question trainer 7 SATA

During the discharge planning session for a chronically ill infant, the nurse observes that the single mother paces almost all of the time while bouncing the infant in her arms. Which suggestion by the nurse is BEST? 1. "See you HCP for a mild tranquilizer" 2. "Buy a baby bouncer infant seat" 3. "Enroll in a parenting class" 4. "Investigate hiring a nanny"

3. "Enroll in a parenting class" Excellent suggestion to make to any parent, but especially under these circumstances; will help both mother and baby

The nurse prepares to discharge the client after an abdominal cholecystectomy. The client will go home with a T tube in place. Which statement, if made by the client to the nurse, indicates a need for further teaching? SELECT ALL THAT APPLY 1. "It will be great to finally get home, take a shower" 2. "If the amount of drainage increases over several days, I should call my HCP" 3. "I can resume swimming laps three times a week" 4. "I will check the skin around the tube once a day" 5. "I will call my HCP if I have green drainage" 6. "I am glad I can lift whatever I want"

3. "I can resume swimming laps three times a week" 5. "I will call my HCP if I have green drainage" 6. "I am glad I can lift whatever I want" - Should avoid strenuous exercise and do not immerse T-tube in water - This is a normal finding do not need to call HCP - Light lifting only for approximately 5 weeks

The nurse obtains a health history from the client taking phenytoin sodium. It is MOST important for the nurse to report which client statement to the HCP? 1. "I've had several "blackouts" in the past year" 2. "My parent has seizures, and this medication does not work for my parent" 3. "I don't know when I had my last menstrual period" 4. "I took this medicine several years ago but stopped when my urine turned pink"

3. "I don't know when I had my last menstrual period" Phenytoin sodium is in pregnancy risk category D; HCP should be notified of the possibility of a pregnancy

The family members of the 85-year-old report to the nurse that they suspect that their father is masturbating. Which response by the nurse is BEST? 1. "I understand your concern b/c this is not a normal part of aging" 2. "Don't worry b/c I think that he will stop soon" 3. "This is considered a normal behavior for men" 4. "The best think you can do is talk to your father about this behavior"

3. "This is considered a normal behavior for men" Masturbation is an activity performed by some elderly men

The nurse cares for the client on the psychiatric unit. Which question BEST aids the nurse in assessing the orientation of a client? 1. "Who is the president of the United States?" 2. "Do you remember my name?" 3. "What is your name?" 4. "What time is it?"

3. "What is your name?" It is a specific question related to orientation of a person

The father of the 1-day-old son works the evening shift (3 pm to 11 pm) at another hospital. Which action is a priority to meet the needs of the father? 1. Encourage the father to call his wife after work 2. Instruct the father about visiting policy and suggest AM visitation 3. Adjust visiting hours to meet the new parent's needs 4. Present a change of visiting hours to the appropriate hospital committee

3. Adjust visiting hours to meet the new parent's needs Role of nurse is to be a family and client advocate; this provides individualized care

The nurse cares for the client who is terminal. The unit has limited visiting hours and restricts children younger than 12 years of age. Which nursing action has the HIGHEST priority? 1. Explain the visiting hours to the client's family 2. Propose a policy change to the medical and nursing staff 3. Allow flexibility with family member visitations 4. Encourage the family to call the unit between visiting hours

3. Allow flexibility with family member visitations Role of the nurse is to function as client advocate; is important to individualize care with all clients

The nurse cares for a teenager in Buck's traction. It is MOST important for the nurse to take which action? 1. Check the pin sites for bleeding or infection 2. Apply topical or antibiotic ointment as ordered 3. Assess that the elastic bandages are not too loose or too tight 4. Remove the bandages daily to lubricate the skin

3. Assess that the elastic bandages are not too loose or too tight Nurse needs to assess the client to make sure circulation is not being compromised

The nurse cares for a client recovering from lower bowel surgery. The nurse determines that teaching is successful if the client selects which menu? 1. Milk, green beans, whole-wheat bread 2. Creamed chicken soup, broccoli, pudding 3. Baked chicken, buttered rice, plain gelatin 4. Cabbage salad, fried chicken, applesauce

3. Baked chicken, buttered rice, plain gelatin Low residue diet will leave a relatively small amount of residue, or indigestible material; in the colon; all meats, fish, and poultry must be broiled or baked

