Prep-U Chapters 29, 34, 36, 39, 44,

A parent reports their 4-year-old child wakes up at night screaming and this occurs shortly after the child has fallen asleep. The nurse determines that the child takes a tub bath and the parent reads a story prior to bedtime at 8 p.m. What is the best response to the parent? Select all that apply. - "It is common for this to occur in this age group." - "Comforting your child when this occurs may help." - "Put the child in your bed to sleep when this occurs." - "You may find a nightlight in his room is helpful." - "You will need to change your child's bedtime routine."

Answer: - "It is common for this to occur in this age group." - "Comforting your child when this occurs may help." - "You may find a nightlight in his room is helpful."

A client reports to the nurse, "Sleep really isn't necessary." Which teaching by the nurse is appropriate? Select all that apply. - "Sleep helps your blood flow to the brain." - "Sleep can make your moods fluctuate over time." - "Sleep helps you to learn easier and remember more." - "Sleep takes time, which can be stressful for some people." - "Sleep helps your immune system to fight off infections."

Answer: - "Sleep helps your blood flow to the brain." - "Sleep helps you to learn easier and remember more." - "Sleep helps your immune system to fight off infections."

Which statements made by the nurse indicate how insulin pens simplify self-administered insulin for clients? Select all that apply. - "The plastic cylinders of insulin pens are softer." - "Insulin pens are less expensive than insulin vials." - "The cylinder of the insulin pen contains a prefilled reservoir of insulin." - "The dose of insulin in an insulin pen is displayed in a window of the syringe." - "The insulin pen automatically resets the dose window to zero, following the injection."

Answer: - "The cylinder of the insulin pen contains a prefilled reservoir of insulin." - "The dose of insulin in an insulin pen is displayed in a window of the syringe." - "The insulin pen automatically resets the dose window to zero, following the injection."

A nurse assesses the vital signs of a healthy newborn infants. What respiratory rate(s) suggests the infant needs further assessment and possible interventions? Select all that apply. - 20 breaths/min - 35 breaths/min - 50 breaths/min - 65 breaths/min - 80 breaths/min

Answer: - 50 breaths/min - 65 breaths/min - 80 breaths/min Rationale: An infant's expected respiratory rate is 20 to 40 breaths/min. Results outside this range should prompt the nurse to perform further assessments and to consider interventions.

The nurse is attempting to insert an NG tube and, as the tube is passing through the pharynx, the client begins to retch and gag. What nursing interventions are appropriate in this situation? Select all that apply. - Inspect the other nostril and attempt to pass the nasogastric tube down that nostril. - Ask the client if he needs to pause before continuing insertion. - Continue to advance tube when the client relates that he is ready. - Have the emesis basin nearby in case client begins to vomit. - Give small air boluses until gastric contents can be aspirated. - Insert a nasointestinal tube.

Answer: - Ask the client if he needs to pause before continuing insertion. - Continue to advance tube when the client relates that he is ready. - Have the emesis basin nearby in case client begins to vomit.

The nurse is teaching a group of clients about general eye care to prevent vision loss and eye injury. What will the nurse include in the presentation? Select all that apply. - Avoid eye damage from ultraviolet rays. - Use caution with corrosive agents. - Use a saline eye rinse daily. - Avoid eye strain and rubbing eyes. - Wear protective goggles for mowing lawns.

Answer: - Avoid eye damage from ultraviolet rays. - Use caution with corrosive agents. - Avoid eye strain and rubbing eyes. - Wear protective goggles for mowing lawns.

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on evaluation of the client? Select all that apply. - Respiratory rate is 33 breaths/min at rest. - Heart rate is 64 beats/min. - Oxygen saturation reads 88% on 5L of oxygen. - Mucous membranes are pink and moist. - Client is able to state the date, time and location.

Answer: - Heart rate is 64 beats/min. - Mucous membranes are pink and moist. - Client is able to state the date, time and location.

The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. - Inhale slowly through the nose for a count of three. - Keep abdominal muscles in a relaxed state. - Shape the lips as if you were about the blow a whistle. - Over time, begin to increase the length of the exhale. - Exhale slowly through pursed lips. - Ensure that the exhale lasts twice as long as the inhale.

Answer: - Inhale slowly through the nose for a count of three. - Shape the lips as if you were about the blow a whistle. - Over time, begin to increase the length of the exhale. - Exhale slowly through pursed lips. - Ensure that the exhale lasts twice as long as the inhale.

A client who was admitted to the critical care unit is experiencing sensory overload. When developing this client's plan of care, which intervention would be appropriate for the nurse to include? Select all that apply. - Provide varying levels of stimulation throughout the day. - Offer simple explanations before a treatment or procedure. - Set up a consistent schedule for routine care activities. - Speak to the client in a loud tone of voice. - Suggest the use of noise-reducing headphones or ear plugs.

Answer: - Offer simple explanations before a treatment or procedure. - Set up a consistent schedule for routine care activities. - Suggest the use of noise-reducing headphones or ear plugs.

The nurse prepares to apply the pulse oximeter to the client's hand. The fingers are edematous, cool to touch, and have black nail polish. Which actions should the nurse take? Select all that apply. - Remove black nail polish and assess circulation. - Assess mental status. - Apply to warm, swollen finger. - Auscultate lungs. - Use alternate site: earlobe or bridge of nose.

Answer: - Remove black nail polish and assess circulation. - Assess mental status. - Auscultate lungs. - Use alternate site: earlobe or bridge of nose. Rationale: Nail polish obstructs the ability to assess capillary refill and the color of the nail bed. Mental status is important to assess because changes occur early with hypoxia. Edema prevents adequate reading. Lungs should be assessed for adventitious sounds such as wheezes, crackles, or rhonchi. Since the fingers are edematous and cool to touch, the nurse should use an alternate site for the pulse oximeter to achieve the best reading, which includes the forehead, earlobe, or the bridge of the nose.

A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply. - The client demonstrates restlessness. - The client's capillary refill is assessed at 4 seconds. - The client has uneven movements of the chest with respirations. - The client has flaring nostrils. - The client has a respiratory rate of 16 breaths/min.

Answer: - The client demonstrates restlessness. - The client's capillary refill is assessed at 4 seconds. - The client has uneven movements of the chest with respirations. - The client has flaring nostrils.

Which of the following accurately describes senses by which individuals maintain contact with the external environment? Select all that apply. - Vision - Hearing - Smell - Taste - Kinesthesia

Answer: - Vision - Hearing - Smell - Taste

The nurse recognizes that sleep deprivation related to environmental concerns will apply to which clients? Select all that apply. - a 67-year-old male who has two beers during the late night newscast - a 16-year-old female who works part time on Saturdays - a 32-year-old male machinist, two-pack-a-day smoker - a 58-year-old female who takes cholesterol-lowering medication and aspirin daily - an 84-year-old male hospitalized for prostate surgery

Answer: - a 67-year-old male who has two beers during the late night newscast - a 32-year-old male machinist, two-pack-a-day smoker - an 84-year-old male hospitalized for prostate surgery Rationale: Alcohol consumption, smoking, pain, and/or a new environment all predispose clients to sleep disruption. The teen with a Saturday job is not particularly in distress. Antilipemics and aspirin do not interfere with sleep patterns.

The nurse is educating a client about nonpharmacologic measures to alleviate restless leg syndrome (RLS). Which education points would the nurse include in the plan? Select all that apply. - drinking a cup of coffee before bed can help relieve the tingling sensations - applying heat or cold to the extremity can help relieve the symptoms - an alcoholic drink is recommended before bed to relax the client - Biofeedback and TENS can help relax the client and relieve symptoms - massaging the legs may relieve symptoms - A mild analgesic before bed can help relieve symptoms

Answer: - applying heat or cold to the extremity can help relieve the symptoms - Biofeedback and TENS can help relax the client and relieve symptoms - massaging the legs may relieve symptoms

During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply. - depression - substance use - constipation - type 1 diabetes mellitus - stroke - glaucoma

Answer: - depression - substance use - constipation - stroke

The nurse is working on a neurological unit and a physician asks the nurse to perform a sensory experience assessment for a client. The nurse thinks about what things may place a person at risk for disturbed sensory perception and comes up with which of the following? Select all that apply. - diminished senses related to advanced age - wearing corrective eyeglasses for poor vision - neuropathy related to diabetes mellitus - medications that alter certain senses - wearing a hearing aid for diminished hearing

Answer: - diminished senses related to advanced age - neuropathy related to diabetes mellitus - medications that alter certain senses

The nurse is working on a neurological unit and must perform an assessment on a client for disturbed sensory perceptions. The nurse thinks about the human senses and knows that they must assess for which of the following? Select all that apply. - use of assistive devices for senses - history of recent immunizations - medications that may alter sensations - anything interfering with sensory reception - any recent changes in sensory stimulation

Answer: - use of assistive devices for senses - medications that may alter sensations - anything interfering with sensory reception - any recent changes in sensory stimulation

Which statement made by the nurse would indicate that teaching regarding the absorption of topical medications in the older adult was effective? A.) "Diminished subcutaneous fat will lead to the rapid absorption of topical medication." B.) "Increased subcutaneous fat will lead to the rapid absorption of topical medication." C.) "Diminished elasticity will lead to the decreased absorption of topical medication." D.) "Increased elasticity will lead to the decreased absorption of topical medication."

Answer: A.) "Diminished subcutaneous fat will lead to the rapid absorption of topical medication."

A nurse is caring for a client, age 4 years, who is being treated for osteomyelitis in his left femur. He is on a 28-day course of IV vancomycin to be administered daily at 1300. Today is day 3 of treatment, and the pharmacist asks the nurse to draw a peak vancomycin level. What would be the most appropriate time to draw this blood? A.) 1500 B.) 1200 C.) 2000 D.) Wait until day 5 of treatment.

Answer: A.) 1500

Which situation demonstrates sensory adaptation? A.) A client has learned to sleep through the frequent beeping of the intravenous pump. B.) A client with hearing loss has learned to communicate using sign language. C.) A client with vision loss has begun buying large-print books. D.) A client believes their hearing has become more acute since the loss of his vision.

Answer: A.) A client has learned to sleep through the frequent beeping of the intravenous pump.

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? A.) An infant with a respiratory rate of 16 bpm B.) A 4-year-old with a respiratory rate of 32 bpm C.) A 12-year-old with a respiratory rate of 20 bpm D.) A 70-year-old with a respiratory rate of 18 bpm

Answer: A.) An infant with a respiratory rate of 16 bpm Rationale: The infant's normal respiratory rate is 20 to 40 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 32 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

A nurse is teaching a client about diabetes and glucose monitoring. What should the nurse include in the teaching? A.) Blood from the fingertips shows changes in glucose more quickly than other testing sites. B.) Use a forearm sample with signs and symptoms of hypoglycemia. C.) Calibrate the glucose meter every six months. D.) Glucose levels will decrease with illness and stress.

Answer: A.) Blood from the fingertips shows changes in glucose more quickly than other testing sites.

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? A.) Bronchial B.) Vesicular C.) Bronchovesicular D.) Adventitious

Answer: A.) Bronchial

The nurse is working with a student nurse on the surgical unit. The nurse should describe what benefit of providing health education before the procedure? A.) Clients are better able to handle new experiences. B.) Time is limited after the procedure because of the trend toward early discharge. C.) Client education is the nurse's professional responsibility. D.) Nurse practice acts dictate this specific practice.

Answer: A.) Clients are better able to handle new experiences.

The older adult client has been reporting sleeplessness for the past 3 days. Which type of sensory problems can result from this? A.) Cognitive dysfunction B.) Hallucinations and delusions C.) Anxiety D.) Sensory deprivation

Answer: A.) Cognitive dysfunction

The pediatric nurse teaches parents about normal sleep patterns in their children. Which education point should the nurse include? A.) Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. B.) Teach parents of infants to report any eye movements, groaning, or grimacing by their infant during sleep periods. C.) Advise parents that waking from nightmares or night terrors is common during the adolescent stage. D.) Inform parents about the preschool child's awareness of the concept of death possibly occurring and encourage parents to help alleviate the child's fears.

Answer: A.) Inform parents that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. Rationale: The nurse would include the education point that daytime napping decreases during the preschool period, and, by the age of 5 years, most children no longer nap. It is normal for infants to have eye movements, groaning, or grimacing during sleep periods. School-age children become aware of the concept of death, not preschool children. Waking from nightmares or night terrors is common during the preschooler stage.

A nurse is caring for a client who has a vitamin B12 deficiency. Which food would the nurse recommend to help with this deficiency? A.) Liver B.) Pork C.) Cantaloupe D.) Broccoli

Answer: A.) Liver Rationale: The best foods from which to obtain B12 include organ meats and seafood. Pork provides thiamin. Cantaloupe provides vitamin B6; broccoli provides vitamin C.

The nurse is conducting a health history with an adolescent client. During the interview, the adolescent tells the nurse about reading with the television on in the background but gets distracted by the sound of his neighbor's dog. What does the nurse identifies is being involved? A.) Reticular activating system B.) Nerve endings in the skin C.) Auditory receptors D.) Cerebral cortex

Answer: A.) Reticular activating system

The nurse is preparing to administer a tuberculin test to a client. Which instructions should the nurse provide to the client? A.) Return in 48 to 72 hours for results. B.) Wait here for 60 minutes for results. C.) Call the nurse in 72 hours for results. D.) We will contact you with the results.

Answer: A.) Return in 48 to 72 hours for results.

The nurse is caring for a client who has dysphagia and is unable to eat independently. The nurse is preparing to assist the client in eating a meal. Which action is appropriate? A.) Speak to the client but limit the need for the client to respond verbally while chewing and swallowing. B.) Arrange food items in a clock face pattern and inform the client which time on a clock corresponds to each food item. C.) Create a positive social environment by asking the client about childhood food memories. D.) Encourage the client to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm.

Answer: A.) Speak to the client but limit the need for the client to respond verbally while chewing and swallowing.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? A.) The client's available hemoglobin is adequately saturated with oxygen. B.) The client's oxygen demands are being met. C.) The client's red blood cell (RBC) count is in the normal range. D.) The client's respiratory rate is in the normal range.

Answer: A.) The client's available hemoglobin is adequately saturated with oxygen.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A.) True B.) False

Answer: A.) True Rationale: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

When planning interventions in the immediate hours after birth the nurse recognizes the need to provide an injection of which vitamin (to manage a lack of it), due to lack of bacteria in the intestinal tract? A.) Vitamin K B.) Vitamin A C.) Vitamin C D.) Vitamin D

Answer: A.) Vitamin K Rationale: Approximately half of the body's requirement of vitamin K is synthesized by bacteria in the lower intestinal tract.

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? A.) Warm the client's hands and try again. B.) Place the probe on the client's earlobe. C.) Shine available light on the equipment to facilitate accurate reading. D.) Use a blood pressure cuff to increase circulation to the site.

Answer: A.) Warm the client's hands and try again. Rationale: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

A client tells the nurse that the client often has a difficult time falling asleep at night. What suggestion offered by the nurse may assist the client in achieving sleep? A.) a snack containing carbohydrates and protein B.) a snack containing carbohydrates and fat C.) a snack containing protein and fat D.) it is best to avoid a snack prior to bedtime

Answer: A.) a snack containing carbohydrates and protein

The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep? A.) decreased REM sleep B.) shorter sleep cycles C.) increased amount of total sleep D.) increased stage IV NREM sleep (delta sleep)

Answer: A.) decreased REM sleep

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: A.) hemoglobin level. B.) age. C.) blood pH. D.) sodium and potassium levels.

Answer: A.) hemoglobin level.

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which injection can be administered at this angle? A.) intradermal B.) subcutaneous C.) intramuscular D.) intravenous

Answer: A.) intradermal

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use? A.) nonrebreather mask B.) Venturi mask C.) nasal cannula D.) simple mask

Answer: A.) nonrebreather mask

A nurse working in a health clinic assesses sleep patterns during each health assessment. Based upon the nurse's knowledge regarding sleep needs, the nurse recognizes which age group as generally needing the least amount of sleep? A.) older adults B.) infants C.) adolescents D.) young adults

Answer: A.) older adults

The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is: A.) reviewing the client's sleep diary for the past 2 weeks. B.) identifying specific foods that negatively impact sleep. C.) having the client recall the number of sleep hours each night for the past week. D.) asking the client's bed partner to describe the sleep problem.

Answer: A.) reviewing the client's sleep diary for the past 2 weeks.

Which nutrient does the nurse identify as appropriate for a client with a normal dietary order who is consuming 2000 calories daily? A.) total fat less than 65 g B.) cholesterol greater than 300 mg C.) sodium less than 2000 mg D.) saturated fat greater than 20 mg

Answer: A.) total fat less than 65 g

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? A.) trauma to the tracheal mucosa B.) prevention of suctioning C.) loss of sterile field D.) suctioning of carbon dioxide

Answer: A.) trauma to the tracheal mucosa

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary? A.) "I will keep track of my sleep information for 2 months." B.) "I will record the time I go to bed and how long it takes me to fall asleep." C.) "I will write down all my morning activities." D.) "I will only keep track of my sleep habits at home, not when I am traveling out of town."

Answer: B.) "I will record the time I go to bed and how long it takes me to fall asleep."

A hospitalized client informs the evening shift nurse about not being able to sleep without a shot of whiskey each night before bed and asks if the spouse can bring in a bottle. Which is the best response by the nurse? A.) "It will be difficult for you to continue that routine in the hospital." B.) "Let's discuss that with your health care provider." C.) "Go ahead and ask your spouse to bring a bottle." D.) "Do you really think that is a good habit?"

Answer: B.) "Let's discuss that with your health care provider."

The parents of a newborn ask when they can expect the baby to sleep through the night. The nurse responds that the baby will most likely sleep through the night by: A.) 6 weeks of age B.) 3 months of age C.) 6 months of age D.) 1 year of age

Answer: B.) 3 months of age

A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set? A.) 60 to 80 mm Hg B.) 80 to 125 mm Hg C.) 100 to 130 mm Hg D.) 100 to 150 mm Hg

Answer: B.) 80 to 125 mm Hg Rationale: For a wall unit for an adult: 100 to 150 mm Hg; neonates: 60 to 80 mm Hg; infants: 80 to 125 mm Hg; children: 80 to 125 mm Hg; adolescents: 80 to 150 mm Hg.

Which client is most likely susceptible to the effects of disturbed sensory perception? A.) An older adult client whose lung disease is being treated in the acute care for elders (ACE) unit of the hospital B.) A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock C.) A client who has just been admitted to the emergency department with reports of chest pain D.) A client who is having cataract surgery in an outpatient eye clinic

Answer: B.) A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock Rationale: Clients in critical care settings are particularly susceptible to severe sensory alterations. A client who has been in a setting for a short time, such as an emergency or day surgery setting, is less likely to experience disturbed sensory perception. Older adults are often vulnerable to sensory disturbances, but the risks posed by an ICU setting likely supersede a geriatric medical unit.

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? A.) Assist with intubation B.) Apply oxygen C.) Educate client on incentive spirometry D.) Raise the head of the bed

Answer: B.) Apply oxygen

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants? A.) Atelectasis B.) Bronchitis C.) Bronchiectasis D.) Croup

Answer: B.) Bronchitis

The nurse reviews the following prescription in the client's medical record: Morphine sulfate (MS) 3 mg every four hours as needed for postoperative pain. Which action by the nurse is correct? A.) Administer MS as prescribed for postoperative pain B.) Clarify the prescription with the health care prescriber C.) Re-enter the prescription using a "trailing 0" D.) Draw the dose up using a 3-mL syringe

Answer: B.) Clarify the prescription with the health care prescriber Rationale: The nurse clarifies the prescription with the health care provider as the prescription, as written, is incomplete. There is no route of administration indicated and morphine may be given orally, intramuscularly, or intravenously. Administering the morphine as prescribed would be a medication error, as the route of administration is not identified in the prescription. Using a "trailing 0" is incorrect, as the dosage could be misinterpreted as 30 mg. Leading 0's are used for doses less than 1 mL. Drawing up the dose in a 3-mL syringe is inappropriate, as the route of administration is missing from the prescription.

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is: A.) Hypoxia related to pneumonia and ineffective airway clearance related to dyspnea edema. B.) Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter. C.) Risk for Ineffective Airway Clearance related to infection as evidenced by dyspnea and yellow-green sputum. D.) Impaired Gas Exchange related to increased carbon dioxide and irritability.

Answer: B.) Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.

The nurse is teaching a new mother who had decided to breastfeed her infant. What nutrient must be supplemented by the mother after the first four months of breast feeding? A.) Vitamin C B.) Iron C.) Calcium D.) Protein

Answer: B.) Iron Rationale: Full-term healthy babies receive enough iron from their mothers in the third trimester of pregnancy to last for the first four months of life. The nurse should teach the mother that human milk contains little iron, so infants who are exclusively breastfed are at increased risk of iron deficiency after four months of age. Bottle-fed babies will receive all of the necessary nutrients from the formula or cereal. Vitamin C, calcium and protein do not need to be supplemented as the breast milk has a sufficient amount.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant? A.) Simple mask B.) Oxygen hood C.) Nasal cannula D.) Venturi mask

Answer: B.) Oxygen hood Rationale: An oxygen hood is a delivery device for infants that can deliver oxygen concentrations up to 80% to 90%. None of the other devices listed can deliver oxygen at the concentration needed.

A nurse is administering medication to a client via a gastric tube and finds that the medicine enters the tube and then the tube becomes clogged. What is the appropriate intervention in this situation? A.) Remove the tube and replace it with a new tube. B.) Use a syringe to plunge the tube to try to dislodge the medication. C.) Call the physician before instituting any corrective interventions. D.) Wait the prescribed amount of time and attempt to administer the medication again before calling the physician.

Answer: B.) Use a syringe to plunge the tube to try to dislodge the medication.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? A.) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. B.) Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. C.) Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. D.) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

Answer: B.) Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Rationale: Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

A client has a history of long-term alcohol use. Which nutrient would need to be required in increased amounts? A.) Calcium B.) Vitamin B C.) Vitamin C D.) Thiamin

Answer: B.) Vitamin B

An older adult client tells his home care nurse that he doesn't seem to sleep as well as he used to. The nurse is aware that the sleep changes that occur in the older adult client which cause a less restful sleep include: A.) a decrease in stage I of the sleep cycle. B.) a decrease in the deep sleep stage of the sleep cycle. C.) a change in the normal progression of the sleep cycle. D.) an increase in stage II of the sleep cycle.

Answer: B.) a decrease in the deep sleep stage of the sleep cycle.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? A.) fluid-filled portions of the lung B.) pattern of thoracic expansion C.) consolidated portions of the lung D.) presence of pleural rub

Answer: B.) pattern of thoracic expansion

A client who hallucinates simply to maintain an optimal level of arousal is experiencing: A.) sensory overload. B.) sensory deprivation. C.) cultural care deprivation. D.) sleep deprivation.

Answer: B.) sensory deprivation.

A client begins snoring and is sleeping lightly. The stage of sleep is: A.) stage 1. B.) stage 2. C.) stage 3. D.) stage 4.

Answer: B.) stage 2.

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep is unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to: A.) ingest a small amount of alcohol prior to bedtime. B.) use caution when driving an automobile. C.) drink at least 1 cup of coffee with the evening meal. D.) change bedtime to later in the evening.

Answer: B.) use caution when driving an automobile.

The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate? A.) "The amount of stimuli different people consider optimal is consistent from person to person." B.) "Adulthood tends to increase sensory functioning." C.) "Religious norms within a culture influence the amount of sensory stimulation a person seeks." D.) "Narcotics and sedatives increase awareness of sensory stimuli."

Answer: C.) "Religious norms within a culture influence the amount of sensory stimulation a person seeks."

What is the body mass index (BMI) of a client who is 1.68 meters tall and weighs 70 kg? A.) 20.2 B.) 22.4 C.) 24.8 D.) 26.2

Answer: C.) 24.8 Rationale: A BMI of 24.8 is correct. The BMI is the ratio of height to weight that more accurately reflects total body fat stores in the general population. To calculate the BMI: divide the weight in kilograms (kg) by the height in meters (m) then divide the answer by the height again to get the BMI.

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? A.) 5,000 mL (5,000 × 109/L) B.) 5,550 mL (5,500 × 109/L) C.) 5,850 mL (5,850 × 109/L) D.) 6,000 mL (6,000 × 109/L)

Answer: C.) 5,850 mL (5,850 × 109/L)

A nurse has administered an injection to a client. Which intervention should the nurse perform to reduce discomfort and provide quick relief? A.) Massage the site following injection. B.) Numb the skin with an ice pack after the injection. C.) Apply pressure to the site during needle withdrawal. D/) Apply a eutectic mixture of local anesthetic to the site.

Answer: C.) Apply pressure to the site during needle withdrawal.

Which is not a lifespan consideration for sleep cycles? A.) Newborns can sleep up to 16 to 18 hours per day. B.) Getting the toddler and preschooler to fall asleep is a common problem. C.) By middle age, the frequency of nocturnal awakenings decreases, and satisfaction with sleep quality increases. D.) In adolescents, there is a shift to late evening bedtime and late morning rise time.

Answer: C.) By middle age, the frequency of nocturnal awakenings decreases, and satisfaction with sleep quality increases.

The nurse observes an order for a client to receive furosemide, 20 mg once daily, and records the specific date and time of the order. What is the appropriate nursing action? A.) Administer the drug. B.) Cosign the order. C.) Call the health care provider for order clarification. D.) Show the order to the nurse manager.

Answer: C.) Call the health care provider for order clarification.

A nurse receives orders from the physician to mix a client's insulin in a syringe with two other medications. What is the recommended guideline in this situation? A.) It cannot be done because it is not possible to mix more than two medications in one syringe. B.) Call the physician to determine the necessity of mixing the three drugs or to see if they are compatible. C.) Call the pharmacist to determine compatibility of the drugs. D.) Check with the nursing team before mixing and administering the drugs.

Answer: C.) Call the pharmacist to determine compatibility of the drugs.

The nurse is assessing an older adult client that reports feeling fatigued and tired throughout the day. What intervention by the nurse will assist with the client's report of fatigue? A.) Encourage the client to increase the amount of fluids during the evening hours B.) Inform the client that taking frequent naps during the day will help C.) Have the client further evaluated for depression D.) Encourage the client to drink or eat more foods with caffeine during the day

Answer: C.) Have the client further evaluated for depression

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? A.) Place the client in the dorsal recumbent position to collect the specimen. B.) Have the client clear the nose and throat and gargle with salt water before beginning the procedure. C.) Instruct the client to inhale deeply and then cough. D.) Discard the first sputum produced by the client.

Answer: C.) Instruct the client to inhale deeply and then cough.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? A.) It prescribes oxygen concentration. B.) It regulates the amount of oxygen received. C.) It determines whether the client is getting enough oxygen. D.) It decreases dry mucous membranes via delivering small water droplets.

Answer: C.) It determines whether the client is getting enough oxygen.

The nurse is caring for a client on the acute care unit who experiences automatic behaviors associated with narcolepsy. What is the priority nursing intervention? A.) Contact the health care provider to consider prescribing a stimulant drug. B.) Educate the client about other symptoms that may be experienced, such as sleep paralysis. C.) Keep the client safe by monitoring ambulation on the unit. D.) Ask the client about willingness to explore taking an antidepressant to reduce symptoms associated with atypical REM sleep.

Answer: C.) Keep the client safe by monitoring ambulation on the unit.

A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system? A.) General adaptation syndrome B.) Local adaptation syndrome C.) Reticular activating system D.) Peripheral nervous system

Answer: C.) Reticular activating system

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness? A.) Coma B.) Stupor C.) Somnolence D.) Asleep

Answer: C.) Somnolence

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? A.) Stridor B.) Crackles C.) Wheezing D.) Absent breath sounds in lower lobes

Answer: C.) Wheezing

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? A.) eupnea B.) hypercapnia C.) cyanosis D.) hypoxemia

Answer: C.) cyanosis

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? A.) left side with a pillow under the chest wall B.) side-lying position, half on the abdomen and half on the side C.) high-Fowler's position D.) Trendelenburg position

Answer: C.) high-Fowler's position Rationale: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

Which is a sign of dyspnea specific to infants? A.) panting respirations B.) a forward-leaning position C.) nasal flaring D.) increased respiratory rate

Answer: C.) nasal flaring Rationale: In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

What structural changes to the respiratory system should a nurse observe when caring for older adults? A.) diminished coughing and gag reflexes B.) increased use of accessory muscles for breathing C.) respiratory muscles become weaker D.) increased mouth breathing and snoring

Answer: C.) respiratory muscles become weaker

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? A.) "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." B.) "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." C.) "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." D.) "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

Answer: D.) "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

A nurse is administering an injection of insulin to a 5-year-old who has type I diabetes. Which statement by the nurse would take into consideration this child's developmental level? A.) "Don't worry, this won't hurt a bit." B.) "If you are brave and don't cry, I will give you a sticker." C.) "Try not to move, or this will hurt more." D.) "You will just feel a little pinch."

Answer: D.) "You will just feel a little pinch."

It is particularly important for the nurse to use this technique when administering intramuscular (IM) medication to which client? A.) A 30-year-old client diagnosed with Tourette syndrome prescribed haloperidol B.) A 40-year-old client diagnosed with breast cancer prescribed fulvestrant C.) A 50-year-old client demonstrating delirium tremors prescribed lorazepam D.) A 70-year-old demonstrating muscle wasting prescribed chlorpromazine

Answer: D.) A 70-year-old demonstrating muscle wasting prescribed chlorpromazine Rationale: The Z-track method is suggested for older adults who have decreased muscle mass. While some agents, such as iron, are best given via the Z-track method due to the irritation and discoloration associated with this agent, none of the other clients demonstrate specific characteristics that suggest the need for Z-tracking.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? A.) Hematocrit values B.) Hemoglobin levels C.) Pulmonary function D.) Arterial blood gas

Answer: D.) Arterial blood gas

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? A.) Assess lung sounds B.) Reposition client C.) Elevate head of the bed D.) Assess oxygen tubing connection

Answer: D.) Assess oxygen tubing connection

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? A.) Edema B.) Hemoptysis C.) Constipation D.) Clubbing

Answer: D.) Clubbing

A neonatal intensive care nurse is caring for an infant born prematurely. How will the nurse manage the infant's environment to best support his sensory needs? A.) Provide an active, stimulating environment. B.) Encourage frequent visitors and tactile stimulation at least hourly. C.) Provide changing patterns of light and shade, and the use of bright objects. D.) Limit lighting, visual, and vestibular stimulation.

Answer: D.) Limit lighting, visual, and vestibular stimulation. Rationale: To facilitate developmentally supportive care, it is recommended that medically fragile infants such as a premature infant should have limited light, visual, and vestibular stimulation to simulate being in the womb. The premature infant is not a full term infant and has developmental issues that are critical to their growth and development. Stimulation such as touch and frequent visitors is not recommended. The use of bright lights are contraindicated as the hospital environment should mimic the intrauterine environment which is quiet and dark.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? A.) Chest x-ray B.) Bronchoscopy C.) Skin tests D.) Pulmonary function tests

Answer: D.) Pulmonary function tests

The nurse is attempting to wake a client from sleep and is having a difficult time arousing them. What stage of sleep does the nurse identify the client is experiencing? A.) stage 1 NREM sleep B.) stage 4 NREM sleep C.) REM rebound period D.) REM sleep

Answer: D.) REM sleep Rationale: The NREM arousal threshold is usually greatest in stage 4 NREM, but it is harder to arouse a person who is in REM sleep than NREM sleep. REM rebound is the term for accumulating REM sleep in balance over time.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? A.) Tidal volume (TV) B.) Total lung capacity (TLC) C.) Forced Expiratory Volume (FEV) D.) Residual Volume (RV)

Answer: D.) Residual Volume (RV) Rationale: During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

When caring for a client with a tracheostomy, the nurse would perform which recommended action? A.) Clean the wound around the tube and inner cannula at least every 24 hours. B.) Assess a newly inserted tracheostomy every 3 to 4 hours. C.) Use gauze dressings over the tracheostomy that are filled with cotton. D.) Suction the tracheostomy tube using sterile technique.

Answer: D.) Suction the tracheostomy tube using sterile technique.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? A.) The contour of the intercostal spaces should be rounded. B.) The skin at the thorax should be cool and moist. C.) The anteroposterior diameter should be greater than the transverse diameter. D.) The chest should be slightly convex with no sternal depression.

Answer: D.) The chest should be slightly convex with no sternal depression.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? A.) Crackles B.) Bronchovesicular C.) Bronchial D.) Vesicular

Answer: D.) Vesicular

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? A.) oxygen analyzer B.) nasal strip C.) nasal cannula D.) flow meter

Answer: D.) flow meter

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: A.) croup. B.) asthma. C.) alcohol use. D.) pneumonia.

Answer: D.) pneumonia.

A client states to the nurse during a sleep assessment that it takes her more than 60 minutes to fall asleep. The nurse documents this time period as the client's: A.) sleep lag. B.) presleep. C.) sleep deficit. D.) sleep latency.

Answer: D.) sleep latency.

The nurse is caring for a client with narcolepsy. The client reports experiencing being unable to move upon awakening from sleep. The client's spouse states that the client makes sandwiches in the middle of the night, yet the client does not recall this behavior. How does the nurse document these concerns? A.) sleep paralysis and hypnogogic hallucinations B.) cataplexy and hypnogogic hallucinations C.) hypnogogic hallucinations and sleep paralysis D.) sleep paralysis and automatic behavior

Answer: D.) sleep paralysis and automatic behavior

The nurse is completing a sleep history on a client who reports sleeping problems. Which of the client's regular behaviors will cause the client to have difficulty with sleep? A.) exercising immediately after getting off work at 5 p.m. B.) drinking 2 cups of coffee every morning C.) using a white noise machine to mask outside noise D.) taking a diuretic at 9 a.m. and 5 p.m. daily

Answer: D.) taking a diuretic at 9 a.m. and 5 p.m. daily

A sensory deficit that may arise from the client's eyes being bandaged after eye surgery can result in: A.) depression. B.) psychic blindness. C.) compensation. D.) total disorientation.

Answer: D.) total disorientation.

The nurse is caring for a client who has been experiencing prolonged wound healing from a surgical procedure. A deficiency in which nutrient would be associated with this condition? A.) vitamin B1 B.) calcium C.) folic acid D.) vitamin C

Answer: D.) vitamin C