QT 6

The RN cares for the client just admitted after sustaining a second-degree thermal injury to the right arm. Which observation is MOST important to report to the health care provider? 1. Pain around the periphery of the injury.2. Gastric pH less than 5.0.3. Increased edema of the right arm.4. An elevated hematocrit.

Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct—client is at risk for Curling's ulcer which may develop 24 hours after a severe burn injury; gastric pH acidic (1-5) (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution

The nurse cares for the client reporting moderate pain. Which nursing action is MOST important to provide the client with effective pain relief? 1. Teach the client about the pain.2. Establish a trusting relationship with the client.3. Determine how various relaxation techniques affect the pain.4. Provide alternative measures to relieve pain.

Strategy: Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct—necessary to work with client to identify interventions to relieve pain (3) part of the evaluation phase (4) only a portion of interventions used to relieve pain

The emergency department nurse cares for the client demonstrating these symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend tells the nurse that the client used hallucinogenic drugs. Which action does the nurse take? 1. Places the client in full restraints.2. Decreases environmental stimulation.3. Calls the security guards.4. Administers a PRN dose of chlorpromazine.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) unnecessary at this time 2) CORRECT — symptoms will subside with time and decreased stimulation 3) unnecessary at this time 4) inappropriate

The nursing assistive personnel(NAP) is assigned to constant observation of a suicidal client. The nurse overhears the NAP talking with the client. Which statement made by the NAP requires IMMEDIATE intervention by the nurse? 1. "Let's put your clothes in the dresser."2. "I'll stay in the bathroom with you while you take your shower."3. "You're going to be moved to a private room later today."4. "I'll be right back with something for you to eat."

Strategy: "Require an IMMEDIATE intervention" indicates that something is wrong. (1) no reason to intervene (2) appropriate, client is not to be left alone for any reason (3) no reason to intervene (4) correct—client under constant observation; must not be left alone for any reason

The nursing assistive personnel comes to take the client by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck. Which observation, if made by the nurse, requires an intervention? 1. The client removes her dentures and gives them to her spouse. 2. The client's vital signs are BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C). 3. The client has a nitroglycerine patch on the right chest area.4. The client has red nail polish on both fingers and toes.

Strategy: "Requires an intervention" indicates an incorrect action. (1) should be removed before the test (2) results are within normal limits (3) correct—should be removed before the test; transdermal patch contains heat-conducting aluminized layerand burning of skin may occur (4) unnecessary to check capillary refill

The nurse stabilizes the client with severe multiple trauma injuries from a motor vehicle accident. Which action does the nurse take next? 1. Limits visiting hours to promote optimal rest.2. Arranges for clergy to visit with the client and family as requested.3. Arranges for a psychologist to visit with the family.4. Arranges for the family to meet with a social worker to discuss financial aid.

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? 1) inappropriate 2) CORRECT — provides the appropriate spiritual support during a crisis 3) inappropriate for the data given in the situation 4) inappropriate for the data given in the situation

The nurse walks into the client's room. The client states, "I just love hot-blooded redheads." The client pats the bed and says, "Why don't you sit down here and get off your feet for a while." Which response by the nurse is BEST? 1. "I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job."2. "I don't think my spouse would like me doing that."3. "You must be very lonesome. I'll come back later and spend some time with you."4. "I bet you flirt with all the nurses like that."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—nurse should confront client about inappropriate sexual behavior (2) should confront the client (3) reinforces inappropriate behavior (4) confront the client about inappropriate and unwanted behavior

The client diagnosed with lung cancer undergoes a pneumonectomy. In the immediate postoperative period, which assessment is MOST important? 1. Presence of breath sounds bilaterally.2. Position of the trachea in the sternal notch.3. Amount and consistency of sputum.4. Increase in the pulse pressure.

Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct—position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation

The mother brings her 17-month-old son to the well-baby clinic for a routine checkup. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed. Which suggestion by the nurse BEST? 1. "If you want the behavior to stop, put a negative reinforcer, such as red pepper, on his thumb."2. "Don't intervene at this time. This behavior usually subsides after 24 months of age."3. "What you are seeing is a common form of self-stimulation. You should discourage this behavior."4. "This behavior will cause malformation of his teeth. You should wrap his thumb at bedtime."

Strategy: "BEST" indicates there may be more than one correct response. Remember growth and development concepts. (1) controversial treatment, for an older child (2) correct—normal behavior, peaks at 18-20 months, most prevalent when child is hungry or tired (3) normal behavior in child this age, should not be discouraged (4) malocclusion occurs if thumb sucking persists past 4 years old or when permanent teeth erupt

The client comes to the local outpatient clinic reporting dizziness and palpitations. The physical exam and laboratory results are normal. The client reports the family-owned company is on the verge of bankruptcy. Which response, if made by the nurse to the client, is BEST? 1. "When did you first notice these symptoms?" 2. "Have you shared this information with anyone?"3. "Are you concerned about your financial difficulties?"4. "Would you like to discuss your situation with me?"

Strategy: "BEST" indicates there may be more than one correct response. Remember therapeutic communication. (1) correct—open-ended question, encourages client to discuss when problems occurred (2) yes/no question, nontherapeutic, doesn't encourage discussion of symptoms (3) yes/no question, nontherapeutic, too confrontational, does not encourage discussion (4) yes/no question, nontherapeutic

The nurse cares for the client after a vaginal delivery. Which action should be implemented FIRST? 1. Check the client's lochial flow.2. Palpate the client's fundus.3. Monitor the client's pain. 4. Assess the client's level of consciousness.

Strategy: "FIRST" indicates that this is a priority question. Remember the ABCs. (1) correct—complication of hemorrhage assessed by observing lochial flow (2) done to assist its natural clamping-down action, assessed as firm or boggy (3) must meet physical needs first (4) not first action; hemorrhage most important complication

The nurse instructs a client about how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor. Which action, if performed by the client, indicates to the nurse the need for further teaching? 1. The client dangles the hand before sticking the finger with the lancet. 2. The client sticks the finger on the side of the distal phalanx.3. The client touches the strip with a large drop of blood hanging from the fingertip. 4. The client milks the finger after sticking it.

Strategy: "Further teaching" indicates an incorrect response. (1) helps facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters the reading (4) correct—forces interstitial fluid to mix with capillary blood and dilutes the blood

The neonatal nurse instructs the family of a newborn about an apnea monitor. The nurse is MOSTconcerned if a family member makes which statement? 1. "We will be able to leave our baby for brief periods of time."2. "We plan to sleep by our baby's crib."3. "We can remove the monitor during our baby's bath."4. "A family member will closely watch the monitor all the time."

Strategy: "MOST concerned" indicates that you are looking for an incorrect statement. (1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct—indicates a feeling that monitor may not let them know if their infant stops breathing

The nurse instructs the prenatal client about the importance of prenatal vitamins. It is MOSTimportant for the nurse to include which instruction? 1. "Take prenatal vitamins with orange juice at bedtime."2. "Take the prenatal vitamins at breakfast with coffee."3. "Take the prenatal vitamins with milk at lunch."4. "Take the prenatal vitamins with water at dinner."

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) correct—taking the vitamins with something acidic increases the absorption of iron; taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep (2) not the best way to take prenatal vitamins (3) not the best way to take prenatal vitamins (4) not the best way to take prenatal vitamins

A client undergoes admission from the recovery room with an intravenous fluid infusing at 100 mL/hour. There are 900 mL left in the bag. One hour later, the client has received 850 mL. The nurse is most concerned by which assessment finding? 1. A CVP reading of 8 mm Hg and bradycardia.2. Tachycardia and hypotension.3. Dyspnea and oliguria.4. Rales and tachycardia.