The 4-month-old infant who had a temperature of 103 F following the last DTaP vaccine. The nurse cares for this child in the clinic for another immunization administration. Prior to the nurse's administering the DTaP, which action should be the priority? 1. Withhold the immunization 2. Give half the dose in this injection 3. Consult the HCP about giving pediatric DT (diptheria and tetanus) 4. Instruct the parents to give acetaminophen following administration of the full dose of DTaP

3. Consult the HCP about giving pediatric DT (diptheria and tetanus) Fever over 103 F in first 48 hours after DTaP is a valid contraindication for pertussis vaccine

During a health history, a teenaged girl tells the nurse, "I have no appetite, and I have lost 4 pounds this week." It is MOST important for the nurse to take which action? 1. Notify the HCP 2. Weigh the client 3. Continue with the interview 4. Examine the abdomen

3. Continue with the interview Complete the health history interview before beginning physical assessment

The nurse admits the client w/possible Haemophilus influenzae meningitis. It is MOST important for the nurse to take which action? 1. Place the client on airborne precautions for 24 hours 2. Perform neurological checks every 4 to 6 hours 3. Dim the lights in the room and minimize environmental stimuli 4. Encourage PO fluids during the day to decrease fever

3. Dim the lights in the room and minimize environmental stimuli Implementation; will minimize the likelihood of seizures for this type of meningitis place patient on droplet precautions for at least 24 hours

The nurse cares for the client in the clinic. The HCP's orders read: "sulindac 200 mg PO BID for 14 days." The nurse should instruct the client to report which symptoms to the HCP? SELECT ALL THAT APPLY 1. Urinary frequency 2. Photophobia 3. Ecchymosis of the extremities 4. Slight edema of the feet 5. Vomiting red-streaked fluid 6. Flank pain

3. Ecchymosis of the extremities 5. Vomiting red-streaked fluid 6. Flank pain - Should notify HCP if easy bruising or prolonged bleeding occurs - Erosion of the gastric mucosa is a side effect that should be reported - Flank pain may indicate nephrotoxicity, should be reported

The nurse cares for the client three days after a spinal cord injury at the level of T5. The client reports a pounding HA. The nurse notes profuse sweating on the clients forehead. Which action should the nurse take FIRST? 1. Determine the patency of the Foley catheter 2. Place ice packs in the neck and head 3. Elevate the head of the bed 4. Apply a rigid cervical collar

3. Elevate the head of the bed Elevate HOB to lower BP Client has Autonomic dysreflexia--> blood pressure must be treated first then try to empty the bladder client must be kept warm--> if BP is not corrected then could lead to stroke

Which intervention is the priority during the nursing care of a 2-month-old infant after surgery? 1. Minimize stimuli for the infant 2. Restrain all of the infant's extremities 3. Encourage the parents to stroke the infant 4. Demonstrate to the parents correct infant care

3. Encourage the parents to stroke the infant Tactile stimulation is imperative for an infant's normal emotional development; after the trauma of surgery, sensory deprivation can cause failure to thrive

The nurse cares for clients in a rehabilitation facility. To support the client learning self-care, the nurse should take which action FIRST? 1. Provide instructions to complete an activity 2. Observe client progress with an activity 3. Establish the goal of the activity with the client 4. Allow the client to complete as much self-care as desired

3. Establish the goal of the activity with the client Client commitment to completing or learning techniques for self-care is supported by participation in goal setting

The client experiences a severe panic attack and has threatened to hurt another client on the unit. The nurse expects to administer which PRN medication as ordered? 1. Chlorpromazine 2. Lithium carbonate 3. Haloperidol 4. Phenytoin

3. Haloperidol Haldol is particularly effective in reducing assaultive behavior associated with severe anxiety

The nurse cares for a client recovering from streptococcal pneumonia. The client has a chest x-ray that reveals a higher degree of atelectasis in the right lower lobe. Which nursing intervention is MOST appropriate? 1. Instruct the client to take deep breaths more frequently 2. Reposition the client every hour to the right side 3. Increase the frequency of IS 4. Change respiratory treatment to every two hours

3. Increase the frequency of IS IS is a quantifiable method of assessing respiratory effort w/deep-breathing exercises; increasing the frequency would be a sound nursing decision in an effort to improve the client's pulmonary status

