid signs. Therefore, the nurse should expect to find truncal obesity. Steroids also can cause altered moods or mood swings. Typically, long-term steroid use results in weight gain. Steroids may inhibit the action of growth hormone. Therefore, a growth spurt is not likely

When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, what would the nurse expect to include as a desired target range for blood glucose levels? a) 40 to 60 mg/dL (2.2 to 3.3 mmol/L) between 1400 and 1600 b) 60 to 100 mg/dl (3.3 to 5.6 mmol/L) before meals and bedtime snacks c) 110 to 140 mg/dL (6.2 to 7.8 mmol/L) before meals and bedtime snacks d) 140 to 160 mg/dL (7.8 to 8.9 mmol/L) 1 hour after meals rationale: The goal is to maintain blood plasma glucose levels at 70 to 100 mg/dL (3.5 to 5.6 mmol/L) before meals and bedtime snacks. Below 60 mg/dL (5.6 mmol/L) indicates hypoglycemia. A range of 110 to 140 mg/dL (6.2 to 7.8 mmol/L) suggests hyperglycemia. The target range 1 hour after meals is 100 to 120 mg/dL (5.6 to 6.7 mmol/L).

When educating the client with type 1 diabetes, the nurse knows that the client needs more education when he or she says: a) "I will need to go to the podiatrist to get my toenails cut so I don't get an infection." b) "I will be able to switch to insulin pills when my sugar is under control." c) "I will need to eliminate sugar from my diet." d) "I will need to give myself insulin every day."

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)? a) Taking a telephone order for pain medications for a postoperative client b) Obtaining vital signs during blood administration c) Teaching a client receiving warfarin about follow-up care d) Assessing the hip wound during a dry sterile dressing change rationale: The nurse may safely delegate obtaining vital signs during blood administration to the LPN. Teaching the client taking warfarin about follow-up care, assessing a hip wound, and taking a telephone order are actions that must be taken by the registered nurse because they aren't within the scope of LPN practice

Which is an expected outcome of pursed-lip breathing for clients with emphysema? a) to promote carbon dioxide elimination b) to strengthen the diaphragm c) to strengthen the intercostal muscles d) to promote oxygen intake rationale: Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursed-lip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles

Which of the following is most helpful to promote circulation for the client with peripheral arterial disease? a) Walking slowly but steadily for 30 minutes twice a day. b) Minimizing activity as much and as often as possible. c) Resting with the legs elevated above the level of the heart. d) Wearing antiembolism stockings at all times when out of bed. rationale: Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.

Which of the following is the priority for a client with a fractured femur who is in traction? a) Develop skills to cope with prolonged immobility. b) Choose appropriate diversional activities during the prolonged recover. c) Adapt to inactivity from the impaired mobility. d) Prevent effects of immobility while in traction. rationale: The priority for this client is to prevent the effects of prolonged immobility, such as preventing skin breakdown, encouraging the client to take deep breaths, and use active range of motion exercises for the joints that are not immobilized. Although not the priority, the nurse also should seek ways to help the client adjust to and cope with the present state of immobility. Emphasis should be placed on what the client can do, such as participating in daily care and exercises to maintain muscle strength. Finding diversional activities is not a priority at this moment. Although the client must adapt to the inactivity, helping the client develop coping skills is the priority at this time.

Which of the following laboratory tests should the nurse monitor when the client is receiving warfarin sodium therapy? a) Serum potassium. b) Prothrombin time (PT). c) Arterial blood gas (ABG) values. d) Partial thromboplastin time (PTT). rationale: Warfarin sodium interferes with clotting. The nurse should monitor the PT and evaluate for the therapeutic effects of warfarin. A therapeutic PT is between 1.5 and 2.5 times the control value; the PT should be established by the health care provider. It may also be reported as an International Normalized Ratio, a standardized system that provides a common basis for communicating and interpreting PT results. The PTT is monitored in clients who are receiving heparin therapy. Serum potassium levels and ABG values are not affected by warfarin.

Which of the following may occur with respiratory acidosis? a) Decreased pulse b) Increased intracranial pressure (ICP) c) Decreased blood pressure d) Third spacing rationale: If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis. Respiratory acidosis does not result in the fluid shifts known as third spacing.

Which of the following measures should a home healthcare nurse implement to minimize the potential for lawsuits? a) Integrate the client's learning needs and goals into plans of care. b) Have the client sign a waiver prior to the entry phase of a visit. c) Perform thorough, accurate, and timely documentation. d) Apply more conservative interventions than those used in a hospital setting.

Which of the following should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? a) Blood pressure. b) Contraction pattern. c) Cognitive function. d) Level of consciousness. rationale: Administration of an epidural anesthetic can result in a hypotensive effect on maternal blood pressure. Therefore, the priority assessment is the mother's blood pressure. Ephedrine or wedging the client to a position to keep pressure off the vena cava, such as on the left side, can be used to elevate maternal blood pressure should it drop too low. Epidural anesthesia has no effect on the level of consciousness or the client's cognitive function. Although the client's contraction pattern may decrease in frequency after administration of the anesthesia, the priority assessment is the client's blood pressure. After blood pressure is maintained, contractions can be assessed.

Which of the following symptoms is common in clients with active tuberculosis? a) Dyspnea on exertion. b) Mental status changes. c) Increased appetite. d) Weight loss. rationale: Tuberculosis typically produces anorexia and weight loss. Other signs and symptoms may include fatigue, low-grade fever, and night sweats. Increased appetite is not a symptom of tuberculosis; dyspnea on exertion and change in mental status are not common symptoms of tuberculosis.

Which outcome criterion is appropriate for a child diagnosed with oppositional defiant disorder? a) The child will recognize responsibility for own behaviors. b) The child will establish his own limits and boundaries. c) The child will verbalize his own needs and assert his rights. d) The child will ask the nurses permission to sleep late. rationale: Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Recognizing accountability for his actions would demonstrate progress for the oppositional child.

While ambulating, a client who had an open cholecystectomy complains of feeling dizzy and then falls to the floor. After attending to the client, a nurse completes an incident report. Which action by the nurse should the charge nurse correct? a) Notifying the physician of the incident and the client's condition b) Documenting the incident factually in her nurses' notes c) Submitting the incident report to the appropriate hospital administrator d) Making a copy of the incident report for the client rationale: A nurse shouldn't copy an incident report for anyone. An incident report is a confidential and privileged document available to agency personnel for risk-management activities. After completing the report, the nurse should submit it according to facility policy. The nurse should document the incident factually in the client's record and notify the physician of the incident and the client's condition

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)? a) Assessing the hip wound during a dry sterile dressing change b) Teaching a client receiving warfarin about follow-up care c) Taking a telephone order for pain medications for a postoperative client d) Obtaining vital signs during blood administration

The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which of the following? a) A full breakfast as desired without coffee, tea, or energy drinks. b) No food or fluids. c) A liquid breakfast of fruit juice, oatmeal or smoothie. d) Only coffee or tea if needed. rationale: Beverages containing caffeine, such as coffee, tea, cola drinks, and energy drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be NPO

What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy? a) The right extremity should be lowered to improve blood flow to the forearm. b) Arm exercises will get rid of the cellulitis. c) Ice pack should be applied to the affected area for 20 minute periods to reduce swelling. d) Antibiotics will need to be taken for 1 to 2 weeks. rationale: Treatment for cellulitis includes oral or intravenous antibiotics for 1 to 2 weeks, elevation of the affected extremity, and application of warm, moist packs to the site. Arm exercises help to reduce swelling, but do not treat the infection

A 5-year-old child is brought to the emergency department after injuries sustained in a motor vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment data would the nurse consider as most significant when assessing for signs of cervical spinal cord swelling? a) Changes in respiration b) Urinary retention c) Retinal hemorrhage d) Nausea and vomiting

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying which of the following? a) "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." b) "Don't worry. Your new hip is very strong." c) "Use of a cushioned toilet seat helps to prevent dislocation." d) "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation." rationale: Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.

A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl? a) Administer one-half of a children's aspirin for a temperature higher than 101° F (38.3° C). b) Sew thick padding into the elbows and knees of the child's clothing. c) Check the color of the child's urine every day. d) Expect the eruption of the primary teeth to produce moderate to severe bleeding. rationale: As the hemophilic infant begins to acquire motor skills, falls and bumps increase that risk of bleeding. Such injuries can be minimized by padding vulnerable joints. Aspirin is contraindicated because of its antiplatelet properties, which increase the infant's risk for bleeding. Because genitourinary bleeding is not a typical problem in children with hemophilia, urine testing is not indicated. Although some bleeding may occur with tooth eruption, it does not normally cause moderate to severe bleeding episodes in children with hemophilia.

A nurse is developing a nursing diagnosis for a client. Which information should she include? a) Expected outcomes b) Actions to achieve goals c) Factors influencing the client's problem d) Nursing history

Which clinical finding should a nurse look for in a client with chronic renal failure? a) Polycythemia b) Uremia c) Metabolic alkalosis d) Hypotension rationale: Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure

Which of the following laboratory tests should be monitored closely by the nurse while the client is receiving heparin therapy? a) Prothrombin time (PT). b) Thrombin time. c) Activated partial thromboplastin time (APTT). d) International Normalized Ratio (INR). rationale: APTT is used to measure the clotting status when the client is receiving heparin. The INR is used to measure clotting status in a client receiving warfarin. Prothrombin time (PT) is used to measure clotting status in a client receiving warfarin. Neither heparin nor warfarin affects thrombin time.

Which condition could a mother have and still be encouraged to breast-feed her child? a) Active tuberculosis (TB) b) Endometritis c) Positive for human immunodeficiency virus (HIV) d) Cardiac disease rationale: Of the listed conditions, endometritis is the only one in which a mother can continue to breast-feed provided that the antibiotics she's taking aren't contraindicated in breast-feeding. A mother who has HIV or active TB is strongly discouraged from breast-feeding because of concerns about transmitting the infection to the neonate. Clients with cardiac disease are also discouraged from breast-feeding because of the strain on the mother's defective heart.

A nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching? a) "If my breasts are uncomfortable, I'll limit the time I spend breast-feeding." b) "I'll use warm packs or a warm shower to ease engorgement." c) "I'll use massage to help soften my breasts." d) "If the baby feeds only on one side, I'll express milk from the other side." rationale: The client stating that she'll limit the time she spends breast-feeding indicates the need for further teaching. Engorgement results from fullness in breast veins and alveolar engorgement with milk. Limiting the time spent breast-feeding causes insufficient breast milk removal; as a result, milk volume exceeds alveolar storage capacity, causing pain. Breast massage, heat application, and milk expression help minimize engorgement.

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? a) Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician. b) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. c) Ask the nursing assistant to notify the physician of the low pulse oximetry level. d) Complete the assessment of the new client before attending to the client who underwent laminectomy. rationale: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

The client newly diagnosed with type 1 diabetes mellitus eats a lot of pasta products, such as macaroni and spaghetti and asks if they can be included in the diet. Which of the following would be the nurse's best response? a) "Pasta can be a part of your diet. It's included in the bread and cereal exchange." b) "Eating pasta can cause hyperglycemia, so it's better to eliminate it." c) "Pasta can be included in your diet but it shouldn't be served with sauces." d) "Because you're overweight, it's better to eliminate pasta from your diet." rationale: Special foods are not required for a client with diabetes, nor should certain foods (except refined sugars) be eliminated entirely from the diet. More important is that meal times, meal size, and meal composition are consistent. Pasta may be included in the diet as part of the bread and cereal exchange. Pasta sauces may be used if they are taken into account in the total diet. A client's ethnic, religious, and cultural food preferences should be taken into account in meal planning. If these preferences are not considered, a client may eat foods without making proper adjustments or may reject the diet entirely. As long as the pasta is counted in the exchanges, it will not necessarily cause hyperglycemia.

The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which of the following complications? a) Hemorrhage. b) Urine retention. c) Rectal spasm. d) Constipation. rationale: Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help prevent constipation

Which of the following techniques is not appropriate when the nurse changes a client's position in bed if the client has hemiparalysis? a) Having the client help lift off the bed using a trapeze. b) Lifting the client when moving the client up in bed. c) Sliding the client to move up in bed. d) Rolling the client onto the side. rationale: Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. Rolling the client is an acceptable method to use when changing positions as long as the client is maintained in anatomically neutral positions and her limbs are properly supported. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury to himself or herself or the client. Having the client help lift herself off the bed with a trapeze is an acceptable means to move a client without causing friction burns or skin breakdown.

A client is receiving fluid replacement with lactated Ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 97.2 (36.2° C); heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 ml for the last 2 hours. The IV rate is currently at 375 ml/hr. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for: a) Fresh frozen plasma. b) Dextrose 5%. c) Furosemide. d) IV rate increase. rationale: The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? a) Avoiding using deodorant soap on the irradiated areas b) Applying talcum powder to the irradiated areas daily after bathing c) Wearing a lead apron during direct contact with the client d) Removing thoracic skin markings after each radiation treatment rationale: Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water and a mild soap only and leave the area open to air. No deodorants or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.

A 10-year-old child is brought to the office with complaints of severe itching in both hands that's especially annoying at night. On inspection, the nurse notes gray-brown burrows with epidermal curved ridges and follicular papules. The physician performs a lesion scraping to assess this condition. Based on the signs and symptoms, what diagnosis should the nurse expect? a) Dermatophytosis b) Contact dermatitis c) Scabies d) Impetigo rationale: Signs and symptoms of scabies include gray-brown burrows, epidermal curved or linear ridges, and follicular papules. Clients complain of severe itching that usually occurs at night. Scabies commonly occurs in school-age children. The most common areas of infestation are the finger webs, flexor surface of the wrists, and antecubital fossae. Impetigo is a contagious, superficial skin infection characterized by a small, red macule that turns into a vesicle, becoming pustular with a honey-colored crust. Contact dermatitis is an inflammation of the skin caused by contact with an irritating chemical or allergen. Dermatophytosis, or ringworm, is a disease that affects the scalp, body, feet, nails, and groin. It's characterized by erythematous patches and scaling.

A child has chickenpox. The father asks how to care for the lesions. The nurse should advise that the child: a) Soak in a hot tub for 30 minutes three times a day. b) Take an antihistamine and use calamine lotion on the closed lesions. c) Remove lesions' crusts as they form. d) Take acetaminophen and use an antibiotic ointment on the lesions.

A child is brought to the emergency department and is diagnosed with status asthmaticus. The child's respiratory rate is 40 breaths/min, and there are decreased breath sounds bilaterally throughout the lung fields. The nurse administers an aerosol bronchodilator and reassesses the lung sounds. Which finding is the best indicator that the bronchodilator has been effective? a) The child is coughing up sputum. b) There is no audible wheezing. c) Breath sounds are louder bilaterally. d) The respiratory rate is 36 breaths/min.

The nurse is assessing a client who is restless and agitated, has dry mucous membranes, and has intense thirst. The nurse should assess the client further for which of the following electrolyte imbalances? a) Hypernatremia. b) Hypomagnesemia. c) Hypokalemia. d) Hypercalcemia. rationale: Restlessness, agitation, dry mucous membranes, and thirst are indicative of fluid loss and hypernatremia. Hypokalemia causes such symptoms as fatigue, muscle weakness, and cardiac irregularities. Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain. Hypomagnesemia is manifested by confusion, tremors, hyperactive reflexes, and seizures

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? a) A 10-year-old with a laceration on his leg. b) A 25-year-old with a sucking chest wound. c) A 20-year-old who is unresponsive and has a high injury to his spinal cord. d) An 80-year-old who has a compound fracture of the arm. rationale: During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.

When developing the teaching plan for a client who uses a walker, which principle should a nurse consider? a) If one leg is weaker than the other, the walker and the stronger leg should move, together, approximately 6″ ahead of the body. The client's weight is supported by his weaker leg. b) When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. c) The hand bar of the walker should be well below the client's waist. d) A standard walker needn't be picked up when moved. rationale: To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor

Which of the following is an early indication that a client has developed hypocalcemia? a) Ventricular dysrhythmias. b) Depressed reflexes. c) Tingling in the fingers. d) Memory changes. rationale: Neuromuscular irritability is usually the first indication that a client has developed a low serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuromuscular irritability. Depressed reflexes, decreased memory, and ventricular dysrhythmias are indications of hypercalcemia.

Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed? a) "Cytotoxic parenteral infusion containers should be marked with special hazard labels." b) "Infusion set administration connections should be tight." c) "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs." d) "Linen contaminated with blood or body fluids of a client receiving cytotoxic drugs should be placed in a leak-proof container and marked with a chemotherapy hazard label." rationale: Pregnant nurses should not administer cytotoxic drugs because long-term exposure to cytotoxic drugs may be associated with teratogenic effects. Nonpregnant nurses should wear double gloves and long sleeve disposable gowns while administering cytotoxic drugs. To prevent exposure and leakage, the nurse should mark all parenteral infusion containers with hazard labels and check infusion container connections before drug administration. Linens that have become contaminated by blood or body fluid of a client receiving chemotherapy should be handled with caution, placed in a leak-proof, closed - system and labeled "chemotherapy contaminated linens

A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? a) Up to 32 b) Up to 20 c) Up to 10 d) Up to 15 rationale: A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? a) Inner ear b) Middle ear c) External ear d) Tympanic membrane

a, c, e

A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which of the following findings is the nurse most likely to observe in this client? Select all that apply. a) Frequent, high-volume urination b) Constipation c) Excessive hunger d) Weight gain e) Excessive thirst f) Urine retention

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety? a) "Maintain a firm grip on the front bar as you step into the walker." b) "Use a walker with wheels to help you move forward." c) "Place the walker directly in front of you and step into it as you move it forward." d) "When you move the walker, set the back legs down first. Then step forward."

A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom? a) Dystonia b) Akathisia c) Tardive dyskinesia d) Pseudoparkinsonism rationale: An adverse reaction to phenothiazines, tardive dyskinesia refers to choreiform tongue movements that are commonly irreversible and may interfere with speech. Dystonia refers to involuntary contraction of a muscle group. Akathisia is restlessness or inability to sit still. Pseudoparkinsonism describes a group of symptoms that mimic those of Parkinson's disease.

A nurse discusses the HIV-positive status of a client with other colleagues. The client can sue the nurse for which of the following? a) False imprisonment. b) Professional negligence. c) Invasion of privacy. d) Defamation of character. The client can sue the nurse for invasion of privacy. Disclosing confidential information to an inappropriate third party subjects the nurse to liability for invasion of privacy, even if the information is true. Defamation of character includes false communication that results in injury to a person's reputation. Prevention of movement or unjustified retention of a person without consent may be false imprisonment. Negligence is an act of omission or commission.

A nurse is caring for a child with intussusception. Which of the following is an expected outcome for a goal to relieve acute pain from abdominal cramping? a) The child is very still. b) The child has a normal bowel movement. c) The child has not vomited in 3 hours. d) The child exhibits no manifestations of discomfort. rationale: An expected client outcome for a goal to reduce acute pain related to cramping is that the client exhibits no manifestations of discomfort, such as crying or drawing the legs to the abdomen. Being very still may indicate either a pain state or a state of relaxation, and the nurse would need to assess the client further. Having normal bowel movements and not vomiting are desired outcomes, but the goal here is to relieve the pain.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a) Pallor, bradycardia, and reduced pulse pressure b) Sore tongue, dyspnea, and weight gain c) Angina pectoris, double vision, and anorexia d) Pallor, tachycardia, and a sore tongue rationale: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs? a) Encourage family or support persons to assist with the client's hygiene needs. b) Provide client with assistance in hygiene, grooming, and dressing. c) Provide complete bathing and grooming tasks for client. d) Instruct client to bathe and dress by 0900. rationale: Interventions should be directed at helping the client complete activities of daily living with the assistance of staff members, who can provide needed structure by communicating tasks in clear, concise bits of instructions. This intervention promotes realistic independence. This client has inappropriate social interaction and it would not be in the client's best interest for his family to provide hygiene needs. The client's condition does not indicate a need for complete assistance, which would only foster dependence.

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take? a) Inform the physician about the living will. b) State that the physician will be a witness. c) Arrange for other colleagues to sign as a witness. d) Note that the nurse caring for the client cannot be a witness.

c,d,e

Choice Multiple question - Select all answer choices that apply. The nurse is caring for a client with a nasogastric tube who is due for an enteral feeding. Which of the following assessments by the nurse would indicate the need to withhold at this time? Select all that apply. a) Watery contents upon aspiration with a pH of 5 b) Auscultation of air in the epigastric area when checking placement c) Aspiration of milky contents and reports of nausea d) Distention of the upper abdomen with vomiting e) Material like coffee grounds noted in the nasogastric tube rationale: The client has an order for enteral tube feedings. The aspiration of milky contents and reports of nausea would indicate that the prior feeding has not been tolerated or absorbed. Distention with vomiting would also indicate intolerance to the feeding. The presence of material that looks like coffee grounds indicates bleeding somewhere in the GI tract, thus feedings would be held. Watery contents upon aspiration with a pH of 5 and auscultation of air in the epigastric area when checking placement are normal and expected findings.

The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section? a) client at 40 weeks' gestation whose fetus weighs 8 lb (3,630 g) by ultrasound estimate b) client at 37 weeks' gestation with fetus in ROP position c) client at 32 weeks' gestation with fetus in breech position d) client at 38 weeks' gestation with active herpes lesions rationale: Herpes simplex virus can be transmitted to the infant during a vaginal birth. The neonatal effects of herpes are severe enough that a cesarean birth is warranted if active lesions—primary or secondary—are present. A client with a primary infection during pregnancy sheds the virus for up to 3 months after the lesion has healed. The client carrying an infant weighing 8 lb (3,629 g) will be given a trial of labor before a cesarean. The client with a fetus in the right occiput posterior position will have a slow labor with increased back pain but can give birth vaginally. The fetus in a breech position still has many weeks to change positions before being at term. At 7 months' gestation, the breech position is not a concern

A client who is 10 weeks pregnant develops spotting; however, the cervix remains closed. The nurse should suspect which of the following? a) Threatened abortion b) Missed abortion c) Inevitable abortion d) Ectopic pregnancy rationale: Spotting in the first trimester may indicate that the pregnancy is in jeopardy. Bed rest and avoidance of physical and emotional stress are recommended. Abortion is usually inevitable if the bleeding is accompanied by pain with dilation and effacement of the cervix. An inevitable abortion is associated with cervical dilation. An ectopic pregnancy is in the fallopian tubes, and a false positive pregnancy could reflect a missed abortion

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus, which sign will the nurse see in the neonate? a) Enlarged breast tissue b) Soft skin c) Vernix caseosa d) Weak sucking response rationale :It's common to see enlarged breast tissue in both male and female neonates in their first few days of life because of maternal estrogen transmitted to the fetus. Weak sucking response isn't related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and aren't related to estrogen.

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? a) Impaired circulation related to blood clot b) Acute pain related to tissue trauma c) Ineffective breathing pattern related to tissue trauma d) Risk for vascular trauma related to pulmonary emboli rationale: Although all of these nursing diagnoses are appropriate for this client, ineffective breathing pattern takes priority. According to Maslow's hierarchy of needs, air is essential to maintain life and is assigned the highest priority, along with the other physiologic needs, such as food, elimination, temperature control, sex, movement, rest, and comfort.

A client is to be discharged from an alcohol rehabilitation program. Which of the following should the nurse emphasize in the discharge plan as a priority? a) Supportive friends. b) Follow-up care. c) A list of goals. d) Family forgiveness. rationale: Follow-up care is essential to prevent relapse. Recovery has just begun when the treatment program ends. The first few months after program completion can be difficult and dangerous for the chemically dependent client. The nurse is responsible for discharge plans that include arrangements for counseling, self-help group meetings, and other forms of aftercare. Supportive friends, a list of goals, and family forgiveness may be important and helpful to the client, but follow-up care is essential.

A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for: a) Knee swelling and pain. b) Absence of the Achilles reflex. c) Tingling in the arm. d) Footdrop. rationale: A client who had a left thoracoscopy is placed in the lateral position, in which the most common injury is an injury to the brachial plexus. Numbness and tingling in the arm suggests a brachial plexus injury. There is no undue pressure on the ankles or knees during thoracic surgery

A child, age 9, is admitted to the emergency department with abdominal pain. The child's mother states the pain began about 12 hours ago. The nurse notes the child has a temperature of 100.8° F (38.2° C) and nausea. The child vomited once. Which abdominal area would be most appropriate for the nurse to assess? a) Left upper abdominal quadrant b) Left lower abdominal quadrant c) Right upper abdominal quadrant d) Lower right abdominal quadrant rationale: The child's symptoms indicate appendicitis. Therefore, the nurse should assess the lower right abdominal quadrant. The nurse would assess the left lower abdominal quadrant to detect descending and sigmoid colon problems; right upper quadrant to detect gallbladder disease; and the left upper quadrant to detect pancreatitis.

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? a) Carbachol b) Ambenonium c) Pyridostigmine d) Edrophonium rationale: Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

A client exhibits increased restlessness. The results of the arterial blood gas test are as follows: pH, 7.52; partial pressure of carbon dioxide, 38 mm Hg (5.1 kPa); bicarbonate, 34 mg/L (34 mmol/L). The nurse should plan care based on the fact that these findings indicate which of the following acid-base imbalances? a) Respiratory alkalosis. b) Metabolic acidosis. c) Metabolic alkalosis. d) Respiratory acidosis.

After the nurse assesses a 2 1/2-year-old's teeth during the physical examination, which of the following instructions should the nurse give to the mother? a) Give the child a small, soft-bristled toothbrush to use. b) Make sure the child brushes his teeth after every meal and at bedtime. c) Add a fluoride supplement to the child's milk. d) Floss the child's teeth using dental floss. rationale: For a toddler, a parent should clean and floss the toddler's teeth because the child does not have the cognitive or motor skills needed for effective cleaning. The child lacks the cognitive or motor skills needed for effective cleaning. Therefore, rather than making sure the child brushes his teeth, the parent should brush the toddler's teeth after every meal and at bedtime using a small toothbrush with soft, rounded nylon bristles that are short and uniform in length. Although a small, soft-bristled toothbrush is appropriate, the child lacks the cognitive or motor skills needed for effective cleaning. Therefore, the parent should brush the toddler's teeth after every meal and at bedtime using a small toothbrush with soft, rounded nylon bristles that are short and uniform in length. A fluoride supplement is needed only if the child ingests minimal amounts of tap water or the family has well water.

The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. To maintain tissue integrity, the primary nursing goal should focus on: a) Applying lanolin lotions to the left ankle stasis ulcer. b) Providing an over-the-bed cradle to protect the left ankle from the pressure of bed linens. c) Encouraging the client to sit up in a chair four times per day. d) Administering prescribed analgesics. rationale: Providing an over-the-bed cradle will decrease the amount of pressure that the linens exert upon the lower extremity and prevent further tissue breakdown. Administering prescribed analgesics would be an intervention for reducing the pain. Applying lanolin lotions to the left ankle ulcer will not promote healing. Encouraging the client to sit up in a chair four times per day is an intervention to promote activity. The nurse would elevate the involved extremity while the client is sitting up to reduce venous stasis and capillary pressure.

A child with rheumatic fever has polyarthritis and chorea. An echocardiogram shows swelling of the cardiac tissue. Which of the following should the nurse include in the child's plan of care? a) Keeping the child in a slightly cool environment. b) Performing neurologic checks every 4 hours until the chorea subsides. c) Promoting ambulation by administering aspirin every 4 hours. d) Explaining that the chorea will disappear over time. rationale: It is important for the child and family to understand that chorea associated with rheumatic fever is not permanent. Therefore, the nurse should explain that the chorea will disappear over time. It is not necessary to assess the child's neurologic status because the chorea is self-limited and nonprogressive. Because the child has cardiac involvement, ambulation is contraindicated. Aspirin is used primarily as an anti-inflammatory drug and secondarily for pain relief. A slightly cool environment is unnecessary. Environmental temperature does not affect the child's polyarthritis and chorea.

A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for: a) Renal failure. b) Liver failure. c) Myocardial infarction. d) Myocarditis. rationale: Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection. The T lymphocytes respond to the viral infection by secreting cytokines to kill the virus, but they also kill the virus-infected myocardium. Myocardial infarction, renal failure, and liver failure are not direct consequences of a viral or parasitic infection.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: a) total incontinence. b) functional incontinence. c) reflex incontinence. d) stress incontinence.

The client with histrionic personality disorder is melodramatic and responds to others and situations in an exaggerated manner. The nurse should recommend which of the following activities for this client? a) Music group. b) Cooking class. c) Role-playing. d) Party planning. rationale: The nurse should use role-playing to teach the client appropriate responses to others in various situations. This client dramatizes events, draws attention to self, and is unaware of and does not deal with feelings. The nurse works to help the client clarify true feelings and learn to express them appropriately. Party planning, music group, and cooking class are therapeutic activities, but will not help the client specifically learn how to respond appropriately to others.

Which of the following describes the movements of a child with spastic cerebral palsy? a) Wide-based gait and poor muscle coordination. b) Slow, wormlike writhing movements. c) Tremors and lack of active movement. d) Increased muscle tone and stretch reflexes. rationale: Spastic cerebral palsy, the most common clinical type, represents an upper motor neuron muscular impairment resulting in increased muscle tone and stretch reflexes, persistent reflexes, and a lack or delay of postural control. Slow, wormlike writhing movements are characteristic of the dyskinetic or athetoid type of cerebral palsy. The ataxic type of cerebral palsy is the least common type. Children have a wide-based gait and perform rapid, repetitive movements poorly. With the common athetoid type, children have tremors and a lack of active movement.

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