Strategy: "Most concerned" indicates a complication. 1) The CVP reading is normal. Normal CVP ranges are 2-8 mm Hg or 3-11 cm H2O. Bradycardia is not related to a sudden influx of fluid. 2) Tachycardia may be associated with a fluid overload. However, hypotension is not relevant to fluid overload. 3) Dyspnea (shortness of breath) and oliguria (lack of urine output) are not related to a fluid overload. 4) CORRECT - Rales indicate fluid in the lungs and tachycardia indicates cardiovascular fluid overload. These would both be associated with a sudden fluid overload.

The health care provider orders metronidazole 250 mg PO tid for seven days for a client. The nurse instructs the client about the medication. Which statement, if made by the client to the nurse, indicates teaching is effective? 1. "I should take this medication between meals to increase absorption."2. "I shouldn't drink alcohol while I am taking this medication."3. "If I experience a metallic taste in my mouth while taking this medication, I should notify my health care provider."4. "I should avoid strong sunlight while I am taking this medication."

Strategy: "Teaching is effective" indicates a correct statement. (1) given with meals to decrease gastrointestinal upset (2) correct—causes metronidazole-like reaction of nausea and vomiting, headache, cramps, flushing (3) frequently seen, not a problem (4) sensitivity to sun not seen with this medication

The nurse instructs a client receiving naproxen 250 mg enteric-coated tablets PO bid. Which response, if made by the client, indicates that the nurse's instruction about the medication is effective? 1. "I have a glass of wine with dinner."2. "I should avoid milk and dairy products when I take this pill."3. "I should call my health care provider if my stools turn very dark."4. "I don't like to take pills, so I will crush the pill and add it to some applesauce."

Strategy: "Teaching is effective" indicates you are looking for a true statement. (1) alcohol increases risk of gastrointestinal bleeding (2) should be taken with food, milk, or antacid to decrease gastrointestinal upset (3) correct—NSAIDs can cause gastrointestinal bleeding (4) enteric-coated tablet should not be broken

The nurse cares for the client with a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the client in respiratory distress. Which action does the nurse take first? 1. Notifies the health care provider immediately to remove the tube.2. Elevates the head of the bed, and administers oxygen.3. Cuts the balloon ports and removes the tube. 4. Calls a code and begins rescue breathing.

Strategy: "first" indicates priority. 1) need to remove tube immediately to provide for airway 2) does not provide a patent airway 3) CORRECT — scissors always secured at the bedside; remove tube if observing signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon 4) unnecessary to call code until respiratory arrest occurs; establish a patent airway first

The nurse teaches the client being discharged on risperidone. Which client statements indicate the teaching has been successful? Select all that apply. 1. "I may gain weight when taking this medication." 2. "I should avoid extreme temperatures." 3. "I can take over-the-counter sedatives if I have trouble sleeping." 4. "I can drink alcohol as long as I drink in moderation." 5. "I will wear long sleeves when I am out in the sun."6. "I will change positions slowly."

Strategy: "teaching has been successful" indicates correct information. 1) CORRECT — causes weight gain 2) CORRECT — medication impairs body temperature regulation 3) check with health care provider before taking any OTC medication 4) check with health care provider before ingesting alcohol 5) CORRECT — causes photosensitive reactions 6) CORRECT — minimizes orthostatic hypotension

The health care provider prescribes sucralfate 1 gm PO tid and 2 Magnesium hydroxide/Aluminum hydroxide tablets tid for the client in the outpatient clinic. The client asks the nurse when to take these medications. Which instruction by the nurse is BEST? 1. Take the sucralfate and the Magnesium hydroxide/Aluminum hydroxide 1 hour ac.2. Take the Magnesium hydroxide/Aluminum hydroxide 1 hour ac and the Carafate 1 hour pc.3. Take the sucralfate and the Magnesium hydroxide/Aluminum hydroxide 2 hours pc and hs.4. Take the sucralfate 1 hour ac and the Magnesium hydroxide/Aluminum hydroxide 1 hour pc.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Magnesium hydroxide/Aluminum hydroxide (antacid) decreases bonding to gastrointestinal mucosa, so don't give within 30 minutes of each other (2) sucralfate best results on empty stomach; antacids decrease bonding to gastrointestinal mucosa, so don't give within 30 minutes of each other (3) antacids decrease bonding to gastrointestinal mucosa, so don't give within 30 minutes of each other (4) correct—sucralfate has best results on empty stomach

The nurse cares for the client diagnosed with a perforated bowel secondary to a bowel obstruction. At the time the diagnosis is made, which should be the priority in the nursing care plan? 1. Maintain the client in a supine position.2. Notify the client's next of kin.3. Prepare the client for emergency surgery.4. Remove the nasogastric tube.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct—when the bowel perforates as a result of increased intraluminal pressure within the gut, intestinal contents are released into the peritoneum, leading to peritonitis (4) should not be done

The nurse answers the phone on the psychiatric unit. The caller identifies himself as the spouse of a client and inquires about the client's condition. Which response by the nurse is MOST appropriate? 1. "I cannot deny or confirm any client's presence in this hospital."2. "Clients are not allowed access to this phone. Please call the number you were given."3. "I cannot give information over the phone. If you come in, we can discuss her condition."4. "I will have to ask her if she wishes for me to give out that information."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) confidentiality prohibits a professional from discussing information about the client (2) correct— psychiatric client retains civil rights to communicate with outside world and have reasonable access to telephones; unless client opts out of the registry, their location may be given out with prearranged codes (3) breaks confidentiality (4) client able to speak for herself

The nurse performs discharge teaching for the client diagnosed with multiple sclerosis. It is MOSTimportant for the nurse to include which instruction? Select all that apply. 1. Ambulate as tolerated every day.2. Avoid overexposure to heat or cold.3. Perform stretching and strengthening exercises.4. Participate in social activities.5. Use cold packs on joints.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—client is encouraged to ambulate as tolerated (2) correct—overexposure to heat or cold may cause damage related to the changes in sensation (3) correct—client is encouraged to participate in an exercise program to include range-of-motion (ROM), stretching, and strengthening exercises (4) correct—client is encouraged to continue usual activities as much as possible, including social activities (5) overexposure to heat or cold may cause damage related to the changes in sensation

The adult client comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back. The nurse should instruct the client to take which action? 1. Clean the area carefully with soap and warm water every day, and cover them with a sterile dressing. 2. Soak in a warm tub twice a day, and rub the areas with a washcloth before covering them. 3. Shower daily using a mild antimicrobial soap from a pump dispenser, and leave the lesions uncovered.4. Clean the lesions twice a day with a diluted solution of povidone-iodine, and leave them open to the air.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered because of open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma

The nurse supervises a student nurse obtaining an infant's vital signs. Which action should the student nurse complete FIRST? 1. Obtain the infant's temperature.2. Count respirations for 15 seconds and multiply the number by 4.3. Count respirations for a minute prior to arousing the infant.4. Use a stethoscope with a 1.5-inch diaphragm to count the apical pulse.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) count respirations for 1 full minute before taking temperature (2) should count for a full minute (3) correct—respirations should be counted for 1 full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations

Following total hip arthroplasty, an elderly client is ordered to begin ambulation with a walker. Which statement by the nurse is correct? Select all that apply. 1. "Sit in a low chair for ease in getting up to use the walker."2. "Make sure rubber caps are in place on all four legs of the walker."3. "You will begin weight bearing on the affected hip soon."4. "Have someone help you tie your shoes before you begin ambulating."5. "Your walker is the correct height when your elbows bend at a 50° angle."6. "Always wear non skid footwear when you walk."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided to prevent dislocation of prosthesis (2) correct—intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided to prevent dislocation of prosthesis (4) correct—flexion of the hip greater than 90° should be avoided (5) If the walker is the correct height the elbows should be at a 30° angle. (6) correct—Non skip footwear is a safety consideration and should always be worn with ambulation.

The nurse prepares the client for a lumbar puncture. It is important that the nurse makes which statement? Select all that apply. 1. "Don't worry because a general anesthetic will be used."2. "You can't drink fluids for eight hours before the test.3. "You will remain flat in bed for eight hours after the test."4. "A compression bandage will be in place for 10 hours after the test."5. "You may feel discomfort in your leg when the needle is inserted."6. "You can have analgesics after the procedure if you have a headache."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) general anesthetic is not used (2) fluids are not restricted before the test (3) correct—to prevent a post-lumbar puncture headache, client should remain flat in bed for eight hours after the test (4) inappropriate for this procedure (5) correct—nerve endings may be touched when performing the procedure. (6) correct—headaches or discomfort may be experienced after the procedure sans pain control can be provided by analgesics.

The client is admitted to the hospital with dry mucous membranes and decreased skin turgor. The client's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the health care provider to order which IV fluids? 1. D5NS.2. 0.45% NaCl.3. 0.9% NaCl.4. Lactated Ringer's.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hypertonic solutions contraindicated in dehydration (2) correct—hypotonic solution, shifts fluid into intracellular space to correct dehydration (3) isotonic solution, not best with dehydration (4) isotonic solution used to replace electrolytes

The nurse cares for the 17-year-old married male scheduled for a hernia repair. The nurse administers fentanyl 100 mcg with hydroxyzine pamoate 25 mg IM. Thirty minutes later the nurse discovers that the informed consent is unsigned. Which action by the nurse is best? 1. Cancel the surgery.2. Ask the client to sign the informed consent.3. Notify the health care provider.4. Ask the client's mother to sign the informed consent.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate action; should inform health care provider (2) can't sign informed consent if client has been drinking alcohol or has been pre-medicated for surgery (3) correct—health care provider needs to be informed (4) married minor is considered emancipated; provides own consent for treatment

The client at 39 weeks gestation in active labor screams, "I have to push, I have to push." The nurse notes that the client is 8 cm dilated. The nurse should take which action? 1. Instruct the client to take a deep breath and bear down.2. Apply gentle but firm pressure to the client's abdomen.3. Coach the client in relaxation techniques.4. Tell the client to pant with pursed lips.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct—describes transition phase of labor, breathing technique allows client to control pain and urge to push and promotes adequate oxygenation of fetus

The nurse cares for the client after a radical mastectomy of the right breast. Upon return to the unit, which position is most appropriate for the nurse to assist the client into? 1. Position the client on the left side with the right arm protected in a sling. 2. Position the client on the right side with the right arm elevated. 3. Position the client in semi-Fowler's position with the right arm elevated. 4. Position the client in the prone position with the right arm elevated.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) sling is not necessary, arm needs to be elevated 2) right arm cannot be elevated from this position 3) CORRECT — this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema 4) prone position is not appropriate

One of the goals the nurse and a client diagnosed with posttraumatic stress disorder (PTSD) mutually agreed upon is that the client will increase participation in out-of-the apartment activities. Which recommendation, if made by the nurse, is MOST therapeutic to achieve this goal? 1. Take a day trip with a friend.2. Take an 11-minute bus ride alone.3. Join a support group, and participate in a victim assistance organization.4. Take a 10-minute walk with the spouse around the block.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (2) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated (3) correct—support groups of people who have suffered similar acts of violence can be helpful and supportive to teach clients how to deal with the traumatizing situation and the emotional aftermath (4) reasonable recommendation to begin using in a systematic desensitization program after the crisis is alleviated

The client is diagnosed with metastatic cancer with a poor prognosis. Recently, the client reports increased pain, is less communicative, very irritable, and anorexic. Which nursing goal should be a priority at this time? 1. Encourage client to talk about the possibility of dying.2. Provide pain assessment and effective pain management.3. Manage nutrition and hydration.4. Verify that the health care provider has discussed the prognosis with the family.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will be difficult if client's pain is not adequately controlled (2) correct—comprehensive and regular pain assessment/management is necessary to facilitate client's ability to maintain comfort, which may enable him to verbalize his feelings (3) important but will be difficult if client's pain is not adequately controlled (4) not highest priority

The nurse assesses the infant with a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which nursing action is MOST appropriate? 1. Elevate the head of the bed.2. Suction the infant's mouth and nose.3. Position the infant on one side.4. Administer oxygen until breathing is easier.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not promote adequate drainage from the upper airways (2) contraindicated based on the infant's operative site (3) correct—will facilitate drainage of mucus from upper airway and will promote adjustment to breathing through the nose (4) does not relieve the congestion

The multipara client comes to the prenatal clinic during her fifth month of pregnancy. The client reports that her breasts are sensitive and sore. Which suggestion by the nurse is best? Select all that apply. 1. "Apply warm compresses to your breasts, and take two aspirin as needed."2. "Massage your breasts with lotion in a downward motion."3. Apply cool compresses to the sides of your breasts." 4. "Take an herbal diuretic once a day."5. Wear a well fitting supportive bra."

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort (2) not effective in decreasing discomfort (3) correct—during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue cool packs will decrease the discomfort caused by this change (4) medications are to be avoided during pregnancy (5) correct—appropriate support of the breast will help decrease the feeling of pulling and the discomfort associated with that occurrence.

The child admitted with failure to thrive has just had a positive sweat test. The nurse anticipates which changes in the child's plan of care? Select all that apply. 1. Administration of replacement enzymes.2. Immediate arterial blood gas.3. A salt-restricted diet.4. Limited activity with physical therapy.5. Social service referral.6. An unrestricted fat diet.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) CORRECT - sweat test is a positive finding for cystic fibrosis; enzyme replacement therapy is necessary 2) no data in this situation to indicate the child is having pulmonary problems 3) salt is increased in diet 4) physical activity as tolerated increases pulmonary function 5) CORRECT - multi-disciplinary care is required for children with this diagnosis 6) CORRECT - unrestricted fat diet is required due to the malabsorption of fat

A client diagnosed with a fracture of the left femur is placed in skin traction (Buck) with a 7-lb (3.2 kg) weight. The nurse notes the client keeps sliding down in bed. The nurse takes which action? 1. Elevates the client's left thigh on two pillows. 2. Elevates the head of bed and tilts the mattress, as in a slight Trendelenburg position.3. Raises the knee gatch on the bed 30°.4. Instructs the client to remain in the middle of the bed.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) This action will not prevent the client from sliding down and may change the pull of the traction. 2) CORRECT- Tilting the mattress (as in a slight Trendelenburg position) and raising the head of bed will help keep leg straight, prevent sliding down and counter the pull of the weights. 3) This position will bend the leg and alter the pull of the traction. 4) This instruction will not be an effective way of preventing the client from sliding down in bed.

An adult multipara client is seen in the prenatal clinic. The nurse notes the client is in the fifth month of pregnancy and has a weight gain so far of 14 lb (6.36 kg). The history indicates the client was of average height and weight prenatally. The nurse knows which statement is most likely true? 1. The client has gained too much weight, and the diet should be re-evaluated. 2. The client has not gained enough weight, and the diet should be re-evaluated. 3. The weight gain is appropriate, and the present diet should be continued. 4. The weight gain indicates possible difficulties may occur later in the pregnancy.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) excessive weight gain is >6.6 lb (3 kg)/month 2) inadequate weight gain is <2.2 lb (1 kg)/month 3) CORRECT — weight gain 2-5 lb (0.9-2.27 kg) first trimester, 0.66-1.1 lb (0.3-0.5 kg) weekly in second and third trimester 4) not substantiated by information presented in question

The client develops severe, crushing chest pain radiating to the left shoulder and arm. Which medication does the nurse administer? 1. Diazepam PO.2. Fentanyl IM.3. Morphine sulfate IV.4. Clopidogrel PO.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) not an appropriate medication in this situation; antianxiety medication 2) fentanyl decreases pain but does not vasodilate to relieve cardiac workload 3) CORRECT — morphine sulfate is given to reduce pain, anxiety, and cardiac workload; reduces the preload and afterload 4) platelet aggregation inhibitor; initial therapy is aspirin

The client is scheduled for a traditional abdominal cholecystectomy. Which statement, if made by the nurse to the client the night before surgery, is MOST important? 1. "It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet."2. "Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times." 3. "There will be a machine available to you after surgery for you to use to continuously receive pain medication."4. "You may come back from surgery with a tube in your nose that drains your gallbladder."

Strategy: All answers are implementations. Determine the outcome of each implementation. Is it desired? (1) not most important initially, teaching should be done before discharge (2) correct—should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring (3) PCA pumps used postoperative but medication administered intermittently (4) NG tube used to drain stomach, T tube used to drain common bile duct

The nurse cares for clients on the surgical floor and has just received report from the previous shift. In which order should the nurse assess the clients? Place the answers in order of priority. All options must be used. 59 YO with collapsed lung; no drainage from chest tube in 8H. 62 YO had ABD perineal resection three days ago; client reports chills 35 YO admitted 3H ago with GSW; 1/5 cm dark drainage on dressing. 43 YO with 2 day old mastectomy; 23 ml of serosanguinous fluid in JP drain

Strategy: All the clients are unstable use ABCs and real vs potential (1) 62 YO had ABD perineal resection three days ago; client reports chills See first; Unstable, unexpected, real problem peritonitis, should be assessed for further symptoms of infection (2)59 YO with collapsed lung; no drainage from chest tube in 8H. See second, Unstable, expected, respiratory, resolution (3) 35 YO admitted 3H ago with GSW; 1/5 cm dark drainage on dressing. See third; Unstable, expected, circulation, potential (4) 43 YO with 2 day old mastectomy; 23 ml of serosanguinous fluid in JP drain. See last; Unstable, expected, potential

The health care provider writes an order for piperacillin 3 g IV q6h for the adult client. Before administering this drug, the nurse should take which action appropriate to this medication? Select all that apply. 1. Check for known allergies to medications.2. Obtain specimen for culture and sensitivity3. Administer dexamethasone sodium phosphate 2 mg IV stat.4. Obtain client's current creatinine clearance results.5. Ensure that the client's respiratory rate is over 12.6. Check the client's blood pressure both sitting and standing

Strategy: Answers are a mix of assessments and implementations. Determine if the assessment is necessary in this situation. (1) correct—assessment; piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) correct—assessment; must be completed prior to starting the antibiotic. (3) implementation; not relevant for administration of this medication (4) correct—assessment; creatinine clearance values necessary to determine appropriate dosage ordered. (5) assessment; not required for this classification of medication. (6) assessment; not required for this classification of medication.

The nurse cares for the client following a cardiac catheterization. Two hours after the procedure, the nurse checks the client's insertion site in the antecubital space. The client reports the hand is numb. The nurse takes which action? 1. Changes the position of the client's hand. 2. Checks the client's grip strength in both hands. 3. Notifies the health care provider.4. Instructs the client to exercise the fingers.

Strategy: Answers are a mix of assessments and implementations. Does the assessment answer validate what is going on? No. Determine the outcome of each answer choice. 1) assumes that numbness is related to positioning of hand, not circulatory changes 2) part of assessment but doesn't indicate status of circulation 3) CORRECT — absent or weak pulse or numbness could indicate problem with circulation; anticoagulants and vasodilators may be ordered 4) assumes that numbness is related to immobility of fingers, not circulatory changes

The client is presently employed as a night watchman. When the client comes to the clinic for a visit, the client reports difficulty sleeping and fatigue. Which response by the nurse is BEST? 1. "Tell me about your usual sleeping habits."2. "You probably sleep when you can during your night tour."3. "This is normal for your age group."4. "Working the night shift is known to disrupt sleep patterns."

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct—assessment; open ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) generalization, closed communication

The client has a cast applied for a fracture of the right femur. Three hours later, the client reports feelings of heat and pain under the cast. Which is the MOST appropriate action for the nurse to take? 1. Assess the cast for wet spots, and increase air circulation in the room.2. Check the circulation in the casted extremity, and change the client's position.3. Take the client's temperature, and observe for other signs of infection.4. Medicate the client for pain, and notify the health care provider.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) heat is sign of pressure (2) correct—heat is sign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all reports must be investigated; medication would mask signs of pressure, assessment first step

The client comes to the nurse's station for their prescribed antipsychotic medication. The nurse notes that the client has torticollis, an arched back, and rapid movement of the eyes. Which action should the nurse take FIRST? 1. Determine what other medications the client is taking.2. Perform a neurological assessment.3. Administer haloperidol decanoate IM stat.4. Administer the PRN trihexyphenidyl IM immediately.

Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) assessment; demonstrating acute extrapyramidal side effects (2) assessment; no validation required (3) haloperidol is antipsychotic, will exacerbate symptoms (4) correct—administer benztropine or trihexyphenidyl

The nurse cares for the client diagnosed with bipolar disorder. The client will not stop swinging a mop to threaten other clients and staff. Which information is most important for the nurse to consider before administering a PRN IM dose of lorazepam? 1. The client is harmful to self.2. The client is psychotic.3. A less restrictive intervention failed.4. The client is harmful to others.

Strategy: Think about each answer choice. 1) important to know but not MOST important 2) should be considered but less restrictive interventions are considered first 3) CORRECT - use the least restrictive interventions in ascending order 4) a factor to consider, but consider less restrictive interventions first

A client is to receive the afternoon dose of nifedipine. The nurse notes this rhythm on the cardiac monitor. Which action is most appropriate for the nurse to take? 1. Withhold the medication.2. Check the urinary output.3. Administer the medication.4. Increase the potassium intake.

Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. 1) CORRECT - Nifedipine is a calcium channel blocker used as an antihypertensive. Bradycardia is an adverse effect. Withholding medication and checking with the health care provider is appropriate. 2) Assessment: This is an appropriate nursing action for a client on an antihypertensive that has diuretic effects because of increased blood flow to the kidney but is not a priority in this instance. 3) This is unnecessary. 4) This is an appropriate nursing action for a client on an antihypertensive that has diuretic effects because of increased blood flow to the kidney but is not a priority in this instance.

The nurse cares for the client with a nasogastric tube in place after extensive abdominal surgery. The client reports nausea. The nurse notes the client's abdomen is distended and there are no bowel sounds. Which action does the nurse take first? 1. Administers the PRN pain medication and an antiemetic.2. Irrigates the nasogastric tube with normal saline.3. Determines if the nasogastric tube is patent and draining. 4. Checks the placement of the nasogastric tube by auscultation.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. 1) implementation; may be carried out after the patency of the tube is determined 2) implementation; nurse should check patency first 3) CORRECT — nurse should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining, nurse does not need to irrigate it 4) assessment; nurse should check patency first by aspirating stomach contents, not by auscultation

The RN talks to the parents of a 6-month-old. They discuss ways to minimize the adverse effects of a DTaP immunization. Which actions are important for the RN to discuss? Select all that apply. 1. Give the child an alcohol bath for an elevated temperature. 2. Administer acetaminophen for discomfort. 3. Place a cool cloth on the injection site for 15 minutes. 4. Check the child's temperature every four hours for three days. 5. Wrap and comfort the child for signs of irritability. 6. Administer a salicylate medication for a fever.

Strategy: Answers are a mix of assessments and implementations. This question is not a priority question; you need to determine if the action is appropriate or not. Determine the outcome of each action. Is it desired? 1) implementation; not recommended for treatment in 6 month old 2) CORRECT — implementation; antipyretics (excluding salicylates) relieve discomfort 3) CORRECT — implementation; cool (not cold) is used to decrease pain; should be used for short temporary intervention 4) assessment; unnecessary unless indicated for another reason 5) CORRECT — decreased moving of the extremity and parental comfort is an appropriate intervention 6) salicylates are not recommended for children.

The OB client comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made. It is MOST important for the nurse to take which action? 1. Start an IV of terbutaline and monitor the client's vital signs closely.2. Prepare the client for an immediate cesarean section.3. Maintain the client on bed rest until spontaneous vaginal delivery is achieved.4. Monitor the client's length and duration of contractions.

Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation; terbutaline used to delay delivery in preterm labor (2) correct—implementation; cannot deliver vaginally (3) implementation; cannot deliver vaginally (4) assessment; cannot deliver vaginally, cesarean section must be performed

The nurse cares for the young adult client. The client is scheduled for the first debridement of a deep partial thickness burn of the left arm. It is MOST important for the nurse to take which action? 1. Assemble all necessary supplies and medications.2. Plan adequate time for the dressing change and provide emotional support.3. Prepare the client and family for the pain the client will experience during and after the procedure.4. Limit visitation prior to the procedure to reduce stress.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) appropriate but is not a high priority (2) correct—planning for burn wound treatment should include organizing and planning to spend time not only on the mechanics of the procedure but also on providing the emotional support necessary for the client (3) appropriate but is not a high priority (4) appropriate but is not a high priority

The nurse plans discharge for the client post mild myocardial infarction (MI). The client smokes one pack of cigarettes per day. Which recommendation by the nurse is BEST? 1. Participate in a program such as nicotine avoidance.2. Avoid aerobic physical activity.3. Install a humidifier in the home heating system.4. Strict adherence to a low-calorie, low-sodium, high-lipid diet.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet

The clinic nurse observes that a 10-year-old child with leukemia has a large burn on her arm. The burn appears to be oily. The child tells the nurse that she touched a hot pan, and her mother put cooking fat on it so that it would not blister. Which action should the nurse take FIRST? 1. Document the findings in the chart. 2. Call the health care provider immediately to report the injury.3. Teach the client that oil holds germs and makes infection more likely.4. Wash the burn with soap and water to remove the oil.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct—because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn

The toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate and dimercaprol. Which nursing action has the highest PRIORITY? 1. Keep a tongue blade at the bedside.2. Encourage the child to participate in play therapy.3. Apply cool soaks to the injection site.4. Rotate the injection sites.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no longer used for seizures, but it is important to have seizure precautions and emergency respiratory equipment available (2) important to implement, but is not a priority (3) contains incorrect information (4) correct—highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites

The nurse cares for the client with a marked depression of T cells. The nurse should take which action? 1. Keep a linen hamper immediately outside the room.2. Restrict eating utensils to spoons made of plastic.3. Provide masks for anyone entering the room.4. Remove any standing water left in containers or equipment.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct—water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium

A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which statement, if made by the client, indicates a correct understanding of aseptic technique? Select all that apply. 1. "I need to buy sterile gloves to redress this wound."2. "I should wash my hands before redressing my wound."3. "I should keep the wound covered at all times."4. "I should only use whatever my health care provider orders for the dressing change."5. "I should make sure someone looks at my wound every dressing change."6. "I will throw the dressing away in the kitchen garbage wrapped in my glove."

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sterile gloves are not commonly ordered. There is no information in the question to suggest this level of dressing (2) correct—indicates understanding of asepsis, hallmark is hand washing (3) is not possible to carry out (4) correct—should use only the prescribed medications on the wound (5) correct—The wound should be observed for changes with every dressing change. (6) correct—The dressing should be discarded after being wrapped in the non sterile glove.

Two days after the client is admitted, the client's sputum culture is reported as positive for tuberculosis. While awaiting orders from the health care provider, the nurse should take which action? 1. Initiate measures to transfer the client to a tuberculosis unit.2. Institute measures to initiate airborne precautions.3. Arrange for all of the client's personal effects to be decontaminated.4. Notify the client's family that they have been exposed to a contagious disease.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) this action is unnecessary at this time, and if indicated, the health care provider will write appropriate transfer orders (2) correct—clients with tuberculosis are placed on airborne precautions in the hospital, and the nurse should begin preparations for this immediately (3) personal effects do not have to be decontaminated (4) it is the health care provider's job to tell the family when indicated

The nurse plans care for the client hospitalized with bipolar disorder. While the client is in the manic phase, the nursing plan should include which intervention? Select all that apply. 1. Explain procedures in depth.2. Distract the client with light physical activities3. Isolate the client until manic phase is resolved4. Concisely remind the client about the rules.5. Provide prn medication for all inappropriate behaviors.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not be effective in changing behaviors, requires an attentive listener (2) correct—client experiences hyperactivity, poor concentration, and distractibility ; redirect into activity that promotes nourishment; are light activity (3) isolation not required, would increase anxiety and hostility (4) correct—clear concise information is appropriate (5) prn medication is a last result and used when physical harm is anticipated.

The adult client with a nasogastric tube (NG) has an order for acetaminophen 650 mg PRN for a temperature greater than 101° F (38.3° C). The nurse takes which action when administering this medication? 1. The tablets should be swallowed carefully with sips of water. 2. The medication should be withheld until the nasogastric tube is removed. 3. Placement of the nasogastric tube should be checked prior to giving the medication. 4. Powdered medication should be used and mixed with water to form a solution.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) client is NPO, so nothing should be administered orally but oral medication can be administered via NG tube 2) medication should not be withheld 3) CORRECT — liquid acetaminophen may be administered via the nasogastric tube after tube placement has been checked; tube placement should be checked before anything is instilled 4) acetaminophen does not come powdered

The nurse makes a home visit to the client with an abdominal wound. When irrigating the draining wound with a sterile saline solution, which sequence is most appropriate for the nurse to follow? 1. Pour the solution, wash hands, then remove soiled dressing. 2. Wash hands, remove soiled dressing, wash hands, then prepare the sterile field. 3. Prepare the sterile field, put on sterile gloves, then remove soiled dressing. 4. Remove soiled dressing, flush the wound, then wash hands.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) hands should be washed first 2) CORRECT — handwashing should be done prior to beginning any procedure, especially irrigating a wound 3) using sterile gloves to remove the dressing would contaminate them 4) hands should be washed first

The nurse instructs the client being discharged on tranylcypromine sulfate. The nurse determines further teaching is needed if the client makes which statement? 1. "To celebrate, my wife and I are going out for pepperoni pizza and wine tonight."2. "I plan to use sunblock at the beach this summer."3. "When I get home, I am going to start a diet so that I can lose some weight."4. "Now that I feel so much better, I have more energy."

Strategy: Determine how each answer choice relates to Tranylcypromine sulfate. (1) correct—Tranylcypromine sulfate is an MAO inhibitor; must avoid food with tyramine (aged cheese, yogurt, beer, wine) to prevent hypertensive crisis (2) sunblock required (3) no contraindication to sensible weight reduction diet (4) expected outcome of antidepressant; takes three to four weeks to work

The nurse cares for clients in an acute care facility. The nurse identifies which client as a likely candidate for developing acute kidney injury? 1. A young client with recent ileostomy due to ulcerative colitis.2. A middle-aged client with elevated temperature and chronic pancreatitis.3. A teenager in hypovolemic shock following a crushing injury to the chest.4. Child with compound fracture of the right femur and massive laceration of the left arm.

Strategy: Determine how each answer choice relates to acute kidney injury. (1) usually ileostomy clients do not experience severe hypovolemia, which would lead to kidney injury problems (2) this type of infection and inflammation does not lead to acute kidney injury (3) correct—common cause of acute kidney injury is kidney ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute kidney injury

The nurse cares for the client in the emergency room. Before administering calcium gluconate 10% 500 mg IV stat, which assessment should the nurse complete FIRST? 1. Stability of the respiratory system.2. Adequacy of urine output.3. Patency of the vein.4. Availability of magnesium sulfate injection.

Strategy: Determine how each answer choice relates to calcium gluconate. (1) unnecessary in this situation (2) unnecessary in this situation (3) correct—if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn (4) irrelevant

The nurse prepares the older client for discharge after treatment for dehydration. Which client statement indicates the nurse needs to provide further teaching? 1. "I should weigh myself daily."2. "I should drink fluids throughout the day." 3. "I can use a measuring cup to find out how much I drink during the day." 4. "I should let my health care provider know if I get dizzy when I change positions."

Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. 1) CORRECT — only indicates overhydration, not response to dehydration 2) helps prevent recurrence of dehydration, should force fluids to 3,000 mL/day 3) good indication of total intake 4) indicates postural hypotension resulting from volume deficit

The nurse cares for the client currently hospitalized with chronic kidney disease. The client has 3+ pitting edema of the lower extremities. Which nursing observation indicates a therapeutic response to therapy for the edema? Select all that apply. 1. Serum potassium 4.0 mEq/L (4.0 mmol/L).2. Plasma glucose 140 mg/dL (7.8 mmol/L).3. Increased specific gravity of the urine.4. Weight loss of 5 lb over last two days.5. Decrease in calf circumference by 2 cm.

Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct—edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective (5) correct—edema is a result of sodium and fluid retention; decrease in peripheral circumference should occur if therapy is effective

The nurse sees the client with a 25-year history of alcohol abuse in the outpatient clinic. The client is being treated for chronic cirrhosis. Which symptom suggests to the nurse that the client is in the early stages of hepatic encephalopathy? Select all that apply. 1. The client has a distended abdomen and protruding umbilicus.2. The client has difficulty describing what he does at work.3. The client states difficulty sleeping through the night.4. The client's exhibits asterixis when hands are assessed.5. The client sleeps 10-12 hours through the day.6. The client's spouse notes a change in the client's handwriting.

Strategy: Determine how each answer choice relates to hepatic encephalopathy. (1) ascites is symptom of cirrhosis (2) correct—impaired thought processes is early symptom (3) correct—insomnia and sleep disturbances are signs of grade 0 (4) flapping of the hands after extension is grade 3 and above; is late symptom (5) lethargy and extended sleep patterns are signs of grade 3; late signs (6) correct—Writing changes and hand tremors are grade 0; early signs

The nurse cares for the client diagnosed with hyperparathyroidism. Which symptom is mostimportant for the nurse to report to the next shift? 1. Abdominal discomfort.2. Hematuria.3. Muscle weakness.4. Diaphoresis.

Strategy: Determine how each answer choice relates to hyperparathyroidism. (1) sign of hyperparathyroidism but does not require reporting (2) correct—hematuria is a sign of urinary tract calculi; 55% of hyperparathyroid clients have urinary tract calculi (3) sign of hyperparathyroidism but does not require reporting (4) sign of hyperparathyroidism but does not require reporting

The RN cares for the 4-year-old diagnosed with epiglottitis. Which observation indicates to the nurse that the child is experiencing an early complication of hypoxemia? Select all that apply. 1. Heart rate of 148 beats per minute (bpm).2. Bluish discoloration of the skin.3. Bluish discoloration around the mouth.4. Throwing toys and kicking the bed.5. Difficulty swallowing.6. Nasal flaring with activity.

Strategy: Determine how each answer choice relates to hypoxemia. (1) correct—heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) correct—Irritability is an early sign of hypoxemia. temper tantrum like behavior is not expected in a 4 year old. (5) sign of epiglottitis not hypoxemia (6) correct—Nasal flaring is an early sign of hypoxemia.

The home health nurse makes a follow-up visit for the elderly client receiving isoniazid 200 mg every day for six months. The nurse is most concerned if the client makes which statement? 1. "I have blurred vision at times."2. "My legs and knees hurt."3. "My hands and feet tingle." 4. "I think I had a migraine yesterday."

Strategy: Determine how each answer choice relates to isoniazid. (1) infrequent side effect of the medication (2) not a side effect of the medication (3) correct—may cause peripheral neuropathy indicated by tingling, may also see nausea (4) not a side effect of the medication

A client is admitted with a diagnosis of urinary tract calculi and is experiencing severe pain. Fentanyl 100 mcg IV is given prior to the change of shift. Which symptom is most important for the nurse to report to the next shift? 1. Nausea with a small amount of vomitus.2. Pain of 5 on a scale of 1 to 10.3. Change in the location and character of pain.4. No known drug allergies.

Strategy: Determine how each answer choice relates to urinary tract calculi. (1) often accompanies pain but is not most important to report to next shift (2) important but not the highest priority (3) correct—location of the pain depends on location of urinary tract calculus; character of pain changes depending on location or movement of stone (4) important but not the highest priority

The nurse prepares the client for a skin biopsy. Which client statement should the nurse report to the health care provider? Select all that apply. 1. "I've been taking aspirin for my sore knees."2. "Using lotion has helped my dry skin."3. "I have a tanning appointment tomorrow."4. "I had a big breakfast this morning."5. "I have changed my mind about having this done."

Strategy: Determine how the statements relate to skin biopsy. (1) correct—aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure (2) does not affect the accuracy or results of the biopsy even though it is not recommended (3) does not affect the accuracy or results of the biopsy (4) does not affect the accuracy or results of the biopsy (5) correct—The client is free to change their mind but the health care provider needs to be informed.

The female client is diagnosed with human papillomavirus (HPV). Which client statement, if made to the nurse, illustrates an understanding of the possible sequelae of this illness? 1. "I will need to take antibiotics for at least a week."2. "I will use only prescribed douches to avoid a recurrence."3. "I will return for a Pap smear in six months."4. "I will avoid using tampons for eight weeks."

Strategy: Determine the "hidden meaning" of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct—several strains of HPV are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome

Several days after the client's myocardial infarction, the health care provider places the client on a 2-gm sodium diet. Which selection indicates to the nurse an understanding of the diet? 1. Scrambled egg, orange slices, and milk.2. Instant oatmeal, toast, and orange juice.3. Poached egg, bacon, and milk.4. Biscuit, fruit cup, and sausage.

Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct—all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all quick breads are high in sodium, as is sausage

The triage nurse receives 4 phone messages. In which order does the nurse return the phone calls? (Please arrange in order. All options must be used.) Multipara client at 6 weeks' gestation reports colicky ABD pain and shoulder tip pain primigravida client at 5 wks gestation has light vaginal spotting, mild cramping primipara client at 7 wks gestation reports increase in milky white vaginal secretions multigravida client at 6 wks gestation reports red vaginal bleeding, moderate cramping

Strategy: Determine the least stable client, and keep prioritizing the clients left. 1) Abdominal pain at 6 weeks needs to be evaluated for a possible ectopic pregnancy. Initially, the pain may be described as "dull" and "unilateral" but can progress to colicky, sharp, severe pain if rupture occurs. The pain may become generalized throughout the lower abdomen. Referred shoulder pain is caused by diaphragmatic irritation secondary to blood in the peritoneal cavity. Referred shoulder pain increases the suspicion for a ruptured ectopic pregnancy, which can lead to shock and death. This client is unstable and has a circulation concern that needs to be immediately addressed. 2) Moderate cramping and bright red bleeding are symptomatic of threatened abortion. This client is potentially unstable and has an issue that can impact circulation, but the client with a suspected ruptured ectopic pregnancy is at greater risk. This client should be seen second. 3) This client has symptoms of spontaneous abortion. "Light vaginal spotting" poses a potential risk to circulation. This client should be seen third. 4) Milky white vaginal secretions (leukorrhea) are expected during the first trimester of pregnancy. The nurse would be concerned about infection if the vaginal discharge were green, yellow, or foul-smelling.

A college student reports a history of a motor vehicle accident six months ago. The client was minimally injured but a friend was killed. The client comes to Student Health Services reporting inability to study or sleep. The client also reports thinking they are "going crazy." Which action by the nurse is MOST important? 1. Perform a complete physical and social history.2. Obtain a complete drug and alcohol history, including reports from a drug screen.3. Review the significant events of the last year.4. Explore the client's coping methods over the crash and the friend's death.

Strategy: Determine the outcome of each answer choice. (1) not most important initially (2) not most important initially (3) not most important initially (4) correct—situational crisis; priority is to determine how client coped with crisis in the past and build on client's coping strategies

An adult client is admitted to an acute locked psychiatric unit one month prior to an election. The client requests the opportunity to vote in the upcoming election. Which response by the nurse is best? 1. "You are not eligible to vote because you are a psychiatric client." 2. "I'll make the appropriate arrangements for you to vote." 3. "You may vote only if you are discharged by Election Day." 4. "I'll contact the Election Board to see if you are registered to vote."

Strategy: Determine the outcome of each answer choice. (1) psychiatric patients do not forfeit their constitutional rights (2) correct—client can vote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility

The charge nurse reviews care for the client with internal radiation. The charge nurse intervenes if which actions are noted? Select all that apply. 1. Visitors are limited to 5 hours per day with the client. 2. A male caregiver is assigned to all care. 3. Time in the room is limited for all care providers.4. Lead-lined apron is worn for all care delivery. 5. Verbal exchanges with the client are made from the doorway. 6. Frequent rest periods are incorporated into client's care.

Strategy: Determine the outcome of each answer choice. If you intervene you are looking for incorrect statements. 1) CORRECT — this is an incorrect statement; all visitors are restricted with regard to the distance they should be from the client, with most text citing 3 hours per day is recommended 2) CORRECT — this is an incorrect statement; caregivers are not to be assigned all care no matter their gender 3) this is a correct statement; principles for radiation therapy are time, distance, shielding; the nurse should decrease the time spent in close proximity to the client 4) CORRECT — this is an incorrect statement; appropriate shielding (lead apron) is to be used when the nurse has to spend any length of time at a close distance, but not for routine care 5) this is a correct action; the distance decreases close exposure for the care provider 6) this is a correct action; radiation implants can cause fatigue and frequent rest periods are appropriate

The nurse leads a class for expectant mothers. Which comment indicates to the nurse that the pregnant woman understands the recommended dietary caloric increase for pregnancy? 1. "I will need to double my calorie intake because I am now eating for two."2. "I can add an additional 500 calories by drinking milkshakes."3. "I need to add 300 calories by increasing my intake of the basic food groups."4. "I really need to watch my calorie intake so that I will not gain too much weight."

Strategy: Determine the outcome of each answer choice. Is it desired? (1) common misconception (2) 500 calories is too many calories, and a milkshake is not a good food source because of its fat content (3) correct—recommended to increase calorie intake by 300 for fetal growth, maternal tissues, and the placenta (4) unsafe for the pregnant client

The nurse supervises the staff caring for clients on the medical-surgical unit. The nurse observes the novice nurse enter a client's room wearing gloves and a mask. The nurse determines the precautions are correct if the novice nurse is caring for which client? 1. The infant diagnosed with rotavirus.2. The young child with a wound infected with S. aureus. 3. The teenager diagnosed with toxic shock syndrome.4. The teenager diagnosed with rubella (German measles).

Strategy: Determine the precautions required for each disease. 1) Contact precautions and standard precautions are required when providing care to a client diagnosed with rotavirus. Wearing a mask, however, is not necessary. 2) S. aureus requires standard and contact precautions, but no mask is required. 3) Only standard precautions are required when providing care to a client diagnosed with toxic shock syndrome. 4) CORRECT - Droplet precautions are used for organisms that can be transmitted by face-to-face contact, such as rubella (German measles). The door, however, may remain open.

The RN obtains a urinalysis from the client reporting dysuria, urinary frequency, and discomfort in the suprapubic area. After evaluating the results, the nurse should order a repeat urinalysis based on which finding? 1. Negative glucose.2. RBCs present.3. No WBCs or RBCs reported.4. Specific gravity 1.018.

Strategy: Determine the significance of each answer choice and how it relates a bladder infection. (1) glucose increases during the inflammation process; it is not a primary component in determining urinary tract infections (2) not as complete a response as answer choice 3 (3) correct—with the client's symptoms, WBCs and RBCs should be present; WBCs are a response to the inflammation process and irritation of the urethra; RBCs are increased when bladder mucosa is irritated and bleeding (4) indicates the concentration of the urine

The nurse provides care for a client diagnosed with hypovolemia. Which observation does the nurse identify as the desired response to fluid replacement? 1. Urine output 160 mL in 8 hours.2. Hemoglobin 11 g/dL (110 g/L).3. Arterial pH 7.34.4. Central venous pressure (CVP) of 8 mm Hg.

Strategy: Determine the significance of each answer choice and how it relates to hypovolemia. 1) Urine output should be at least 30 mL/hr to be considered normal. A urine output of 160 mL in an 8 hour period is equivalent to 20 mL/hr; therefore, this indicates a hypovolemic state. 2) This finding indicates a hypervolemic state. 3) This finding indicates acidosis. 4) CORRECT - The normal range for CVP is 2 to 8 mm Hg (3 to 11 cm of water). A CVP of 8 mm Hg (11 cm of water) indicates a desired response to fluid replacement.

The nurse plans discharge for a group of clients. The nurse identifies which clients require a referral for home care? Select all that apply. 1. A postoperative appendectomy client who reports incisional pain.2. A newly diagnosed diabetic client who has a vision impairment.3. A postoperative cholecystectomy that requires steps to get into their apartment.4. A client with congestive heart failure who underwent diuresis in the hospital.5. An elderly client with a new right hip replacement who lives with a daughter.

Strategy: Determine the the need for follow up care. (1) expected outcome, treat with analgesics (2) correct—Follow up on medication administration and ability for self care at home. (3) teach client to limit trips up and down and take stairs slowly (4) correct—assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia (5) correct—the client will need assessment in the home for self care; family can help but not full care.

The nurse cares for clients in the outpatient clinic. The young adult female arrives for help with weight loss. The client's weight is 257 pounds, and the client is 5'7". Which diet choice indicates the MOST appropriate choice for breakfast? 1. Applesauce, cream of wheat, toast.2. Scrambled eggs and toast, one slice of bacon.3. One glass of grapefruit juice.4. Bagel with two ounces of cream cheese and a banana.

Strategy: Determine the topic of the question. (1) correct—breakfast with some substance, won't leave client feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the client feeling very hungry before lunch (4) high fat content

During the nursing history interview, the preschooler's parent reports the child has frequent bouts of gastroenteritis. Which question is most important for the nurse to ask? 1. "Are there other children in the family?"2. "Does the child attend a day care center?" 3. "Does the child play with neighborhood children?"4. "Is the child current on the immunizations?"

Strategy: Determine why the nurse would make the assessment and how it relates to gastroenteritis. 1) does not pose a problem or solution regarding gastroenteritis 2) CORRECT — environments with increased numbers of children (day care centers) are more likely to promote infections due to close living conditions and increased likelihood of disease transmission 3) possible source of infection but not as likely as a day care center 4) does not pose a problem or solution regarding gastroenteritis

The nurse returns to the nurse's station after making client rounds and finds four phone messages. Which message should the nurse return FIRST? 1. A client with hepatitis A who states, "My arms and legs are itching."2. A client with a cast on the right leg who states, "I have a funny feeling in my right leg."3. A client with osteomyelitis of the spine who states, "I am so nauseated that I can't eat."4. A client with arthritis who states, "I am having trouble sleeping at night."

Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat with calamine lotion and antihistamines (2) correct—may indicate neurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority

The nurse admits the client from the postoperative recovery area after abdominal exploratory surgery. In which order should the nurse perform the actions? List from first action performed to last action performed. All options must be used. Assess RR. Determine pulse. Check dressing for evidence of bleeding. Position client on left side. Check chart for surgical notes. Monitor incision site for purulent drainage.

Strategy: Place the actions in order. Consider priority of each action. (1) This is the first action. respiratory assessment is highest priority. (2) 2nd action to perform. assessment of cardiac status is second priority. (3) assessment; dressing should be checked on admission to the room and frequently for the next several hours (4) 4th action; implementation but priority assessments should be completed first (5) 5th action; knowing what occurred in surgery is an action but assessment and position the client will take priority. (6) 6th action; baseline assessment would be required but much to soon for infection assessment

An 18-month-old is brought by her parent to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry. Which comment by the nurse is the MOST appropriate? 1. "Don't cry. It will be better if you try to behave."2. "I know you are frightened. It will be over with soon."3. "A big girl like you shouldn't cry. It's only going to hurt a little."4. "Please stop crying. There is nothing to be afraid of."

Strategy: Remember therapeutic communication (1) nontherapeutic; doesn't respond to feeling tone and tells child what to do (2) correct—doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic; minimizes child's reaction (4) nontherapeutic; minimizes child's reaction, should indicate it is okay to feel afraid

The nurse administers sublingual nitroglycerin to the client reporting chest pain. Which observation is MOST important for the nurse to report to the next shift? 1. The client indicates the need to use the bathroom.2. Blood pressure has decreased from 140/80 to 90/60.3. Respiratory rate has increased from 16 to 24.4. The client indicates that the chest pain has subsided.

Strategy: The topic of the question is unstated. Read answer choices for clues. (1) not a side effect of this medication (2) correct—hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome

The client, gravida 2/para 1, is admitted for induction of labor with oxterm-94ytocin. It is MOST important for the nurse to take which action? 1. Mix oxytocin in D5W, begin at 5 mg/ml as primary IV to gravity flow.2. Decrease the rate/flow of oxytocin if the fetal heart rate is below 150.3. Piggyback the oxytocin into the mainline IV, and maintain the flow by gravity.4. Start an IV line, and piggyback the oxytocin with an infusion pump.

Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) oxytocin should be a secondary infusion (2) normal range for fetal heart tones is 120 to 160 beats per minute (3) rate should be maintained by an infusion pump (4) correct—oxytocin should always be a secondary infusion controlled by an IV pump

The nurse cares for the client diagnosed with dementia in a long-term care facility. Which action by the nurse is best? 1. Encourage the client to verbalize feelings about being placed in a nursing home. 2. Ask the client what favorite pastimes and what types of activities the client used to participate in. 3. Orient the client to the present time and assist the client to be alert and oriented when the family comes to visit. 4. Direct conversation toward assisting the client to reminisce and talk about important past events in life.

Strategy: The topic of the question is unstated. Read the answer choices for clues. 1) the client may not remember own identity or location 2) not as important as encouraging reminiscences 3) even with orientation, the client soon forgets 4) CORRECT — geriatric client should be encouraged to talk about past life and important things in the past because the client has recent memory loss

The nurse prepares the client for a myelogram. It is MOST important for the nurse to ask which question? 1. "Do you have any allergies?"2. "Have you been drinking lots of fluids?"3. "Are you wearing any metal objects?"4. "Are you taking medication?"

Strategy: Think about each answer choice and how it relates to a myelogram. (1) correct—dye is injected into subarachnoid space before an x-ray of spinal cord and vertebral column to assist in identifying spinal lesions; if client is allergic to dye, there is a major safety issue (2) important that client drink extra fluids after the test to replace the CSF lost during test (3) appropriate for magnetic resonance imaging (MRI) (4) obtain history of medication that can lower seizure threshold (phenothiazines, neuroleptics)

Which behavior by the client should the nurse record to indicate that the client is experiencing hallucinations? 1. The client sits immobilized for long periods of time.2. The client turns and tilts his head as if talking to someone.3. The client expresses the belief that the health care provider is out to get him.4. The client wrings his hands and paces constantly.

Strategy: Think about each answer choice. (1) describes behavior associated with depression (2) correct—hallucinations are sensory perceptions for which there is no external stimulus; this option describes client behavior that would be observed when the client is responding to voices (3) describes behavior associated with delusional thinking (4) describes behavior most associated with anxiety

The nurse reviews charts on a medical/surgical unit. The nurse identifies which example is a properly recorded client chief complaint in a nursing health history? 1. "Complains of midepigastric discomfort with flatus after meals."2. "Area above umbilicus appears to be painful and tender to palpation."3. "My stomach hurts after dinner every night."4. "Rebound tenderness present in mid- to upper-abdominal area."

Strategy: Think about each answer choice. (1) incorrectly stated (2) objective finding (3) correct—chief complaint should be recorded using the client's own words (4) objective finding

The mother of a 4-year-old boy comes to the prenatal clinic to confirm her second pregnancy. During the initial visit, it is MOST important for the nurse to take which action? 1. Assess the client's feelings about pregnancy, labor, and delivery. 2. Obtain a history of the client's last labor and delivery. 3. Determine how the client's 4-year-old feels about the pregnancy.4. Identify the client's general health needs.

Strategy: Think about each answer choice. (1) physical needs take priority (2) physical needs take priority (3) priority is taking care of pregnant client (4) correct—optimal opportunity for preventive health maintenance

The home care nurse visits an infant who had a myelomeningocele repair. The home care nurse determines the parents are accepting of their infant if which finding is observed? 1. The parents state that the infant will outgrow this problem in time.2. The parents ask a neighbor to perform bladder expression.3. The parents measure the head circumference daily.4. The parents relate that they believe the child will walk in 1 year.

Strategy: Think about each statement and how it relates to myelomeningocele. (1) child has a chronic problem (2) indicates the parents' lack of interest and inability to care for the child (3) correct—parents' participation in care may be first sign of acceptance; head circumference measurement is important because of risk of hydrocephalus following surgery; even simple care like bathing child could bring acceptance (4) shows a lack of understanding about myelomeningocele

Which plan is most appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization? 1. Show a videotape about cardiac catheterization, one specifically prepared for children. 2. Provide the child with a pamphlet about the procedure, and encourage the child to read it. 3. Draw a picture of a heart, and explain where the tube will go and what the health care provider will see. 4. Present a puppet show explaining the anatomy and physiology of the heart.

Strategy: Think about the developmental stage of a 10-year-old. 1) video will provide correct information but is not best preparation for a school-age child 2) pamphlet will contain correct information but is not best preparation for a school-age child 3) CORRECT — explain procedures in simple terms; allow choices when possible 4) more appropriate for a younger child

The nurse obtains a history from the client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential. Which response by the nurse is BEST? 1. "I'll share any information you give me with staff members only with your approval."2. "If the information you share is important to your care, I'll need to share it with the staff."3. "We can keep the information just between the two of us."4. "I have an obligation to maintain nurse/client confidentiality about anything you tell me."

Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personnel directly involved with the client's care (2) correct—the nurse obligated to share client information with personnel directly involved with the client's care (3) nurse must never agree to keep information confidential without knowing the content of the information (4) nurse not obligated to report information that is not relevant to the client's care or well-being

The nurse observes a graduate nurse perform a moist-to-dry dressing change on a client's 2-inch incision. In which order does the student perform the procedure? (Please arrange in order. All options must be used.) Remove dressing Moisten prescribed # of gauze with prescribed amt of sln Dry skin surrounding wound. Apply moist gauze as single layer. Cover with dry dressings.

Strategy: Think about the process. Find the first and the last step then insert the steps in the middle. All the steps must be used but all the steps are not listed. 1) Attempt to remove dry unless dressing sticks. If dressing does stick, apply NS to help with removal. 2) The exposed skin around the wound is cleaned and dried. 3) Because this is a moist-to-dry dressing, the first clean layer of gauze is moistened with prescribed amount of prescribed solution. 4) Moist gauze is applied in a single layer. 5) Dry gauze is then applied.

The nurse knows that which assessment is BEST to indicate relief from abdominal pain for a child who received morphine 1 hour ago? 1. The child states that pain has gone away.2. The child's heart rate has changed from 80 to 95.3. The child sleeps except when receiving nursing care.4. Results from the incentive spirometer have improved.

Strategy: Think about what the words mean. (1) contains correct information but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct—when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer