Q REVIEW ONE

The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? A. Document the medication with times and doses to be given, then administer the medication as ordered. B. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. C. Stop the medication on the client's medication administration record. D. Check the client's allergy band against the list of client allergies documented in the medical record. E. Call the pharmacy to see if the medication needs to be changed.

2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record. Rationale: Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication prescription that conflicts with the client's list of medication allergies. The medication should be discontinued on the medication administration record, and the client's allergy band checked against the list of allergies documented in the medication record for accuracy. All of these actions place the nurse in the role of client advocate and ensure the client's safety.

Which nurse is providing cost effective care to a client? A. Providing palliative care to a terminally ill client. B. Beginning discharge planning on admit. C. Counseling clients on cigarette smoking cessation. D. Educating a group of parents on the importance of childhood immunizations. E. Performing a postop wound dressing change using clean gloves.

A, B, C, D Rationale: Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. Two additional preventive interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low dose aspirin.

The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? A. Color Changes B. Drainage C. Odor D. Fever E. Bleeding F. Increased Pain

A, B, C, D, F Rationale: Infections may cause color changes, drainage, odor, fever, & increased pain. Bleeding is a sign of hemorrhage, trauma, anemia or other blood disorders but not infection.

A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement? A. Monitor stools for occult blood. B. Place on fall prevention. C. Place client in protective isolation. D. Restrict venipunctures. E. Limit visitors.

A, B, D Rationale: A normal platelet count ranges from 150,000-400,000 mm3. This is a low platelet count, so interventions should focus on bleeding precautions. The white cell count (WBC) is normal (5,000-10,000 cells/mcL). Bleeding precautions would include monitoring for bleeding, such as monitoring stools for occult blood. The client is at risk for injury, so fall prevention is needed. Since the client will bleed more easily, restrict venipunctures.

The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? A. Check shoes for rough spots in the lining. B. File toenails straight across. C. Cover feet and between toes with creams to moisten the skin. D. Break in new shoes gradually. E. Use pumice stones to treat calluses.

A, B, D Rationale: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day.

A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? A. Firm, nodular liver B. Ascites C. Increased serum albumin levels D. Increased ALT and AST levels E. Lowered ammonia levels F. Bleeding from the GI tract

A, B, D, F Rationale: With cirrhosis, the liver can become very large in size and feels very firm and nodular upon palpation. Third spacing of fluids out of the vascular space (ascites) occurs due to lowered albumin levels. The client is often in a nutritional deficit which contributes to the lowered albumin level. Also, the liver is sick and unable to synthesize albumin. The liver enzymes ALT and AST will be elevated with liver problems such as cirrhosis. Increased pressure in the liver (portal hypertension) causes a backward pressure throughout the GI tract. Esophageal varices may form as a result of this pressure. If variceal rupture occurs, GI bleeding will be noted. In addition, liver diseases, such as cirrhosis, are the common causes of blood clotting problems because the liver is unable to produce the needed clotting factors.

The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful? A. "Exhale completely before using my inhaler." B. "Use my steriod inhaler before the bronchodilator." C. "Inhale slowly and push down firmly on the inhaler." D. "Rinse my mouth with water after using my inhaler." E. "Wait 5 minutes between puffs."

A, C, D Rationale: The client should exhale completely before using the inhaler; this response indicates the teaching was effective. The client should inhale slowly and push down firmly on the inhaler when administering the medication; therefore, the teaching was effective. The client should rinse the mouth after using the inhaler to prevent thrush.

Which task would be appropriate for the charge nurse to assign to a LPN/VN? A. Collect data on a new client admit. B. Administer morphine IVP to a two day post-op client. C. Bolus feeding a client who has a gastrostomy tube. D. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. E. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.

A, C, D, E Rationale: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN also. A LPN/VN can monitor the PCA pain medication but cannot initiate or administer the medication

A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? A. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. B. Appears to be having abdominal discomfort. C. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. D. Pre op Diazepam 10.0 mg given po. E. Transferred to surgical suite per stretcher with side rails up, in stable condition.

A, C, E Rationale: These are written correctly with complete, concise and objective information for each statement pertaining to the client.

A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the best response by the nurse? A. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " B. "You experience depression because of your elevated levels of thyroid hormones." C. "The primary healthcare provider will have to explain to you what is causing your depression." D. "Tell me what you think causes you to be depressed."

A. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " Rationale: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression. By giving this type of information to the client, it helps with their understanding of the depression and empowers them with knowledge.

The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? A. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." B. "I have been gaining a lot of weight lately." C. "My stools are darker. Sometimes they are even black." D. "When I start hurting, it helps if I drink milk or have a small snack."

A. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." Rationale: The gallbladder assists in digestion of fat. When foods high in fat are ingested, bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or are blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat.

The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected? A. Abrupt onset of dyspnea, fever. B. Small papule on skin resembling an insect bite. C. Pustular vesicles on skin. D. Fatigue.

A. Abrupt onset of dyspnea, fever. Rationale: Correct: Inhalation of anthrax spores is very serious, and clients will experience abrupt dyspnea and fever. Treatment must begin immediately.

A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? Hgb - 15 g/dl (2.3 mmol/l) Hct - 42% Platelets - 110,000/ mm3 aPTT - 110 seconds INR - 1.2 A. Administer protamine sulfate 50 mg over 10 minutes. B. Type and cross match for 2 units PRBCs C. Increase enoxaparin dose to increase INR D. Give the scheduled dose of enoxaparin

A. Administer protamine sulfate 50 mg over 10 minutes. Rationale: Protamine sulfate is given for heparin overdose. It is a heparin antagonist. Overdose is seen with a aPTT of 110 seconds. Depending on therapeutic intent, a client's aPTT levels should be between 60-80 seconds. (Normal aPTT for a client not on an anticoagulant is 25-35 seconds).

A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? A. Administer the digoxin. B. Hold the digoxin. C. Notify the primary healthcare provider. D. Repeat the digoxin level.

A. Administer the digoxin. Rationale: This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL.

The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? A. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. B. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. C. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? D. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.

A. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. Rationale: The case manager should be involved in coordinating the client's care from the date of admission in order to help the client navigate unexpected situations like a last-minute hospital admission. The ability to make telephone calls to notify family and friends will help to decrease the client's sudden sense of isolation from normal daily life, loss of control, and anxiety.

Which intervention should the nurse initiate for a client post liver biopsy? A. Apply direct pressure to site immediately after needle is removed. B. Assess puncture site every 15 minutes for 1 hour. C. Position client on left side. D. Keep client NPO for 24 hours. E. Advise client that pain may occur in right shoulder as the anesthetic wears off.

A. Apply direct pressure to site immediately after needle is removed. B. Assess puncture site every 15 minutes for 1 hour. E. Advise client that pain may occur in right shoulder as the anesthetic wears off. Rationale: Anyone who has a liver problem is at risk for bleeding. The clotting factor produced in the liver is prothrombin. Anytime a needle is inserted into the body and removed, bleeding can occur. Whenever there is risk for bleeding, the preventive measure is to apply pressure. The puncture site should be monitored frequently. The client may experience some discomfort once the anesthetic wears off.

Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? A. Bathe the client who is on telemetry. B. Apply cardiac leads and connect a client to a cardiac monitor. C. Help position a client for a portable chest x-ray. D. Feed a client who is dysphagic. E. Collect a stool specimen.

A. Bathe the client who is on telemetry. B. Apply cardiac leads and connect a client to a cardiac monitor. C. Help position a client for a portable chest x-ray. E. Collect a stool specimen. Rationale: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen.

A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? A. Blood cultures times two B. Ceftriaxone 250 mg IV every 12 hours C. Start IV & monitor site. D. 1/2 normal saline at 40 mL/hr

A. Blood cultures times two Rationale: Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high. The nurse would also need to get diagnostics before treatment is initiated so that correct interventions are prescribed.

Which client should the charge nurse assign to a new RN? A. Child needing pre-operative medication prior to reduction of a fracture. B. Adult client reporting abdominal pain after being beaten up in a fight. C. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. D. Child admitted with cystic fibrosis 2 hours ago.

A. Child needing pre-operative medication prior to reduction of a fracture. Rationale: This is the least complicated client that could be given to a new, inexperienced nurse. Even though he client has a fracture, the focus is on giving pain medication prior to a major procedure.

The nurse is planning to teach a group of assisted living residents about tuberculosis (TB) infection. What should the nurse include? A. Cover mouth when coughing. B. Proper handwashing. C. Obtain a TB skin test. D. Obtain a yearly chest x-ray. E. Proper disposal of tissues.

A. Cover mouth when coughing. B. Proper handwashing. C. Obtain a TB skin test. E. Proper disposal of tissues. Rationale: In an effort to prevent transmission of TB to others, the nurse should carefully instruct about the importance of hygiene measures, including mouth care, covering the mouth when coughing and sneezing, proper disposal of tissues, and hand hygiene. A TB skin test is especially important when living in tight quarters such as an assisted living center.

A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? A. Depersonalization B. Echopraxia C. Neologism D. Concrete thinking

A. Depersonalization Rationale: Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance)

What should the nurse include when educating a client about the use of nitroglycerin sublingual. A. Do not swallow nitroglycerin. B. Keep the medication is a moist, warm place. C. The medication may burn when taken. D. Sit or lie down when taking this medication. E. The most common side effect is vomiting.

A. Do not swallow nitroglycerin. C. The medication may burn when taken. D. Sit or lie down when taking this medication. Rationale: Nitroglycerin is to be taken sublingually. Do not swallow because this will decrease the effectiveness of the medication. The medication may or may not burn or fizz when placed under the tongue. Because hypotension occurs due to vasodilation, the client should sit or lie down when taking to prevent injuries from falls.

Three hours after delivery of a client's newborn, the nurse assesses for bladder distention. What signs would the nurse note if the client's bladder is distended? A. Fundus 3 cm above umbilicus B. Excessive lochia C. Voids 200 mL every 2 hours D. Fundus in abdominal midline E. Tenderness above symphysis pubis

A. Fundus 3 cm above umbilicus B. Excessive lochia E. Tenderness above symphysis pubis Rationale: Monitor client for signs of distended bladder, such as fundal height above the umbilicus or baseline level, and/or fundus displaced from midline over to the side. Bladder bulges above the symphysis pubis, excessive lochia, tenderness over the bladder area, frequent voiding of less than 150 mL (indicative of urinary retention with overflow) are also sign of distended bladder.