The nurse talks w/the nursing student w/a recent history of breast cancer. The nursing student reports they just developed shingles. Which action by the nurse is BEST? 1. Suggest that the nursing student contact her HCP 2. Assign the nursing student to clients that are not high risk 3. Inform the nursing student that they cannot care for clients 4. Restrict the nursing student from performing invasive procedures

3. Inform the nursing student that they cannot care for clients Because student is immunosuppressed; restrict from client contact until lesions have crusted

The nurse checks the patency of the client's Salem sump tube. The nurse finds stomach contents draining from the air vent. Which nursing actions is MOST appropriate? 1. Insert water through the air vent 2. Pull the sump tube back 2-3 inches 3. Insert 30 mL of air through the air vent 4. Insert a new NG tube

3. Insert 30 mL of air through the air vent Clearing the air vent with air will re-establish proper suction in the Salem sump tube

The nurse monitors the client diagnosed w/cholecysititis. The nurse is MOST concerned if which finding is observed? 1. Nausea 2. Frequent bleeding 3. Jaundice 4. Right upper abdominal pain

3. Jaundice Jaundice indicates a possible stone in the bile duct causing obstruction all others are symptoms of cholecystitis and do not necessarily indicate a complication

Which action should the nurse instruct the client to complete FIRST to establish a normal urinary pattern? 1. Urinate every 2 hours 2. Record each time the client urinates 3. Keep a record of daily fluid intake 4. Stay near a bathroom

3. Keep a record of daily fluid intake Client needs to know how much and when fluid is ingested

A client with sudden onset of VTE is started on IV heparin. Which order should the nurse question? 1. Warm, moist packs to the affected leg 2. Elevate the foot of the bed 6 inches 3. Keep client on bed rest 4. Elastic stockings on unaffected leg

3. Keep client on bed rest On bed rest until anticoagulant therapy is begun; early ambulation after acute VTE results in more rapid resolution of complications

The nurse cares for clients in a rehab facility. The nursing team reports a client recovering from a hip fracture has repeatedly "transferred herself to the floor." Which action, if taken by the nurse, is BEST? 1. Place the call light w/in the client's reach 2. Remove the footrests from the wheelchair 3. Observe the client rise from a sitting to a standing position 4. Place a Posey vest restraint on the client

3. Observe the client rise from a sitting to a standing position Assessment; nurse can determine if client is safe to perform this activity

At a health-screening clinic, the adult male client's total plasma cholesterol level is 200 mg/dL. Which action by the nurse is BEST? 1. Refer the client to the HCP for appropriate medication 2. Refer the client to the dietitian 3. Obtain a diet history 4. Recheck the cholesterol level in two years

3. Obtain a diet history Assessment; total cholesterol level for an adult male should be under 200 mg/dL; higher levels require a low-fat diet; obtain diet history before instructing on a low-fat diet

One hour after receiving 7 units of regular insulin, the client presents w/diaphoresis, pallor, and tachycardia. Which action should the nurse take first? 1. Notify the HCP 2. Call the lab for a blood glucose level 3. Offer the client milk and crackers 4. Administer glucagon

3. Offer the client milk and crackers Onset of action for regular insulin is 30-60 minutes; assessment indicates a problem w/hypoglycemia; foods such as milk and crackers should be given if blood sugar is around 40-60 mg/dL; if OJ or simple sugar is given, it should be followed w/a meal or w/protein intake

The HCP adds cholestyramine (Questran) 4 mg PO AC and HS to the medication regimen for the older client. The client is also taking digoxin (Lanoxin) 0.125 mg PO QD and hydrochlorothiazide (Esidrex) 25 mg PO QD. The nurse assists the client to set up a medication schedule. Which medication schedule is BEST? 1. Questran 8 am, noon, 5 pm, HS Lanoxin 8 am Exidrex 8 am 2. Questran 8 am, noon, 5 pm, HS Lanoxin 8 am Esidrex 5 pm 3. Questran 8 am, noon, 5 pm, HS Lanoxin 7 am Exidrex 7 am 4. Questran 8 am, noon, 5 pm, HS Lanoxin 5 pm Esidrex 7 am

3. Questran 8 am, noon, 5 pm, HS Lanoxin 7 am Exidrex 7 am Cholestyramine interferes with absorption of digoxin

The client is diagnosed with a tumor of the pituitary gland. The client has a transsphenoidal hypophysectomy performed. The nurse plans care for the client two days after surgery. It is MOST important for the nurse to monitor which finding? 1. Complete Blood Count 2. Temperature 3. Specific gravity of urine 4. ICP

