practice exam

A nurse is talking to a client with bulimia nervosa about the complications of laxative abuse. Which client statement indicates an understanding of the risks?

"Using laxatives prevents the absorption of essential nutrients."

A client tells the mental health nurse that they are feeling better after a relapse of major depression. However, the client is increasingly saddened by a loss of desire to have sex with their spouse and an increasing disconnection in the relationship. Which response by the nurse best addresses the problem the client is experiencing?

"What other medications are you taking in addition to your antidepressant?" The client's change in sexual functioning is causing the client's distress, and the dysfunction could be related to medication side effects. The nurse will set the goal of identifying the cause of the dysfunction. Focusing on the spouse's reaction would not be therapeutic for the client's needs. Other comorbidities and their treatments could compound the sexual side effects of the antidepressant. Drugs and alcohol can compound sexual side effects; however, the nurse does not have enough information to make the assumption that these are the cause in this case.

The nurse has identified a problem of anxiety for a 4-year-old preparing for a tonsillectomy. What should the nurse tell the child?

"When it is done you will get to see your mommy and get a popsicle." When preparing a child for a procedure the nurse should use neutral words, focus on sensory experiences, and emphasize the positive aspects at the end. Being reunited with parents and having a popsicle would be considered pleasurable events. Children this age fear bodily harm. To reduce anxiety, the nurse should use the word "fixed" instead of "removed" to describe what is being done to the tonsils. Using the terms "put to sleep" and "IV" may be threatening. Additionally, directing a play experience to focus on IV insertion may be counterproductive as the child may have little recollection of this aspect of the procedure.

A client who has been treated for diverticulitis is being discharged on oral propantheline bromide. The nurse should instruct the client to take the drug

30 minutes before meals and at bedtime. Propantheline bromide is used to reduce secretions and spasms of the GI tract in clients with diverticulitis, a condition characterized by bowel inflammation and colonic irritability and spasticity. The nurse should instruct the client to take the drug 30 minutes before meals and at bedtime to reduce GI motility, thus relieving spasticity. Taking it with a meal, immediately before a meal, or 1 hour after a meal would interfere with the drug's action and absorption, thereby reducing its effectiveness.

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day?

Complete regular admission procedures. Clients entering the hospital setting for outpatient surgery have regular admission procedures conducted by the nurse. Scheduling of screening tests and initial teaching is completed in the days prior to the surgery. Same-day surgery and discharge may require community-based follow-up but it generally does not require long-term care. Detailed information on the procedure will be provided by the physician performing the procedure.

An older adult is being discharged following a repair of an inguinal hernia. The client is independent and lives alone, but the client's family lives 60 miles from the client's house. When at home, the client is to cleanse and inspect the incision for signs of infection. The client and family are able to read and understand written instructions. When giving discharge instructions, what should the nurse do? Select all that apply.

Explain the instructions to the client. Ask the client to demonstrate the procedure. Provide written instructions for the client.

The client being treated for alcohol addiction is receiving thiamine. What is the expected outcome for using thiamine with this client?

Prevent the development of Wernicke's encephalopathy.

A nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How should the nurse respond initially?

Stay with the client during the anxiety attack. Explanation: Because the presence of a calm person provides a feeling of security, the nurse should initially remain with a client during an anxiety attack and assure the client that they are safe. Then the nurse should assist the client to deep breathe. The other options can be taught when the client's anxiety is not at the panic level. During an attack, a client isn't capable of learning new behaviors or achieving insight.

When teaching the client older than age 50 who is receiving long-term prednisone therapy, the nurse should make which suggestion to the client?

Take the prednisone with food. Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the health care provider (HCP) who prescribed the prednisone. The client should ask the HCP about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.

The most effective health-promotion measure related to glaucoma that the nurse could teach clients is:

annual intraocular pressure measurements for people older than 40 years.

The nurse is educating a client with type 2 diabetes from France who speaks English as a second language. What behavior alerts the nurse to a possible lack of communication of the educational material? Select all that apply.

asking questions about shopping laughing at some of the brochures looking away from the speaker Behaviors that indicate the client is not understanding the nurse's teaching include asking inappropriate questions to change the subject, laughing to disguise embarrassment, and looking away from the speaker. Taking notes and writing down medical terms are positive behaviors indicating that the client is engaged in learning.

The physician orders "acyclovir, 200 mg P.O., every 4 hours while awake" for a client with herpes zoster. The nurse should inform the client that this drug may cause

diarrhea.

A 2-month-old infant has been diagnosed with pyloric stenosis. The infant will undergo a pyloromyotomy to remedy the condition. Prior to the surgery, which conditions represent the most danger to the infant?

electrolyte imbalance

A nurse knows that a physician has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid:

has a more predictable onset of action. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

hypoxia not responsive to oxygen therapy A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate?

prone with hips in abduction

The mother of a toddler diagnosed with iron deficiency anemia asks what foods she should give her child. The nurse should evaluate the teaching as successful when the mother later reports that she feeds the toddler which foods?

raisins, chicken, and spinach Good sources of dietary iron include red meats, poultry, green leafy vegetables, and dried fruits such as raisins. Milk products are poor sources of iron. Carrots are high in vitamin A.

A 30-year-old multigravida pregnant with dizygotic twins at 37 weeks' gestation is being continuously monitored with electronic fetal monitoring. After giving instruction about the purpose of the electronic monitoring, the nurse determines that the client needs further instruction when she says that an electronic monitor performs which function?

ensures a more comfortable atmosphere for the client and labor

A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task?

initiating I.V. therapy, as ordered The RN must confirm that the LPN has specialized I.V. training before asking the LPN to begin I.V. therapy for this client. Initiating I.V. therapy is beyond the usual scope of practice for an LPN. Weighing the client, teaching coughing and deep breathing exercises, and teaching the client how to collect a urine specimen are within the scope of LPN practice and don't require additional training.

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet?

prevent the development of ketosis. 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.

The nurse is caring for a seven-month-old infant with bronchiolitis. Which symptoms would the nurse expect to find during their assessment? Select all that apply.

wheezing heart rate of 128 respiratory rate of 68 poor feeding

A neonate receives an IV infusion of dextrose 10% administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that apply.

when the infusion is started at the beginning of each shift when the neonate returns from X-ray The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been taken out of the crib, it is not necessary to check alarm settings after the parents visit.

The nurse is caring for a 9-month-old child who was admitted with severe dehydration after several days of diarrhea. The child has completed initial rehydration therapy. The nurse is instructing the parents on the best way to maintain adequate fluids. Which course of treatment should the nurse recommend?

Continue with breast milk or lactose-free formula.

In an initial screening for lead poisoning, a toddler is found to have a minimally elevated lead level. What is the most important action the nurse should take?

Educate parents on ways to reduce lead in the environment. Treatment for children with minimally elevated lead levels should include family lead education, follow-up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach high levels, 45 mcg/dL (2.2 μmol/L). There is no such thing as a "normal" lead level because there is no beneficial action in the body.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that the client has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Ineffective tissue perfusion: cerebral, cardiopulmonary, GI These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension—and thus inadequate perfusion—pose the greatest risk to the physiological integrity of the client.

The client is diagnosed with a detached retina in the right eye. What should the nurse do first?

Promote measures that limit mobility. Promoting measures that limit mobility may prevent further injury. Following surgical repair of a detached retina, cool or warm compresses are applied to edematous eyelids, if prescribed. The client should avoid lying face down, stooping, or bending preoperatively. It is not necessary to remove all pillows.

The rapid response team has been called to manage an unwitnessed cardiac arrest in a client's hospital room. How long should the nurse estimate the maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage?

4 to 6 minutes

A client with a history of cardiac problems reports severe chest pain. What should be the nurse's first response?

Assess the client's pain.

Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which action?

Allow the 5-year-old undivided attention several times a day. The most appropriate guideline is to suggest that the mother give some undivided time each day to her 5-year-old, who may be jealous of the new baby, thus allowing the older child to feel special and loved. Ignoring the behaviors of the older child related to jealously fails to meet the child's needs.Dividing time equally between the two children may not be feasible, especially because infants often require full-time care.Telling the 5-year-old that the infant is just like a doll is inappropriate, possibly resulting in injury to the infant from rough play.Although allowing the older child to hold and feed the baby occasionally helps the older child feel like a participant in the family, it is unlikely to help overcome jealousy. Also, the older child may injure the infant if the behavior typical of jealously is ignored.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. What should the nurse do first?

Assist the client to take several deep breaths and cough. Deep breathing and coughing help to increase lung expansion and prevent the accumulation of secretions in postoperative clients. An O2 saturation of 89% is not an unexpected or emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period. It is not necessary to notify the HCP prior to intervening with coughing/deep breathing, and it is not appropriate to position this client with the head of bed lower because this would make it more difficult for the client to expectorate secretions. Oxygen may be necessary, but the nurse should assist the client to cough and deep breath first, in an attempt to improve his oxygenation and saturation.

The nurse in the emergency department is administering a prescription for 20 mg intravenous furosemide, which is to be given immediately. The nurse scans the client's identification band and the medication barcode. The medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. What should the nurse do next?

Contact the pharmacist immediately to check the order and the barcode label for accuracy.

A nurse notes that another nurse on the previous shift made an entry on the wrong client's health record. What are the most appropriate steps for the first nurse to take?

Contact the previous nurse requesting that the nurse correct the error. The nurse who wrote the original record and performed the care must make the correction to health record. Nurses have a responsibility to ensure documentation is clear, accurate, and concise to ensure continuity of care. The other options are incorrect because they do not follow established procedures for correcting legal medical records.

A postoperative client has exhibited decreased urine output, hypotension, and tachycardia. Which nursing assessment is the priority?

Check the dressing

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. Clients exposed to anthrax should place contaminated clothes in a plastic bag and mark the bag "contaminated." Wearing protective clothing, instructing exposed clients to wash thoroughly, and restricting access to the exposed area are appropriate actions to take in response to a bioterrorism threat.

A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response?

Confer with the HCP about whether a less expensive drug could be prescribed.

A client with a cerebral embolus is receiving IV recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy?

Dissolved emboli Thrombolytic agents such as alteplase are used for clients with a history of thrombus formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic agents act by dissolving emboli. Thrombolytic agents do not directly improve perfusion or improve cerebral vascularization, nor do they prevent cerebral hemorrhage.

A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best?

Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Explaining what the fetal scalp electrode is, how it's applied, and that bedrest is required after application provides correct information about fetal scalp electrode application; however, these statements don't address the client's clinical situation, which prevents fetal scalp electrode application. The fetal scalp electrode helps monitor fetal heart rate, but it doesn't shorten labor.

The nurse is discharging a client who has been hospitalized for preterm labor. Which client statement indicates the need for further instruction?

If I travel on long trips, I need to get out of the car every 4 hours." Traveling is usually discouraged if preterm labor has been a problem, as it restricts normal movement. A client should be able to walk around frequently to prevent blood clots and to empty her bladder at least every 1 to 2 hours. Bladder infections often stimulate preterm labor, and preventing them is of great importance to this client. Contractions that recur indicate the return of preterm labor, and the health care provider needs to be notified. Dehydration is known to stimulate preterm labor and encouraging the client to drink adequate amounts of water helps to prevent this problem.

The nurse is caring for a client during the 1st hour after a vaginal birth of a term neonate under epidural anesthesia and intravenous fluids. While assessing the client, the nurse observes that the client has a heart rate of 65 bpm, temperature of 99.9°F (37.7°C), fundus firm at one finger breath above the midline, and a slow trickle of dark red vaginal bleeding on the perineal pad. The client's legs are still numb. What action should the nurse take?

Massage the fundus and contact the client's primary care provider immediately. A slow, dark red trickle of blood after a birth is a symptom of postpartum hemorrhage; it should be reported and treated immediately. If the cause is due to uterine atony, the nurse should gently massage the fundus, call for assistance, and prepare to administer oxytocic drugs. If the cause is due to massive blood clots in the uterus, the client may need to have the clots manually extracted.It is not unusual for the client's legs to still be numb; therefore, it is not necessary to call the anesthesiologist.The client's temperature is normal for this stage of the postpartum period.If the client has an intravenous line, this should not be discontinued until the bleeding is under control because the client may need intravenous fluids or blood replacement therapy to prevent shock. Hemorrhage is one of the three leading causes of maternal mortality. The other two causes are infection and pregnancy-induced hypertension.

A nurse is administering oxytocin to a client in labor. During oxytocin therapy, which intervention should the nurse include on the client's plan of care?

Monitor of intake and output. Oxytocin has an antidiuretic effect; prolonged I.V. infusion may lead to severe fluid retention, resulting in seizures, coma, and even death. Therefore, the nurse should monitor intake and output closely. It isn't necessary to insert a catheter. Clients in labor have do not oral fluid restrictions. There is no need for the client to maintain complete bed rest.

A term primigravida was involved in a car accident 3 hours ago. She is having labor contractions every 4 minutes, and her cervical exam is dilated 3 cm, 100% effaced, and station −1. She is crying uncontrollably and states her pain is constant and severe, rating it at 10/10. What is the nurse's the priority action?

Notify the provider of the pain and request an assessment for potential abruption. The woman is at risk for placental abruption due to her recent car accident. Symptoms of a placental abruption include unrelenting pain and a rigid boardlike abdomen. She may or may not have vaginal bleeding. In contrast, labor contractions are intermittent. The priority action by the nurse should be to ensure that this client is further evaluated by her HCP. Subsequent actions could include assisting with pain control measures, assessing contractions, and checking cervical dilation.

To prevent shoulder ankyloses following chest surgery, what should the nurse teach the client to do?

Raise the arm on the affected side over the head. The nurse should teach a client who has undergone chest surgery to raise the arm on the affected side over the head to help prevent shoulder ankylosis. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power.

A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?

The client shouldn't shave the surgical area at home. Any necessary clipping of hair will be done at the surgical center. Allowing the client to shave the area with a razor could cause skin abrasions and subsequent infections. Washing with an antibacterial soap for a few days before surgery reduces the skin's bacterial count. The client shouldn't use lotions or cosmetics on the day of the surgery. The client can shower before coming to the hospital.

Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other births were like this." Which factor is most important for the nurse to consider when responding to the client?

The client's feeling of grief is a normal reaction.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. By initiating a code blue, the nurse didn't follow the client's advance directive and DNR order. The physician was correct to follow the client's wishes and stop resuscitation efforts. The physician had the authority to stop the code.

The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?

a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction. The 3- and 4-year-olds are exhibiting signs and symptoms of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve, the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13-year-old is exhibiting signs and symptoms of bronchitis. Treatment includes rest, antipyretics, and hydration.

A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks if the client has an advance directive. The client asks for an explanation of advance directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is:

a legal document initiated by the physician to give the client "do not resuscitate" (DNR) status.

When preparing to use seclusion as an alternative to restraint for a client who has not yet lost control, the nurse expects to use a room with limited furniture and no access to dangerous articles. What should the nurse also consider as critical for the safety of the client?

a security window in the door or a room camera When using seclusion, the safety of the client is paramount. Therefore, staff must be able to see the client in seclusion at all times, such as through a security window in the door or with a room camera. Although outside access for dimming the lights to decrease stimuli may be appropriate, it is not critical for the client's safety. Having one staff member stay in a room alone with a potentially violent client is unsafe. A prescription for seclusion can be obtained before or after it is initiated.

A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which infection control practice does the nurse consider most important for this client?

adhering diligently to aseptic technique

Which client would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP) for morning care?

an elderly client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea The most appropriate client to assign to a UAP is the elderly client with COPD and mild dyspnea because of the relative stability of the client's chronic condition.The client with a new laryngectomy requires close observation to maintain a patent airway, promote comfort, and decrease anxiety.The client who is receiving chemotherapy will need to be monitored for adverse effects related to the chemotherapy.The client with a suspected pulmonary embolus is acutely ill and requires close observation.

The nurse should warn a client who is taking a benzodiazepine about using which medication in combination with his current medication?

antacids Combining a benzodiazepine with an antacid impairs the absorption rate of the benzodiazepine. Acetaminophen, vitamins, and aspirin are safe to take with a benzodiazepine because no major drug interactions occur.

When a nurse reflects on questions such as "Why am I here?" the nurse is attempting to

develop a philosophical base for clearer thinking. In terms of spiritual care, the nurse's background, family, culture, and religion are integral parts of interactions with clients. For this reason, taking a step back and examining one's own spirituality, values, and beliefs is essential to develop clearer thinking and have unbiased reactions to clients' points of view. The question "Why am I here?" is philosophical but may or may not have a religious or spiritual dimension, depending on the nurse's beliefs. The question tends to lead to thinking about purpose in life but does not seek answers that lead to holism (the treating of the whole person, including mental, social, and physical factors) and integration (assimilation of life experiences such as illness into the self and activities of daily living).

The nurse is assisting the health care provider in irrigating a client wound. If the nurse is holding the gauze pads to collect the drainage during the irrigation procedure, which protective barriers are required? Select all that apply.

gloves face mask gown; eye shield The Centers for Disease Control (CDC) mandates protective barriers that support safety by following standard precautions when health care professionals come in contact with blood and body fluids. The nurse and health care provider are at high risk for exposure due to the procedure and close proximity. The nurse would wear a face mask and eye shield (googles), a gown ,and gloves to protect from either direct contact or splatter contamination. Head and shoe coverings are required primarily in sterile/surgical procedure but not required in this case.

A neonate, admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS), weighs 10 lb, 4 oz (4,650 g), and is at 42 weeks' gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/min with periods of apnea. The nurse should further assess the neonate for which condition?

hypoglycemia MAS affects small-for-gestational age, term, and postterm neonates who have experienced long labor. Meconium in the lungs allows inhalation but not exhalation. These neonates often require resuscitative efforts at birth to establish adequate respirations. Hypoglycemia is common due to low glucose reserves at birth.Acidosis, not alkalosis, is associated with MAS.Hyporesonance is not associated with MAS. However, coarse bronchial sounds may be auscultated from air trapped in the alveoli. Excessive coughing is not associated with MAS. Rather the neonate exhibits signs of respiratory distress.

According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal for the debriefing?

improving the staff's use of restraint procedures The long-term goal of the debriefing after restraining a client is to improve aggression management procedures so that prevention of aggression improves and the frequency of restraint use decreases. Providing feedback and comparing perceptions are single aspects that would eventually lead to the ultimate goal of improving aggression management procedures. When a client can be released from restraints is not immediately predictable.

A client is receiving methotrexate, 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?

leucovorin (citrovorum factor or folinic acid)

A client has been diagnosed with bacterial pneumonia. After 1 day of IV antibiotic therapy, the client's white blood cell count is still 14,000/mm3 (14 X 109/L). The nurse should:

notify the health care provider. If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The health care provider should be notified as he or she may want to consider changing antibiotics.While rechecking the client's white blood cell count may be appropriate, it is the health care provider's responsibility to make this decision.Reverse isolation is used for clients with a very low white blood cell count.The antibiotic dosing schedule should be strictly maintained.

The nurse is developing long-term goals with a family that has a toddler with a developmental delay. Which is a priority concern for the nurse to address with the family regarding the care of the child within the next several years?

preparing for school and learning difficulties In the next several years, the child will be entering the education system. Children with developmental delays have increased risk of school and learning difficulties. Individual education plans that provide a personalized and appropriate intellectual and social environment for school-age children are essential, in addition to a supportive and fostering environment. Strain on caregivers, diagnostic evaluation, and physical limitations may present as ongoing problems rather than ones evident only in a few years based on the child's age.

"I'm a whale," a client with anorexia nervosa reports. However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the care plan?

telling the client of the nurse's concern and desire to help the client make decisions to stay healthy A client with anorexia nervosa has an unrealistic body image that causes the client to consume little or no food. Therefore, this client needs assistance with making decisions about health. Instead of protecting the client's health, asking the client to make self comparisons with people in magazines, assigning the client to a group therapy, and confronting the client about actual appearance may make the client defensive and more invested in the unrealistic body image.

A 4-year-old child is admitted for a cardiac catheterization. Which is most important to include as the nurse teaches this child about the cardiac catheterization?

the parents The most important aspect of teaching a preschooler is to have the family members there for support. Preschoolers are able to understand information that is individualized to their level. Including a plastic model of the heart and a catheter as part of the preoperative preparation may be helpful. The other family members will understand the heart model and catheter better than the preschooler will.

The nurse instructs a primigravid client to increase her intake of foods high in magnesium. This nutrient plays a role in which process?

synthesis of proteins, nucleic acids, and fats Magnesium aids in the synthesis of protein, nucleic acids, and fats. It is important for cell growth and neuromuscular function. Magnesium also activates the enzymes for metabolism of protein and energy. Calcium prevents demineralization of the mother's bones. Vitamin B6 is important for amino acid metabolism. Folic acid assists in the development of neural pathways in the fetus.

A parent says that her family will soon be traveling abroad and asks why the drinking water in many regions must be boiled. The nurse should explain that, in addition to various types of dysentery, contaminated drinking water is most commonly responsible for the transmission of which disease?

typhoid fever Water is the usual vehicle for spreading typhoid fever.Yellow fever is spread through insect bites.Brucellosis (undulant fever) is spread by contaminated cow's milk.Poliomyelitis is most probably spread through respiratory secretions.

A client who was discharged earlier in the day returns to the nursing unit and demands acetaminophen with codeine. The client is advised that the client is no longer being treated on the unit and this medication cannot be administered. The client states, "I know where you park your cars, and you'd better watch out when you leave here tonight." What is the next step that the nurse should take?

Call the police. The nurse should call the police because threatening staff is a criminal act. Nursing supervisors are not able to take the same actions as police officers to protect the staff. Asking to meet with the client privately is unsafe; the client's behavior is unpredictable, and the client could be a risk to others or self. Calling the client's family is not appropriate given the threats uttered.

Which method would the nurse use to identify the educational needs of clients in a senior center?

Conduct focus group interviews and have the clients fill out a survey. Initial gathering of information from the clients using a survey would help identify individual clients' needs and interests. Focus groups will also help generate discussion of needs and common concerns. This gathering of information on risk identification can then help individualize interventions. The other choices are not enough for the families or caregivers to determine the needs of the seniors because they need to have a voice. Discussing with caregivers does not allow for individual consideration.

The nurse and parents plan for the discharge of a child with leukemia who is receiving dactinomycin and vincristine. Which intervention should the nurse include in the teaching plan?

Encourage increased fluid intake. Dactinomycin and vincristine both cause nausea and vomiting. Oral fluids are encouraged, and antiemetics are given to prevent dehydration. Avoiding sun exposure is not necessary because photosensitivity is not associated with these drugs. Heart rate changes and memory issues also are not associated with either of these two drugs.

The health care provider (HCP) has prescribed hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain for a client who underwent right total knee replacement. When the nurse reassesses pain following administration, the client reports pain is still a 9 on a 10-point scale. When the nurse informs the HCP, the HCP states that one hydrocodone/APAP tablet should be sufficient and refuses to issue a new prescription. Which measure should the nurse select to act as an advocate for the client?

Follow the chain of command to obtain adequate pain relief for the client. Clients must receive adequate pain relief. Allowing a client to experience a pain score of 9 out of 10 is unacceptable nursing practice. Acting as a client advocate requires a nurse to be assertive, even if this means confronting another member of the health care team. If the prescribing HCP doesn't give an order for adequate pain relief, the nurse should follow the chain of command to report the HCP's inaction and obtain adequate pain relief for the client. A nurse may not adjust medication frequency or dosage without a valid prescription.

An infant is scheduled for surgery to repair an inguinal hernia. The parent asks the nurse why the infant has been scheduled for surgery when the hernia has been asymptomatic. Which statement offers the best explanation of why the surgical repair should be done at this time?

Less danger and fewer complications result when surgery is an elective procedure. Inguinal hernia repair is ordinarily done promptly after diagnosis in healthy infants and children. Delaying surgery may result in a possible partial obstruction due to a loop of bowel protruding into the inguinal canal. Serious progression with complete obstruction and perhaps strangulation of the bowel requires emergency surgery to prevent gangrene, which could be fatal.Infants do not have a physiologic or psychological advantage in surgery compared with older children.Infants, like other children and adults, experience stress and fear when having surgery.Although performing surgery around the genitals before the preschool years is recommended, the best reason for performing this surgery immediately would be to avoid having to perform emergency surgery later.

What is the nurse's priority action in caring for a client who has just had a liver biopsy?

Monitor vital signs. Internal bleeding is a potential complication following a liver biopsy. Elevated pulse and decreased blood pressure are indications that the client may be developing shock, which results in altered circulation. Physiologic needs take priority over psychological needs, Assessing feelings and teaching should be addressed after immediate needs. Pain is considered a psychological reaction unless the client is experiencing an acute episode that is causing physiologic response.

The nurse is preparing a client who has had a knee replacement with a metal joint to go home. What should the nurse instruct the client to do? Select all that apply.

Notify health care provider (HCP) about the joint prior to invasive procedures. Inform the HCP prior to having magnetic resonance imaging (MRI) scans. Notify airport security that the joint may set off alarms on metal detectors. The nurse should instruct the client to notify the dentist and other HCPs of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia. The nurse should also advise the client that the metal components of the joint may set off the metal-detector alarms in airports. The client should also report having the metal joint prior to having MRI studies because, depending on the type of joint replacement, the implanted metal components could be pulled toward the large magnet core of the MRI. Any weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to 5 lb (2.3 kg). After surgery, the client can resume a normal diet with regular fluid intake.

A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best?

Stop the nurse and ask that the injection techniques be reevaluated. Vitamin K should be administered by I.M. injection. Therefore, the nurse preceptor should stop the nurse and have injection techniques reevaluated by the nurse. The nurse preceptor can praise the nurse after the injection is administered correctly. The nurse preceptor can distract the neonate by talking calmly, but the nurse preceptor should first stop the nurse from administering the medication by the wrong route. The injection should be administered by the I.M. route, not by the Z-track method.

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol?

Stop the visitor, and ask for identification. Labor and delivery units are locked to prevent neonate abduction. All visitors should be stopped at the door, identified, and matched to a current client. If an unidentified visitor gains entry without having gone through this process, it is appropriate to stop the person to ask for identification and confirm who the visitor is there to see. Calling security, making sure that each neonate is with its parent and noting the time and a description of the individual would not be the priority actions in this case; but rather what one would do for an attempted abduction.

In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open-heart surgery, what should the nurse tell the family?

The client will receive medication to relieve pain. Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.

The nurse orients an unlicensed assistive personnel (UAP) new to the mental health unit about the principles for the care of a client diagnosed with a personality disorder. What information should the nurse include?

The clients are accepted although their behavior may not be.

The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use?

Use of an infusion pump to regulate the flow rate Use of an infusion pump to regulate the flow rate is the appropriate safeguard, because infants and children are particularly vulnerable to I.V. fluid overload. Administering fluid at the slowest possible rate may not benefit the infant. Using a gravity infusion set or a micro drop infusion set will not protect against fluid overload when I.V. administration is too rapid.

A nurse is caring for clients on a medical/surgical unit. Which client should the nurse see first?

a 60-year-old client admitted with partial-thickness (second-degree) burns covering the arms, chest, neck, and face. The client with partial-thickness (second-degree) burns covering the upper body is the most at risk for airway complications and should be assessed first. The postoperative client with low-grade temperature should be assessed next. Although temperature elevations are common postoperatively, the fact that this client is only 48 hours post-CABG makes this assessment the next highest priority. Third, the nurse should assess the client awaiting cholecystectomy. Chills are common when cholecystitis is present, but because the client has a procedure pending the next day, the nurse needs to ensure the client has no acute changes that need to be addressed. Finally, the client with hypertension and dizziness would be assessed. An elevated blood pressure in this range is not urgent.

A client undergoing a bilateral adrenalectomy has postoperative prescriptions for hydromorphone hydrochloride 2 mg to be administered subcutaneously every 4 hours as needed for pain. Why should the nurse administer hydromorphone in small doses? A small dose is:

as potent as morphine in larger doses. Hydromorphone hydrochloride is about five times more potent than morphine sulfate, from which it is prepared. Therefore, it is administered only in small doses. Hydromorphone hydrochloride can cause dependency in any dose; however, fear of dependency developing in the postoperative period is unwarranted. The dose is determined by the client's need for pain relief. Hydromorphone hydrochloride is not irritating to subcutaneous tissues. As with opioid analgesics, excretion depends on normal liver function.

A client is undergoing a diagnostic workup for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to

cryptorchidism Cryptorchidism (failure of one or both testes to descend into the scrotum) appears to play a role in testicular cancer, even when corrected surgically. Other significant history findings for testicular cancer include mumps orchitis, inguinal hernia during childhood, and maternal use of diethylstilbestrol or other estrogen-progestin combinations during pregnancy. Testosterone therapy during childhood, sexually transmitted disease, and early onset of puberty aren't risk factors for testicular cancer.

A client is admitted to the emergency department with a history of abdominal aortic aneurysm. The nurse assesses the client for which sign or symptom that suggests the client's abdominal aortic aneurysm is extending?

increased abdominal and back pain Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

A nurse is caring for a client with bipolar disorder. The care plan for a client in a manic state would include:

listening attentively to the client's requests with a neutral attitude, and avoiding power struggles. The nurse should listen to the client's requests, express willingness to seriously consider each request. The nurse should encourage the client to take short daytime naps because of so much energy expended. High-calorie finger foods should be offered to supplement the diet if the client can't remain seated long enough to eat a complete meal. The client shouldn't be forced to stay seated at the table to finish a meal. The nurse should set limits in a calm, clear, and self-confident tone of voice.

A client has an ileal conduit. Which solution will be useful to help control odor in the urine collecting bag after it has been cleaned?

vinegar

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

"I should lie on my back as much as possible to relieve the pain." The client needs more teaching when she states, "I should lie on my back as much as possible to relieve the pain." Instead, the client should lie in the Sims position as much as possible to aid venous return to the rectal area and to reduce discomfort. Stool softeners can decrease pain with defecation, but clients should discuss their use with their provider before taking them. Analgesic sprays and witch hazel pads are helpful in reducing the discomfort of hemorrhoids. Drinking lots of water and eating roughage aid in bowel elimination, minimizing the risk of straining and subsequent hemorrhoidal development or enlargement.

Which statements would indicate that the parents of a child being treated with antibiotics for an ear infection understand the reason for a follow-up visit after the child completes the course of therapy?

"We need to make sure that her ear infection has completely cleared." Because ear infections are sometimes difficult to treat, determining if the antibiotic has resolved the infection is essential. If the child is not rechecked, it will be difficult to determine if another infection is a continuation of a previous infection or a separate, new infection.Although studies may be done to determine if an infection has impaired the child's hearing, they are not done routinely after each course of antibiotic therapy.A visit to the primary care provider's office cannot validate that all the medication was taken.A follow-up visit helps to determine if the infection has completely cleared. If the infection is resolved with one course of antibiotics, another course would not be prescribed.

A 34-year-old multigravida at 36 weeks' gestation in active labor has been diagnosed with Rh sensitization. The fetus is in a frank breech presentation. The client's membranes rupture spontaneously, and the nurse documents the color of the fluid as yellowish. What does this color indicate?

Rh sensitization Amniotic fluid is normally clear. Yellowish fluid indicates Rh sensitization. The yellowish color is related to fetal anemia and bilirubin in the amniotic fluid.In an abnormal presentation, in this case a breech presentation, it is not uncommon for the amniotic fluid to be green in color owing to meconium expelled by the fetus.Amniotic fluid embolism is not related to the fluid color. This condition, a medical emergency, may occur naturally after a difficult labor or from hyperstimulation of the uterus.Oligohydramnios refers to a markedly decreased volume of amniotic fluid. It has no association with the color of the fluid.

When approaching a family to discuss organ or tissue donation, a nurse should be mindful of which guideline?

The facility should provide the family with an opportunity to speak with an organ procurement coordinator. The facility should offer the family an opportunity to speak with an organ procurement coordinator who is knowledgeable about organ donation and who should have exceptional interpersonal skills for dealing with grieving family members. Physician support in the process is desirable but referral to the organ procurement organization does not require a physician's consent or written order. The requestor must believe in the benefits of organ donation and support the process with a positive attitude. The possibility of speaking with an organ procurement coordinator should be introduced only after the family has been made aware of the client's condition and prognosis. Approaching a family member who believes there's still hope for recovery will likely result in a negative outcome

While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist?

Timely administration of breathing treatments. The nurse should collaborate with the respiratory therapist to make sure breathing treatments are administered and the client's respiratory status is watched closely before and after surgery, because of the increased risk of infection and post operative pneumonia. An induced sputum specimen is not necessary at this time. The nurse alone can teach the client coughing and deep breathing exercises and monitor the color and consistency of sputum specimens.

Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure?

increased pulmonary artery diastolic pressure 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.

A nurse is administering IV fluids to a dehydrated client. When administering an IV solution of 3% sodium chloride, what should the nurse do? Select all that apply.

Measure the intake and output. Inspect the jugular veins for distention. Evaluate the client for neurologic changes. A 3% sodium chloride solution is hypertonic; it will pull fluid into the intravascular compartment and may increase renal perfusion, so intake and output should be monitored. As fluid is pulled into the vasculature, the client may demonstrate signs of fluid overload such as jugular vein distention. Hypernatremia and hyperchloremia will produce neurologic signs and symptoms. Fluids should not be forced in a client with fluid overload. There is no need for an indwelling urinary catheter.

A nurse is assessing a client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg, and on admission to the postsurgical nursing unit it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. After determining that other vital signs are normal, what should the nurse do first?

Notify the health care provider (HCP). The client's systolic blood pressure is dropping, and the pulse pressure is narrowing, indicating impending shock. The nurse should immediately notify the HCP. Elevating the head of the bed will not increase the blood pressure. Administering pain medication could cause the blood pressure to drop further. It is not necessary to activate the rapid response team unless the client's vital signs change before the HCP evaluates the client.

A client has been diagnosed with avoidant personality disorder. The client reports loneliness, but has fears about making friends. The client also reports anxiety about being rejected by others. In a long-term treatment plan, in what order, from first to last, should the nurse list interventions for the client? All options must be used.

Talk with the client about self-esteem and fears. Teach the client anxiety management and social skills. Help the client make a list of small group activities at the center that the client would find interesting. Ask the client to join in a chosen activity with the nurse and two other clients. The client needs a stepwise plan for developing a social life. The client needs to first work on self-esteem and reduce fears of rejection before talking about how to decrease anxiety and learn new social skills. Helping the client chose interesting activities is important before suggesting an activity. Then, the client will be ready to try a structured activity with the nurse present for support and role modeling.

A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and does not respond to verbal or tactile stimuli. Which nursing intervention is a priority?

assessing the client's nutritional and hydration status Priority is placed on immediate physical needs over psychosocial needs. In this situation, nutritional needs are the priority for a client in a catatonic state. Providing therapeutic communication, emotional stimulation, and a safe, nurturing, supportive environment and orienting the client to the environment are all appropriate actions, but the client's immediate physical needs must be met first.

An adolescent client is hospitalized with bacterial meningitis. At 1730, the client's mother reports her child is "burning up." The nurse is reviewing the client's medication administration records in the medical record. The health care provider (HCP) has prescribed ibuprofen 325 mg every 3 to 4 hours for temperature over 99°F (37.2°C). The child's temperature at 1730 is 102.5°F (39.1°C). What should the nurse do first?

Notify the HCP. Because the client's temperature continues to rise in spite of recently administering ibuprofen, the nurse notifies the HCP. After notifying the HCP, the nurse can bathe the client with tepid water. If the temperature cannot be lowered quickly, the client is also at risk for seizures; the nurse pads side rails and observes for seizure activity. The nurse cannot administer another dose of ibuprofen without the HCP's orders.

A client is being discharged to home 3 days after transurethral resection of the prostate (TURP). What should the nurse instruct the client to do? Select all that apply.

Report bright red bleeding to the health care provider (HCP). Drink at least 3,000 mL of water per day. Report a temperature over 100.4° F (38° C). The nurse should instruct the client to drink a large amount of fluids (about 3,000 mL/day) to keep the urine clear. The urine should be almost without color. About 2 weeks after TURP, when desiccated tissue is sloughed out, a secondary hemorrhage could occur. The client should be instructed to call the surgeon or go to the emergency department if at any time the urine turns bright red. The nurse should also instruct the client to report signs of infection such as a temperature over 100.4° F (38° C). The client is not specifically at risk for nutritional problems after TURP and can resume a diet as tolerated. The client is not specifically at risk for airway problems because the procedure is done under spinal anesthesia and the client does not need to take deep breaths and cough.

A nurse on a surgical unit is caring for a client who needs to provide informed consent for surgery. When the surgeon arrives on the unit to obtain consent, which client condition must the nurse immediately bring to the surgeon's attention?

The client was given morphine 6 mg IM 20 minutes ago. The nurse is aware that a client is unable to provide informed consent if the client has been given sedation or a narcotic. These medications may cause mental status changes, such as disorientation, which could interfere with the ability to provide consent. The other options, on their own, do not lead to disorientation and, therefore, would not prevent the client from providing informed consent.

A client needs to be transferred to the oncology unit for further care. Which information is necessary to include in the transfer report?

current client assessment The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report.

Which client statement indicates a need for additional teaching about self-care during pregnancy?

"I should sit in a hot tub for 20 minutes to relax after working." The client needs further instruction when she says it is permissible to sit in a hot tub for 20 minutes to relax after working. Hot tubs and saunas should be avoided, particularly in the first trimester, because their use can lead to maternal hyperthermia, which is associated with fetal anomalies such as central nervous system defects. The client should use nonskid pads in the shower or bath to avoid slipping because the client's center of gravity has shifted and she may fall. The client should avoid using soap on the nipples to prevent removal of the natural protective oils. Douching is not recommended for pregnant women because it can destroy the normal flora and increase the client's risk of infection.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first?

the prescriber After discovering a medication error, the safety of the patient is top priority. The nurse should immediately check the client and observe for any adverse effects which may develop. The first person the nurse needs to notify is the prescriber, followed by the nursing manager (or the nursing supervisor). Then pharmacist and risk manager should also be notified.

The client has been taking magnesium hydroxide to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids?

diarrhea The magnesium salts in magnesium hydroxide are related to those found in laxatives and may cause diarrhea. Aluminum salt products can cause constipation. Many clients find that a combination product is required to maintain normal bowel elimination. The use of magnesium hydroxide does not cause anorexia or weight gain.