The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement? A. I will wear long sleeves and a hat when I go for my afternoon walks. B. I will limit my alcohol intake to one glass of red wine with supper. C. I need to limit my fluid intake in order to avoid fluid retention. D. I need to maintain a high calorie diet and eat 6-8 small meals a day.

A. I will wear long sleeves and a hat when I go for my afternoon walks. Rationale: When taking tricyclic antidepressants such as amitriptyline, the skin may be sensitive to sunburn. Use sunscreens, wear protective clothing and sunglasses.

The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body? A. Lowers the blood glucose B. Provides more energy C. Increases insulin need D. Reverses complications of diabetes E. Increases the workload of the liver

A. Lowers the blood glucose B. Provides more energy Rationale: In the presence of adequate insulin, exercise lowers the blood glucose. Exercise releases endorphins, providing the client with increased energy and feelings of well-being.

A client has just delivered a newborn. Based on the primary healthcare provider's notation, what prescriptions does the nurse anticipate administering to the mother? A. Measles, mumps and rubella (MMR) vaccine B. Hepatitis A vaccine C. Hepatitis B immune globulin D. RH0(D) immune globulin E. Tetanus toxoid

A. Measles, mumps and rubella (MMR) vaccine D. RH0(D) immune globulin Rationale: A client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine, or measles, mumps and rubella vaccine (MMR) during the postpartum period to protect a subsequent fetus from malformations. Clients should not get pregnant for 4 weeks following the vaccination. All Rh negative moms who have Rh positive newborns must be given RH0(D) immune globulin IM within 72 hours of newborn being born to suppress antibody formation in the mother.

Which action, if done by a nurse, needs to be interrupted by the charge nurse? A. Mixes diazepam and hydromorphone in one syringe. B. Administers diazepam before meals. C. Raises side rails after administering hydromorphone. D. Instructs client to call for assistance getting out of bed after administration of diazepam.

A. Mixes diazepam and hydromorphone in one syringe Rationale: In this question, you are looking for the answer that is unsafe and should not be done. Diazepam cannot be mixed with any other medication. The charge nurse should intervene.

The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase? A. On-going support from weight-loss program personnel. B. Periodic weigh-ins with the nurse. C. Discontinue programmatic exercise plan. D. Relapse prevention plan. E. Continued peer support.

A. On-going support from weight-loss program personnel. B. Periodic weigh-ins with the nurse. D. Relapse prevention plan. E. Continued peer support. Rationale: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase.

Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider? A. Parent states infant tastes salty. B. Frequent coughing with thick, blood-streaked sputum. C. Foul-smelling, greasy stools. D. Able to hold head upright without head wobbling. E. No weight gain since last check-up.

A. Parent states infant tastes salty. B. Frequent coughing with thick, blood-streaked sputum. C. Foul-smelling, greasy stools. E. No weight gain since last check-up. Rationale: These are signs/symptoms of cystic fibrosis (CF) and should be reported to the primary health care provider. One of the first signs of CF that parents may notice is that their baby's skin tastes salty when kissed. People who have CF have thick, sticky mucus that builds up in their airways. This buildup of mucus makes it easier for bacteria to grow and cause infections. Infections can block the airways and cause frequent coughing that brings up thick mucus or mucus that's sometimes bloody. Mucus can block tubes, or ducts, in the pancreas, preventing enzymes from reaching the intestines. As a result, the intestines can't fully absorb fats and proteins. This can cause ongoing diarrhea or bulky, foul-smelling, greasy stools. A hallmark of CF in children is poor weight gain and growth. These children are unable to get enough nutrients from their food because of the lack of enzymes to help absorb fats and proteins.

Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? A. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." B. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. C. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. D. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.

A. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." Rationale: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery.

The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? A. Progesterone B. Estrogen C. Follicle-stimulating hormone (FSH) D. Human chorionic gonadotropin (hCG)

A. Progesterone Rationale: Progesterone causes amenorrhea.

In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? A. Promote maximal stability by utilizing a wide base of support. B. Maintain a low center of gravity. C. Use both the arms and the legs when performing strenuous activity. D. Save effort by lifting rather than rolling, turning, or pivoting. E. Utilize muscles of the back rather than muscles of the shoulders. F. Obtain assistance from other nurses or nurse assistants as needed.

A. Promote maximal stability by utilizing a wide base of support. B. Maintain a low center of gravity. C. Use both the arms and the legs when performing strenuous activity. F. Obtain assistance from other nurses or nurse assistants as needed. Rationale: When in a standing position, the center of gravity is at the center of the pelvis. The wider the base of support and the lower the center of gravity the nurse maintains, the greater the stability for the movement. Using both the arms and the legs provides a sense of balance for the activity. It is always smart to seek more assistance when needed to avoid injury to self.

A client is admitted with a diagnosis of myasthenia gravis. What interventions should the nurse include to manage this client's swallowing and chewing impairment? A. Provide foods that are soft and tender. B. Allow client to rest between bites. C. Encourage client to drink thickened liquids. D. Position upright with head tilted slightly backwards. E. Dissolve the cholinesterase inhibitor medication in water.

A. Provide foods that are soft and tender. B. Allow client to rest between bites. C. Encourage client to drink thickened liquids. Rationale: Myasthenia gravis is a disorder wherein the postsynaptic neuromuscular junction receptor sites are decreased. This decrease in receptor sites causes decreased muscular depolarization. The clinical manifestations of this disease are progressive muscle weakness and fatigue. Eventually clients may experience difficulty breathing due to weakness and fatigue of the respiratory muscles. Muscle fatigue impairs chewing and swallowing. These actions (options 1, 2, and 3) decrease the risk of aspiration, decrease the work of muscles, and allow for improved swallowing.

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? A. Provides "just in time" posters outlining the importance of pain assessment. B. Conducts brief in-services for each shift. C. Counsels nurses when pain level scale is not utilized. D. Ensures that a complete and clear performance standard exists. E. Assesses nurses' reasons for not using pain level scale. F. Disciplines offenses through unpaid time off.

A. Provides "just in time" posters outlining the importance of pain assessment. B. Conducts brief in-services for each shift. C. Counsels nurses when pain level scale is not utilized. D. Ensures that a complete and clear performance standard exists. E. Assesses nurses' reasons for not using pain level scale. Rationale: If nurses have been provided the knowledge and performed the skill before, but have not practiced the skill on a regular basis, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Counseling the nurses when pain level scale is not utilized may improve understanding and performance. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance.

Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? A. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. B. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). C. Two year old taking only clear liquids since admission 24 hours ago. D. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula.

A. Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. Rationale: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate.

What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? A. Suggest client eat several small meals a day, with the largest at breakfast. B. Recommend eating meals in a semi-recumbent position. C. Administer metoclopramide 1 hour after meals. D. Avoid fruit juices and carbonated beverages.

A. Suggest client eat several small meals a day, with the largest at breakfast Rationale: Large meals are difficult to manage when the client is anorexic and has loss of appetite, as is usually the case with Hepatitis B. Anorexia may also worsen during the day, making intake of food difficult later in the day.

The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? A. Turn every two hours B. Place a pillow between legs when turning C. Sit in a chair three times per day D. Encourage fluid intake E. Encourage ankle and foot exercises

A. Turn every two hours B. Place a pillow between legs when turning D. Encourage fluid intake E. Encourage ankle and foot exercises Rationale: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT).

A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? A. Use simple words. B. Speak loudly to the client. C. Do not speak to the client at this time. D. Use open-ended questions to ask what is wrong.

A. Use simple words. Rationale: Use simple words, because the client cannot comprehend anything but the most elemental communications during a panic attack.

What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? A. White blood cell count of 3,800 (3.8 x 109/L) B. White blood cell count of 15,000 (15.0 x 109/L) C. Platelet count of 90,000/µL (90 x 109/L) D. Platelet count of 450,000/µL (450 x 109/L) E. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) F. Red blood cell count of 7.3 million/mcL (7.3 x 1012/L)

A. White blood cell count of 3,800 (3.8 x 109/L) C. Platelet count of 90,000/µL (90 x 109/L) E. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) Rationale: Pancytopenia is a condition in which there is a concurrent leukopenia (a reduction in white blood cells), thrombocytopenia (a reduction in platelets), and anemia (reduction in red blood cells). The normal white blood cell count is 5,000-10,000 (5.0 to 10.0 x 109/L), so a level of 3,800 (3.8 x 109/L) represents leukopenia. The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L), so a level of 90,000/µL represents thrombocytopenia. The normal red blood cell count for a Female is 4.2 - 5.4 million/mcL ( 4.2 - 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 - 6.1 million/mcL (4.7 - 6.1 X 1012/L). Therefore, a red blood cell count of 3.0 million/mcL (3.0 x 1012/L) is indicative of anemia, regardless of the sex of the client.

A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence? A. Ecchymosis of incision B. Tenderness over the kidney C. Frequent polyuria D. Subnormal temperature

B. Tenderness over the kidney Rationale: Tenderness over the kidney indicates a problem with the kidney, and the primary healthcare provider should be notified immediately. Other s/s of an acute rejection are fever, increased BUN/CR, weight gain, decreased urine output, and increased BP.

As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number.

Answer: 30 Calculate BMI by dividing weight in pounds by height in inches squared and multiplying by a conversion factor of 703.

The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number.

Answer: 90 5mg x 18 kg = 90 mg/day

What symptoms does the nurse expect to see in a client with bulimia nervosa? A. Amenorrhea B. Feelings of self-worth unduly influenced by weight C. Recurrent episodes of binge eating D. Recurrent inappropriate compensatory behavior to prevent weight gain E. Lack of Exercise

B, C, D Rationale: Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating: recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight. Amenorrhea is found in anorexia nervosa

Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? A. "I will read labels to be sure there is no hidden alcohol in food." B. "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." C. "I can call the clinic or my sponsor whenever I feel tempted to drink alcohol." D. "Even one glass of alcohol can cause me to start drinking regularly again."

B. "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." Rationale: This statement indicates the need for further instruction for this client. When discharged home following rehabilitation for alcohol, clients are told to attend at least one AA meeting every single day, whether feeling the need to drink or not. Constant reinforcement is found to increase the rate of success following inpatient rehabilitation.

A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful? A."I will try to keep my legs together as close as possible." B. "I will not elevate the head of the bed." C."I know that I cannot ever swim again." D. "I can resume my exercises at the gym within one month."

B. "I will not elevate the head of the bed." Rationale: Flexion of the hip should be avoided after hip surgery. Elevating the HOB would cause flexion, which could cause hip dislocation.

A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment? A. -1 mm Hg B. 4 mm Hg C. 10 mm Hg D. 15 mm Hg

B. 4 mm Hg Rationale: This CVP reading is indicative of a normal fluid volume state. This would be the desired response of treatment for dehydration.

A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? A. Maintain continuous cardiac monitoring. B. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn. C. Provide alprazolam 0.25 mg PO PRN. D. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr.

B. Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn. Rationale: The respiratory status of the client takes priority. The administration of naloxone will block the opioid, initiating a reversal of the central nervous system (CNS) and respiratory depression.

Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? A. Ascites B. Bibasilar crackles C. Orthopnea D. Hepatomegaly E. Anorexia

B. Bibasilar crackles C. Orthopnea Rationale: Bibasilar crackles that do not clear with coughing occur with left sided heart failure. Fluid backs up into the lungs. Orthopnea occurs in left sided heart failure when the client lies flat, because fluid backs up into the lungs.

A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? A. Surgical cannulation of the bile duct is causing spasm and pain. B. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. C. Large abdominal retractors used in the procedure compressed a nerve. D. Side lying position in the operating room generated pressure damage.

B. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. Rationale: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If the CO2 irritates the phrenic nerve, it radiates to the shoulder.

Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? A. Client admitted with possible tuberculosis (TB) awaiting skin test results. B. Client diagnosed with seizure disorder. C. Client with a new pacemaker scheduled to be discharged in the morning. D. Client with a history of mild heart failure prescribed one unit of packed red blood cells for anemia.

B. Client diagnosed with seizure disorder. Rationale: OB nurses would have the appropriate knowledge needed to care for a client with a seizure disorders, because they care for clients who have eclampsia (seizures).

A client arrives at the emergency department with a pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, what intervention should the nurse initiate? A. Ausculate the lung sounds. B. Document the finding. C. Notify the primary healthcare provider. D. Place the client on oxygen.

B. Document the finding. Rationale: Tidaling (fluctuations in the water-seal chamber) with respiratory effort is normal.

A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation? A. Calcium supplement B. Ferrous sulfate C. Folic acid D. Cetirizine

B. Ferrous sulfate Rationale: Ferrous sulfate commonly causes constipation and GI upset. These side effects can be diminished with proper teaching regarding diet and taking medication with food.

The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? a. My weight may decrease while taking this drug. b. I may expect increased sweating while taking this drug. c. I may actually feel more depressed while taking this medication. d. I should feel better within a couple of days after beginning the medication.

B. I may experience increased sweating while taking this drug Rationale: This medication causes temperature dysregulation, with increased sweating in some patients

The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? A. In a puncture-resistant biohazard container B. In a chemotherapy sharps container C. In a biohazard waste container D. In a chemical container

B. In a chemotherapy sharps container Rationale: Empty vials and sharps such as needles and syringes used in delivering chemotherapy agents should be disposed of in a chemotherapy sharps container. These waste containers are designed to protect workers from injuries and are disposed of by incineration at regulated medical waste facilities.

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? A. Take a stool softener. B. Increase intake of fruit in the diet. C. Monitor elimination habits for the next week. D. Rest after each meal.

B. Increase intake of fruit in the diet. Rationale: Increased fiber intake may help to establish regular elimination habits.

A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? A. Directly observe the client at least every 4 hours. B. Maintain a low level of stimuli. C. Remove all dangerous objects from environment. D. Convey a calm attitude toward the client. E. Discourage client's expression of negative feelings.

B. Maintain a low level of stimuli. C. Remove all dangerous objects from environment. D. Convey a calm attitude toward the client. Rationale: Anxiety rises in stimulating environments. Individuals may be perceived as threatened by a fearful and agitated client. Removing dangerous objects will prevent the confused and agitated client from using them to harm self or others. Anxiety is contagious and can be transmitted from staff to client.

A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? A. Yes, I believe that God will heal you. B. Many people of faith believe that one way God works to heal is through medication. C. We are talking about taking your medications right now. D. What if God does not heal you and you should have taken the medication?

B. Many people of faith believe that one way God works to heal is through medication. Rationale: This allows the client to keep the belief that God will heal but will do it through the medication. This promotes compliance with the prescribed medication regimen.

A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? A. Send the client to the waiting room. B. Place the client in a negative pressure room. C. Put a surgical mask on the client. D. Initiate contact precautions.

B. Place the client in a negative pressure room. Rationale: The client may have smallpox, which is very contagious. Smallpox can also be used as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure.

The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth? A. Dilated pupils after 1 minute of CPR B. Presence of a carotid pulse with each compression C. Cardiac rhythm on the monitor D. Rise and fall of client's chest with ventilations

B. Presence of a carotid pulse with each compression Rationale: If chest compressions are being given with enough force and depth, a pulse will be felt with each compression.

The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? A. Shaving the hair with a razor. B. Removing the hair with clippers. C. Lathering the skin with soap and water prior to shaving with a razor. D. Using a depilatory cream. E. Always use a new, sharp razor.

B. Removing the hair with clippers. D. Using a depilatory cream. Rationale: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery.

A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis Rationale: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal.

The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? A. Cottage cheese B. Salami C. Baked chicken D. Potatoes

B. Salami Rationale: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis.

The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? A. Confusion and disorientation. B. Scared and lonely and grabs the nurse's hand for comfort. C. Would like to talk with the nurse. D. Would like to reminisce with the nurse.

B. Scared and lonely and grabs the nurse's hand for comfort. Rationale: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client.

A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? A. Accepts the treatment of the nurse and think that it is appropriate. B. Takes offense to the abrupt nature of the treatment. C. Thinks that the nurse is busy and needs to rush. E. Thinks that the nurse is very efficient.

B. Takes offense to the abrupt nature of the treatment. Rationale: The family is likely to be offended by the abrupt manner of the nurse. The Hispanic culture is present time oriented and desire attention and interaction. It would not be relevant that the nurse may be busy. To overlook this cultural variation is rude and does not treat the mother with dignity.

The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? A. It is not necessary to treat mild hypoglycemia indicated by irritability. B. Treat a mild episode with 10-15 grams of carbohydrate. C. The client should consume 12 ounces of regular cola. D. The client should consume 2 cups of orange juice without added sugar.

B. Treat a mild episode with 10-15 grams of carbohydrate. Rationale: 10-15 grams of carbohydrate should raise the blood sugar 40 - 50 mg/dL. Then the family can check the blood sugar and repeat the carbohydrate if necessary.

The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? A. Apply gauze padding beneath the tubing. B. Use petroleum jelly on the nares and cheeks. C. Provide mouth and nose care every 4 hours as needed. D. Place the oxygen tubing above the ears.

B. Use petroleum jelly on the nares and cheeks. Rationale: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy.

The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? A. Family members are responsible for preventing future suicidal attempts. B. When the client stops talking about suicide, the risk has increased. C. Warning signs, even if indirect, are generally present prior to a suicide attempt. D. One suicide attempt increases the chance of future suicide attempts. E. Report sudden behavioral changes.

B. When the client stops talking about suicide, the risk has increased. C. Warning signs, even if indirect, are generally present prior to a suicide attempt. D. One suicide attempt increases the chance of future suicide attempts. E. Report sudden behavioral changes. Rationale: A common myth is that the person who doesn't talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions, especially if that is the primary focus of their thoughts and feelings.

What should the nurse include when teaching a client in renal failure about peritoneal dialysis? A. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. B. Use cool effluent when instilling into the peritoneal cavity. C. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. D. The fluid that is returned should be clear in appearance. E. If all the fluid does not drain out, place the bed in the Trendelenburg position. F. A sweet taste may be experienced when peritoneal dialysis is used.

C, D, F Rationale: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste.

A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? A. "You are experiencing maternity blues, which will go away on its own." B. "You are just tired. Tell your husband that you need his help." C. "Come to the clinic now so that we can help you." D. "Have you thought about getting a family member to help with the baby?"

C. "Come to the clinic now so that we can help you." Rationale: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked.

An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? A. "I'm going to miss having my evening glass of wine now." B. "I told my daughter to buy spinach for me. I'll have to eat more servings now." C. "I will have to watch my intake of salads, something that I really love." D. "I am going to begin eating more fish and pork and leave beef alone now."

C. "I will have to watch my intake of salads, something that I really love." Rationale: Patients taking warfarin sodium must watch their intake of vitamin K, which is present in leafy green vegetables and tomatoes.

A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs further instruction? A. "I will not alter the height of my crutches." B. "My body weight should be supported at the hand grips with my elbows flexed at 30 degrees." C. "When I rise from a chair, I should position my crutches on my unaffected side." D. "I will not lean on my crutches while standing."

C. "When I rise from a chair, I should position my crutches on my unaffected side." Rationale:The client should position crutches on affected side when sitting or rising from a chair. This will give the client more stability with position changes.

A nurse assesses the 5 minute Apgar on a term, newborn infant. Based on the Apgar score, what should be the nurse's priority intervention? A. Continue Apgar scoring every five minutes until 20 minutes of life. B. Transfer newborn to the neonatal intensive care unit ASAP. C. Administer "blow-by" oxygen while suctioning. D. Perform cardiopulmonary resuscitation.

C. Administer "blow-by" oxygen while suctioning. Rationale: An Apgar score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance or in the form of suctioning if breathing has been obstructed by mucus. A source of oxygen called "blow-by" may be placed near but not directly over the nose and mouth of the newborn during suctioning.

A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider? A. Blood pressure 136/84 B. Report of nausea C. Anxiety D. Urinary output at 50 mL/hour

C. Anxiety Rationale: Anxiety, restlessness, or a sense of apprehension is often the first sign/symptoms of acute pulmonary edema.

A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? A. Medium rare steak, potato salad, peas and coffee B. Ham sandwich, chips, fruit salad and juice C. Broiled white fish, baked potato, mixed salad and tea D. Baked chicken, vegetable medley, rice and milk

C. Broiled white fish, baked potato, mixed salad and tea Rationale: Fish is allowed if it has fins and scales. Shellfish is not kosher. Pasta, potatoes, salads and tea are allowed.

Which client should the nurse, working the Emergency Department (ED), see first? A. Client diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who has a non-productive cough. B. Client who is a diabetic and has an infected sore on the foot. C. Client with adrenal insufficiency who feels weak. D. Client with a fracture of the forearm that has been placed in a splint.

C. Client with adrenal insufficiency who feels weak. Rationale:Adrenal insufficiency with weakness think SHOCK first. This is a client that does not have enough of all their steroids, including glucocorticoids, mineralocorticoids or sex hormones. The most pertinent of these is aldosterone, which causes loss of sodium and water, and leads to shock (fluid volume deficit). Since the client is feeling weak, this is a clear sign of fluid volume deficit (FVD) and potentially for shock.

When caring for young adult clients, which developmental tasks would the nurse expect to see? A. Satisfying and supporting the next generation. B. Reflecting on life accomplishments. C. Developing meaningful and intimate relationships. D. Giving and sharing with an individual without asking what will be given or shared in return. E. Developing sense of fulfillment by volunteering in the community.

C. Developing meaningful and intimate relationships. D. Giving and sharing with an individual without asking what will be given or shared in return. Rationale: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust.

A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? A. Administer the medication as prescribed. B. Obtain pre-filled syringes from the pharmacy. C. Discuss client rights with the primary healthcare provider. D. Tell the client what has been prescribed.

C. Discuss client rights with the primary healthcare provider. Rationale: Not only does deceitful use of placebos in place of appropriate pain treatment violate the client's right to the highest quality of care possible, it clearly poses a moral, ethical, and professional danger to healthcare providers. Perhaps the most important reason for not using placebos in the assessment and treatment of pain is that deception is involved. Deceit is harmful to both clients and healthcare professionals.

A nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate? A. Sit with the client and say a prayer. B. Send the client to the session after explaining that shouting is not allowed. C. Escort the client to an easel and canvas in order for the client to paint. D. Call for assistance and put the client in seclusion.

C. Escort the client to an easel and canvas in order for the client to paint. Rationale: Get them active. Redirect their activity. This is a much more therapeutic and effective intervention to help the paranoid client.

The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority? A. Check blood glucose level. B. Assess for proper shoe size. C. Examine the client's feet for signs of injury. D. Test sensory perception in the client's feet.

C. Examine the client's feet for signs of injury. Rationale: Clients with decreased peripheral sensation are at risk for injury to the extremity. They may sustain an injury and be unaware the injury has occurred. In addition to this, diabetics are at risk for poor wound healing (related to impaired circulation) and infection (related to elevated glucose levels). This is the assessment that should be performed first and takes priority.

The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? A. Mediastinal shift B. Tension pneumothorax C. Flail chest D. Pulmonary contusion

C. Flail chest Rationale: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a see-saw effect when observing the rise and fall of the chest.

An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has? A. Hypocalcemia B. Hypermagnesemia C. Hypokalemia D. Metabolic alkalosis E. Respiratory acidosis

C. Hypokalemia D. Metabolic alkalosis Rationale: Clients who vomit lose acid; therefore, they will have metabolic alkalosis. A client who is not eating and is vomiting will also lose potassium. Potassium is the electrolyte most significantly lost from the upper GI tract.

The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C. Metabolic acidosis Rationale: A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. Hyperventilation occurs due to excess ketones in the body causing metabolic acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing. The hyperventilation occurs to reduce the arterial pCO2 level.

A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning? A. Ask the family to restrict the client to the first floor. B. Instruct the client on home safety issues. C. Notify social services to arrange a home visit. D. Discuss cast care with client and family.

C. Notify social services to arrange a home visit. Rationale: The nurse is aware that a spiral fracture is caused by a twisting or jerking motion, in this case, of the forearm. While a fall could cause many injuries, contusions of the face combined with a spiral forearm, are indicative of abuse. The priority is to alert social services to follow-up with this client and family in the home setting, to determine the severity of the situation and possible interventions for the client's well-being.

The primary healthcare provider (PHP)has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's best first action? A. Administer the injection. B. Take vital signs. C. Question prescription with primary healthcare provider. D. Notify the nursing supervisor.

C. Question prescription with primary healthcare provider. Rationale: A placebo is any medication or procedure that produces an effect in clients resulting from its implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or in a misguided attempt to determine if the client's pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment.

One week ago a client was involved in a motor vehicle crash and was brought to the Emergency Department. The client received two sutures to the forehead and was sent home. Today, the client's spouse notes the client "acts drunk" and cannot control the right foot and arm. Based on this data, what should the nurse suspect? A. Meningitis B. Transient ischemic attack C. Subdural hematoma D. Meniere's disease

C. Subdural hematoma Rationale: Subacute subdural hematoma is a head injury with slow venous bleed. The body does not have symptoms until compensation is exhausted.

An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? A. "Soap and water should be used for hand washing when our hands are visibly soiled." B. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." C. "Standard precautions should be used on all clients." D. "When caring for a client who has a suppressed immune response, a N95 mask should be worn."

D. "When caring for a client who has a suppressed immune response, a N95 mask should be worn." Rationale: Standard precautions are needed. If there is a risk for coming in contact with client secretions or excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask. This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB).

What task by the RN should be performed first? A. Changing a burn dressing that is scheduled every four hours. B. Administering scheduled IV antibiotic. C. Teaching a new diagnosed diabetic about diet and exercise. D. Assessing a newly admitted client.

D. Assessing a newly admitted client. Rationale: The admit assessment should be done first. It is important to initiate the assessment and physical exam within one hour of being admitted to the unit or floor. The assessment and plan of care should be completed within 8 hours of admission.

What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? A. Jogging B. Volleyball C. Tennis D. Bicycle riding E. Swimming

D. Bicycle riding E. Swimming Rationale: Rheumatoid arthritis is an autoimmune disease that affects the joints and other body symptoms. Low impact activities on joints are best such as swimming and bike riding.

Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? A. Clinical nutritionist B. Primary nurse each shift C. Primary healthcare provider D. Case manager

D. Case manager Rationale: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client.

A home health nurse visits a recently discharged client with right-sided paresis due to a stroke. The nurse discovers that the spouse has been feeding the client. What action should the nurse take? A. Instruct the spouse to require the client to feed independently. B. Suggest the spouse hire an aide to feed and bathe the client. C. Advise the spouse to consider an extended care facility for the client. D. Determine why the spouse is not encouraging self-care by the client.

D. Determine why the spouse is not encouraging self-care by the client. Rationale: Because family members are important in promoting client self-care and preventing further illness, it is important to include family members in the teaching plan for the client. In a family support model, the goal is client self-care activities through formal and informal support systems.

After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action? A. Leave the client lying with the unaffected ear facing up. B. Place a cotton ball firmly into the affected ear for 15 minutes. C. Pull the pinna of the ear down and back. D. Gently massage the tragus of the ear.

D. Gently massage the tragus of the ear. Rationale: This is a correct nursing measure that will facilitate the flow of medication in the auditory canal.

The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? A. Calmly sit with the client and have the client repeat the room number at frequent intervals. B. Have the client remain in the room so the client can become familiar with it. C. Place a sign on the client's door that clearly has the client's name so the client can identify it. D. Hang a familiar object on the door to enhance room recognition.

D. Hang a familiar object on the door to enhance room recognition. Rationale: A client with Alzheimer's is likely to recognize a familiar object before reading the name on the door.

The admit assessment should be done first. It is important to initiate the assessment and physical exam within one hour of being admitted to the unit or floor. The assessment and plan of care should be completed within 8 hours of admission. A. Alternate the injection sites from one body area to another with each dose. B. Draw up the isophane suspension insulin first and then regular insulin into the same insulin syringe. C. Massage the injection site after the medication is injected. D. Insulin syringes should be stored at room temperature.

D. Insulin syringes should be stored at room temperature. Rationale: Insulin syringes and needles should be stored at room temperature. The potential benefits or risks of refrigerating the syringe are unknown.

The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? A. Endotracheal tube (ET) B. Head tilt-chin lift maneuver C. Oropharyngeal airway D. Jaw thrust maneuver

D. Jaw thrust maneuver Rationale: This is a trauma client that could possibly have a C-spine injury. The jaw thrust maneuver will open the client's airway without manipulating the client's C-spine.

The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which sign or symptom would cause the greatest concern? A. Nasal congestion B. Hiccups C. Blood glucose of 150 D. Muscle spasms

D. Muscle spasms Rationale: This client could have preeclampsia and would be at risk for seizures.

A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client? A. Continue to assess every 15 minutes. B. Stimulate the client with a sternal rub. C. Administer acetaminophen with codeine for headache. D. Notify the primary healthcare provider.

D. Notify the primary healthcare provider. Rationale: On the Glasgow coma scale, we like a number between 13 to 15. This assessment score has dropped to 12, so the client is getting worse and the headache could mean increasing intracranial pressure (ICP). This is the only intervention that can fix the problem.

A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? A. Postpartum woman who delivered at term. B. Woman in preterm labor at 35 weeks gestation. C. Woman with placenta previa at 37 weeks gestation. D. Pre-term labor client with twins at 28 weeks gestation.

D. Pre-term labor client with twins at 28 weeks gestation. Rational: Both clients are presenting with the possibility of preterm deliveries. The room should be kept quiet to decrease stimulation of the clients. Also, the client with preeclampsia should not be stimulated which could increase her blood pressure.

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first? A. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. B. Diagnosed with early onset of Alzheimer's disease with confusion. C. Post operative internal fixation of the femur with crust forming on the Steinman pins. D. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.

D. Receiving treatment for dehydration, and is now picking at bedding and IV tubing. Rationale: Being restless is an early sign of hypoxia, so oxygen may be necessary. Remember oxygenation takes priority over the other issues with these clients. The client may also be exhibiting manifestations of fluid volume deficit (FVD)

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene? A. TPN has been hanging for 12 hours B. Central venous catheter's dressing is clean and dry C. TPN fluid is room temperature when beginning administration D. TPN appears oily in consistency

D. TPN appears oily in consistency Rationale: Do not use TPN if it looks curdled, oily, or has particles in it. This is an indication that something is wrong with the solution and could harm the client if given. TPN can infuse for 24 hours

Which client diagnosis would require the nurse to initiate droplet precaution? A. Methicillin-resistant Staphylococcus aureus (MRSA) B. Varicella C. Vancomycin-resistant enterococci (VRE) D. Whooping cough

D. Whooping cough Rationale: Droplet isolation precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should wear a surgical mask while in the room. Mask must be discarded in trash after leaving the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room.