3. Specific gravity of urine Lack of ADH from pituitary will cause DI and diuresis with very low specific gravity

The nurse overhears a conversation in the cafeteria between two nurses regarding the client's home situation. Which action is the MOST appropriate? 1. Report the incident to the nurse manager 2. Join the conversation w/the nurses 3. Suggest that the nurses continue the conversation in private 4. Ignore the incident b/c the nurse is not involved

3. Suggest that the nurses continue the conversation in private Client's confidentiality is being violated; it is nurse's responsibility to intervene to protect the client

The nurse prepares the client for insertion of a subclavian triple lumen catheter to be used for administration of parenteral nutrition (PN). The nurse should position the client in which position? 1. High-Fowler's position with the client's head in a neutral position 2. Semi-Fowler's position with the client's head extended 3. Supine with the client's head low and turned away from the insertion site 4. Left lateral with the client's head turned toward the insertion site

3. Supine with the client's head low and turned away from the insertion site Produces dilation of neck and should veins, making entry easier and preventing air embolus

The nurse performs hypertension screening at the local grocery store. It is MOST important for the nurse to complete which task? 1. Use a blood pressure cuff that overlaps the arm at least 4 inches 2. Support the client's arm above the level of the heart 3. Take two readings at least five minutes apart 4. Take the blood pressure after the client has exercised for 10 minutes

3. Take two readings at least five minutes apart Recognition of adult HTN should be done after two readings taken at least 5 minutes apart

The nurse supervises an NAP transferring the client from the bed to the chair after a right total hip replacement. The nurse should intervene if which is observed? 1. The NAP helps the client to a sitting position 2. The NAP positions the chair at a 90 degree angle to the bed 3. The NAP stands on the same side of the bed as the client's unaffected side 4. The NAP pivots the client on the unaffected side

3. The NAP stands on the same side of the bed as the client's unaffected side Should stand on affected side

The adult child of an elderly client diagnosed w/Alzheimer's disease provides care for the parent at home. The nurse identifies which observation represents caregiver burnout? SELECT ALL THAT APPLY 1. The adult child fails to transfer the client into a wheelchair daily 2. The home environment is extremely cluttered at each visit 3. The adult child is always wearing a robe at the time of the nurse's visit 4. The adult child's spouse is seen assisting w/the parent's care 5. The adult child reports difficulty sleeping 6. The parent reports the adult child never has friends over

3. The adult child is always wearing a robe at the time of the nurse's visit 5. The adult child reports difficulty sleeping 6. The parent reports the adult child never has friends over -Cluttered environment may represent depression and burnout - Disturbed sleep patterns more or less than normal can be sings of burnout - Social isolation is a sign of burnout

Four days ago the HCP prescribed lithium carbonate 600 mg TID for the client. The client returns to the outpatient clinic for evaluation. Which statement regarding the medication is MOST important for the nurse to reinforce with the client and the client's significant other? 1. The client should check for ankle swelling and decreased UOP 2. The client should keep a log of the time of day medication is taken and the way he is feeling 3. The client should call the clinic if tremors, muscular weakness, or ataxia develops 4. Because of the medication, the client should be experiencing remission of the symptoms

3. The client should call the clinic if tremors, muscular weakness, or ataxia develops 50% will develop dose-related tremors; signs of toxicity are diarrhea, vomiting, drowsiness, muscular weakness, ataxia

The nurse cares for the client after a craniotomy. The client's history reveals breast cancer w/metastatic lesions to the brain, and the client has received chemotherapy for one month. Postoperatively, the nurse is MOST concerned if which finding is observed? 1. Urine is foul smelling, and the urine specific gravity is 1.035 2. The client's 24-hour fluid intake is 3,ooo mL 3. The client's 24-hour urinary output is 4,000 mL 4. The client has diarrhea and excoriation of the anal area

3. The client's 24-hour urinary output is 4,000 mL Indicates surgically induced diabetes insipidus; increased UOP w/pale-colored urine and low specific gravity

The nurse assesses the daily lab reports for the client with a long history of cirrhosis w/acute hepatic encephalopathy. Which finding indicates to the nurse that the client is improving? 1. The client's fasting blood sugar decreased from 100 to 90 mg/dL 2. The client's prothrombin time (PT) increased from 20 to 25 seconds 3. The client's ammonia level decreased from 110 to 75 mcg/dL 4. The client's AST increased from 24 to 30 units

3. The client's ammonia level decreased from 110 to 75 mcg/dL Indicates a decrease in ammonia; normal ammonia 15-45 mcg/dL; still elevated but is improving

The client has been placed on phenelzine sulfate 11 mg PO daily to assist in treating depression. The nurse determines that teaching is effective if the client makes which statement? SELECT ALL THAT APPLY 1. " I will call my HCP and stop taking the medication if I begin to have severe HAs" 2. "I can drink wine, but I should avoid alcoholic beverages that contain high levels of alcohol" 3. "I know I am going to feel better in a couple of days. I am so glad that I finally got some medication" 4. "I can take the OTC cold medications that contain pseudoephedrine" 5. "I will carefully watch my diet"

1. " I will call my HCP and stop taking the medication if I begin to have severe HAs" 5. "I will carefully watch my diet" - Medication is an MAOI, hypertensive crisis may be precipitated by foods containing tyramine; client should be taught to report problems associated w/HTN - Foods containing tyramine interact w/this medication

The client is seen in the HCP office for follow-up after treatment for calcium urinary tract calculi. The nurse discusses methods to prevent a recurrence of the problem. Which instructions by the nurse are beneficial? SELECT ALL THAT APPLY 1. "Drink at least 3 L of water a day" 2. "Increase the amount of milk in your diet" 3. "Increase the amount of whole grains that you eat" 4. "You should eat a diet low in sodium" 5. "Increase your fluids in warm or hot environments" 6. "Limit your intake of coffee"

1. "Drink at least 3 L of water a day" 4. "You should eat a diet low in sodium" 5. "Increase your fluids in warm or hot environments" 6. "Limit your intake of coffee" - Prevention program; diet, medications, fluid 3 to 4 L/day - Dehydration is a risk factor for calculi formation - High sodium intake increases calcium exertion; increasing risk for calculi formation - Intake of colas, coffee and tea increase risk of calculus formation

The nurse talks w/the parents of the child just diagnosed w/a chronic illness. The parents share w/the nurse that they are concerned about the brother's sudden change in behavior. Which is the BEST response by the nurse? 1. "Her brother is feeling left out right now, but we plan to include him in his sister's care." 2. "Her brother is just feeling left out right now, but he will start acting normal soon" 3. "Her brother is worried about her and is just reacting to his fear" 4. "Her brother is going through a normal developmental change"

1. "Her brother is feeling left out right now, but we plan to include him in his sister's care." Total family participation is accomplished when the nurse includes siblings

The nurse performs dietary teaching for the client diagnosed w/asymptomatic diverticular disease. The nurse determines further teaching is required if the client makes which statement? 1. "I am glad that I can eat the tomatoes from my garden" 2. "I eat baby carrots as a snack almost every day" 3. "I mix several different kind of lettuce for my evening salad" 4. "I only eat whole-wheat bread for my lunch sandwich"

1. "I am glad that I can eat the tomatoes from my garden" Tomatoes have seeds that may block the neck of a diverticulum

The nurse cares for clients in the prenatal clinic. The nurse is MOST concerned if the client diagnosed with diabetes in the third trimester makes which statement? 1. "I am taking less insulin now than I did two months ago" 2. "I am eating a large bedtime snack" 3. "I walk 15 minutes after lunch every day" 4. "I check my blood sugar two hours after each meal"

1. "I am taking less insulin now than I did two months ago" Placenta produces hormones that make the cells insulin-resistant; as pregnancy progresses, these hormones increase; if insulin requirement is decreased, this indicates that the placenta is not functioning appropriately

The client is diagnosed w/myasthenia gravis. The nurse instructs the client about the disease. Which statement, if made by the client to the nurse, indicates the need for further teaching? SELECT ALL THAT APPLY 1. "I should have a glass of wine every night" 2. "I should not go places that are crowded" 3. "I should try to stay calm" 4. "I should use my hot tub daily" 5. "I should do all my work in the morning" 6. "I will change to an all thin liquid diet"

1. "I should have a glass of wine every night" 4. "I should use my hot tub daily" 5. "I should do all my work in the morning" 6. "I will change to an all thin liquid diet" - Should be avoided - Should avoid heat (sauna, hot tubs, sunbathing) - Activities should be spread out to decrease fatigue - Thicker liquids are easier to swallow than thin

The client has an order for hydrochlorothiazide 50 mg daily. The nurse determines further teaching is needed if the client makes which statement? SELECT ALL THAT APPLY 1. "I should not operate heavy machinery" 2. "I should only drink five glasses of liquid per day" 3. "This medication will cause my urine to turn orange" 4. "I should eat dried apricots each day" 5. "I should take this medication on an empty stomach"

1. "I should not operate heavy machinery" 2. "I should only drink five glasses of liquid per day" 3. "This medication will cause my urine to turn orange" 5. "I should take this medication on an empty stomach" - Medication does not cause drowsiness - There are no specific restrictions on fluid at this time - Does not occur - This medication should be taken with food b/c it causes GI upset

The nurse prepares to discharge the infant home with the parents. Which statement, if made by the mother to the nurse, indicates a need for further teaching about newborn care? SELECT ALL THAT APPLY 1. "I will notify my HCP about absence of breathing for 10 seconds" 2. "I will notify my HCP about more than one episode of projectile vomiting" 3. "I will notify my HCP if my baby's temperature is greater than 101 F" 4. "I will rock and cuddle my infant frequently to promote a sense of trust" 5. "I will put my baby in the sun if I notice the baby's eyes are yellow" 6. "I will call my HCP if my baby has yellow stool"

1. "I will notify my HCP about absence of breathing for 10 seconds" 5. "I will put my baby in the sun if I notice the baby's eyes are yellow" 6. "I will call my HCP if my baby has yellow stool" - Is normal for a neonate; apnea lasting longer than 15 seconds should be reported - If the newborn sclera is yellow the newborn should be seen - This is a normal occurrence in newborns

The nurse cares for the client on the postpartum unit. The client receives heparin for the treatment of VTE. The client says to the nurse, "I am so upset that I can not breast-feed my infant" Which statement, if made by the nurse, is BEST? 1. "You will be able to breast-feed your baby" 2. "Why do you think that it will be a problem?" 3. "We will check your baby's clotting times" 4. "We will give the baby protamine sulfate"

1. "You will be able to breast-feed your baby" Heparin is not transmitted in breast milk; breast-feeding considered safe

The nursing team consists of an RN, and LPN/LVN, and an NAP. The nurse should assign which client to the LPN/LVN? 1. A 72-year-old client w/diabetes requiring a dressing change for a stasis ulcer 2. A 55-year-old client w/terminal cancer being transferred to hospice home care 3. A 42-year-old client w/cancer of the bone complaining of pain 4. A 23-year-old client w/a fracture of the right leg asking to use the urinal

1. A 72-year-old client w/diabetes requiring a dressing change for a stasis ulcer Stable client w/an expected outcome

The client is to receive regional anesthesia during surgery. Which action is the MOST important for the nurse to perform regarding this anesthesia? 1. Adequately hydrate the client 2. NPO client for at least 12 hours 3. Assess the client for any allergies to Povidone-iodine preparations 4. Determine the specific gravity of the urine

1. Adequately hydrate the client Implementation; important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated

The nurse cares for the client w/a complete heart block. The nurse should question which order? 1. Administer lidocaine 50 mg IVP for PVCs in excess of six per minute 2. Administer atropine sulfate 0.5 mg IV for symptomatic bradycardia 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease 4. Mix 10 mL of 1:5,000 solution of isoproterenol in 500 mL D5W for sustained bradycardia below 30

1. Administer lidocaine 50 mg IVP for PVCs in excess of six per minute In complete heart block, the AV node blocks all impulses from the SA node, so the atria and ventricles beat independently; b/c lidocaine suppresses ventricular irritability. It may diminish the existing ventricular response; cardiac depressants are contraindicated in the presence of complete heart block

The nurse performs a home visit on the client diagnosed w/progressive MS. The HCP orders cyclophosphamide and adrenocorticotropic hormones. It is MOST important for the nurse to take which action initially? 1. Advise the client to purchase a wig or a hairpiece 2. Instruct the client to decrease fluid intake 3. Test the client's serum glucose concentration 4. Observe for indications for GI bleeding

1. Advise the client to purchase a wig or a hairpiece Client receiving cyclophosphamide usually develop alopecia four or five weeks after starting treatment

The client on continuous mechanical ventilation desires to go home. In order to determine the client's ability for home care, the nurse should take which action? 1. Assess the ability of others in the home to be trained to provide appropriate care for the client 2. Confer w/the client's HCP, and discuss the feasibility of the client's request 3. Assess the number of people in the home and the adequacy of space to care for the client 4. Examine the client's reasons for wanting to go home, and discuss the implications of home care

1. Assess the ability of others in the home to be trained to provide appropriate care for the client To ensure safety and to provide client w/quality care at home, assessing ability of others in home is critical before proceeding w/efforts to discharge the client

The nurse cares for the client receiving chemotherapy. The client has a WBC count of 1,200/mm3. Which nursing action should the nurse take FIRST? 1. Check temperature every 4 hours 2. Monitor UOP 3. Assess for bleeding gums 4. Obtain an order for blood cultures

1. Check temperature every 4 hours Important to monitor for infection, which would be evidenced by an elevated temperature in a client with a low WBC

The adolescent is seen in the ER for an overdose of aspirin. Which action will the nurse take? SELECT ALL THAT APPLY 1. Determine when the client took the aspirin 2. Administer protamine sulfate 3. Administer vitamin K 4. Obtain an ABG 5. Obtain client's temperature

1. Determine when the client took the aspirin 4. Obtain an ABG 5. Obtain client's temperature - Charcoal, if given within two hours, will absorb particles of salicylate - Severe acid-base disturbance can occur so ABGs will be needed - Hyperthermia is a sign of overdose, monitor temperature is a correct action

The nurse cares for the client diagnosed w/chronic alcoholism. The client occasionally uses marijuana and cocaine. The client is attending a second group therapy meeting with the nurse. The client comments, "I am having difficulty sitting still. Am I bothering some of the group members? Maybe I should stop coming to these group meetings?" Which action is MOST appropriate? 1. Encourage the client to share his problems with the group members 2. Remove the client from the group and assess his needs 3. Recognize that this is manipulative behavior and encourage the client to remain in the group 4. Tell the client not to concern himself about the group members and to continue in the group

1. Encourage the client to share his problems with the group members Client is experiencing some mild anxiety related to detoxification as well as participation in group process; needs reinforcement and encouragement to continue attending the group meetings and to share feelings

The nurse plans care for the client with Graves' disease. The nurse should intervene if the client drinks which fluid? SELECT ALL THAT APPLY 1. Iced coffee 2. Diet cola 3. Orange juice 4. Hot tea 5. Apple juice 6. Milk

1. Iced coffee 2. Diet cola 4. Hot tea - Stimulant that would increase metabolic rate not limited for Graves' disease - Stimulant that would increase metabolic rate - Stimulant that would increase metabolic rate

The nurse performs a health screening at a senior citizen facility. The client has been taking oral iron supplements for a month and reports constipation. The nurse should adapt the diet plan to include which food? SELECT ALL THAT APPLY 1. Oatmeal 2. Celery 3. Grits 4. Buttermilk 5. Green beans 6. Cheddar cheese

1. Oatmeal 2. Celery 5. Green beans All contain high fiber to assist in couteracting constipation

The 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which action by the nurse is BEST? 1. Observe the child at mealtime 2. Inquire about the child's eating patterns 3. Weigh the baby each month 4. Attempt to feed the baby for the mother

1. Observe the child at mealtime Assessment; will provide the most information

The client has a cataract removed from the left eye. Which action is important for the nurse to take in the immediate post-op period? SELECT ALL THAT APPLY 1. Position the client on the right side w/the head slightly elevated 2. Place the client on the left side to protect the eye 3. Perform sensory neurological checks every 2 hours 4. Maintain complete bed rest for the first 48 hours 5. Assess clients LOC 6. Assess client knowledge of home care

1. Position the client on the right side w/the head slightly elevated 5. Assess clients LOC - Should be positioned on back or unaffected side to prevent trauma to surgical eye - Assessing the level of anesthesia is necessary immediately post-op

The nurse cares for the client admitted in the first trimester of pregnancy. The client experiences hyperemesis gravidarum. The client presents with decrease in weight, poor skin turgor, and a chloride deficiency. Which nursing order should the nurse implement? SELECT ALL THAT APPLY 1. Start an IV upon admission 2. Complete an intake and output record every 4 hours 3. Provide oral fluids every hour 4. Perform a weight check every morning 5. Hold all anti-nausea medications 6. Place client on bed rest

1. Start an IV upon admission 2. Complete an intake and output record every 4 hours 4. