practice exam

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my spouse look at the soles of my feet each day." A client with peripheral vascular disease should examine their feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on their own, then a caregiver or family member should help. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make them unable to tell if the water is too hot. The client should always wear shoes or slippers on their feet when out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse best addresses this nursing diagnosis?

"Support the neonate's head and back with the forearm." To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate's back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

The client's health care provider prescribes buspirone hydrochloride for increased anxiety. The nurse understands the health care provider's choice of this medication is based on what principle?

Buspirone is not habit forming. Buspirone is not habit forming, is administered on a schedule, and does not work immediately. Buspirone may have side effects such as chest pain, dizziness, headache, drowsiness, or nausea. Buspirone hydrochloride is not chemically or pharmacologically related to benzodiazepines or other sedative medications.

A nurse is assessing the chest of a 4-month-old infant. The nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:2. Which actions should the nurse take next?

Document the findings in the client's medical record. This is a normal finding and requires no further action. As this is a normal finding, a chest X-ray is unnecessary. All the other responses suggest a respiratory disorder and that further evaluation is needed.

A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. What should the nurse do first?

Engage the child in quiet activities. One of the characteristics of children with KD is irritability. They are often inconsolable. Engaging the child in quiet activities help calm the child and reduce the workload of the heart. Although peeling of the skin occurs with KD, the child's irritability takes priority over applying lotion to the hands and feet. Children with KD usually are not hungry and do not eat well regardless of what is served. There is no indication that the parents need rest. Additionally, in this situation, the child takes priority over the parents.

The family of a client who dies lives an hour away from the facility. What should the nurse do to support the family at this time?

Keep the client in the bed until the family arrives.

A client has signed a document indicating a wish not to be resuscitated. During morning rounds, the nurse finds the client without vital signs. What is the most appropriate action for the nurse to take?

Notify the physician that the client has no vital signs. The client has signed a document indicating a wish not to be resuscitated. The other options are incorrect because the nurse should be aware of the client's "do not resuscitate" (DNR) status and should not need to go to the desk to confirm this. The nurse should notify the physician so the physician can pronounce the death and notify the family.

A client is taking phenytoin as an antiepileptic medication. What should the nurse instruct the client to do?

Schedule twice-yearly dental examinations. Phenytoin causes hyperplasia of the gums, and the client needs dental examinations twice a year and meticulous oral hygiene. Phenytoin therapy may contribute to a folic acid deficiency, but it is not related to iron or calcium metabolism. A need for frequent eye examinations is not related to the side effects of phenytoin, but the client should have regular eye exams as appropriate.

A client is scheduled to undergo an open reduction internal fixation of the right femur. The night before surgery, the nurse administers zolpidem as ordered. Which statement about zolpidem is correct?

The nurse should administer the drug immediately before bedtime. The nurse should administer zolpidem immediately before bedtime because the onset of action is rapid. Diluting the drug in fruit juice doesn't improve its absorption. Zolpidem doesn't come in liquid form; it's available in 5- and 10-mg tablets. Grapefruit juice doesn't interfere with absorption.

When planning care for a group of clients, the nurse should identify which client as having the greatest risk for the development of pressure ulcers?

a client who has a decreased serum albumin level. Risk factors for the development of pressure ulcers include poor nutrition, indicated by a decreased serum albumin level. According to the Guidelines for Pressure Ulcers published by the Agency for Healthcare Research and Quality, other risk factors include immobility, incontinence, and decreased sensation. A client who does not ambulate often can be repositioned frequently to prevent pressure ulcers. Having an indwelling urinary catheter does not normally increase the risk of developing a pressure ulcer unless pressure from the tubing impinges on urethral or other tissue. An elevated white blood cell count does not place a client at risk for pressure ulcers.

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to

a perinatologist. An elevated AFP level may indicate a fetal congenital abnormality. The physician will likely refer the client to a perinatologist, who cares for clients with high-risk pregnancies. A nutritionist provides guidance about a healthy diet. A nurse-midwife follows low-risk pregnancy cases. An endocrinologist deals with metabolic disorders. Referrals to these providers aren't necessary at this time.

A client is diagnosed with agoraphobia without panic disorder. Which type of therapy would most the nurse expect to see included in the plan of care?

behavior therapy The nurse should suggest behavior therapy, which is most successful for clients with phobias. Systematic desensitization, flooding, exposure, and self-exposure treatments are most therapeutic for clients with phobias. Self-exposure treatment is being increasingly used to avoid frequent therapy sessions. Insight therapy, exploration of the dynamics of the client's personality, is not helpful because the process of anxiety underlies the disorder. Group therapy or psychoanalysis, which deals with repressed, intrapsychic conflicts, is not helpful for the client with phobias because it does not help to manage the underlying anxiety or disorder.

Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

care-based ethics; Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology concerns duty and obligation. Utilitarianism prioritizes the greatest happiness of the greatest number of people. Principle-based ethics is a framework that focuses on autonomy, non-maleficence/beneficence, and justice. Each prioritizes goals and principles outside the particularities of the nurse-client relationship.

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining this client?

checking that the restraints have been applied correctly. A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding has been used. The nurse should document the client's response and status carefully after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. If an as-needed medication is ordered, it should be administered before the restraints are in place and with the assistance of other team members. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained.

A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply.

older adult client who had hip replacement surgery and needs to walk in the hall with a walker; adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours The UAP can assist clients ambulate and take vital signs. It is within the RN scope of practice to teach the client to administer insulin, change dressings, and administer tube feedings.

Which factor is a priority when evaluating discharge plans for an older adult after a lower left lobectomy for lung cancer?

support available for assisting the client at home. Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support for assistance and self-care at home. If the client has support at home, the distance from the hospital may be irrelevant. The client or support team will monitor vital signs as needed, but blood pressure monitoring is not specifically indicated. It is more important at this point for the client to understand how to manage his care at home, rather than knowing the causes of lung cancer.

A nurse is caring for a newborn exposed to drugs while in utero. Which behaviors will the nurse expect the newborn to exhibit? Select all that apply.

tachypnea with excessive secretions; sensitive gag reflex; hyperactivity and increased muscle tone. Newborns exposed to drugs while in utero can have tachypnea, excessive secretions, a sensitive gag reflex, hyperactivity, and increased muscle tone. Newborns exposed to drugs while in utero will not be satisfied with breastfeeding or eating and are not easily consoled or comforted.

The nurse is caring for a multigravida woman who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment?

temperature of 100.8° F (38.2° C). Within the first 24 hours postpartum, maternal temperature may increase to 100.4° F (38° C), a normal postpartum finding attributed to dehydration. A temperature above 100.4° F (38° C) after the first 24 hours indicates a potential for infection. The hemoglobin is in the normal range. WBC count is normally elevated as a response to the inflammation, pain, and stress of the birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fluid into the vascular bed, decreased pressure from the uterus on vessels, blood flow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume.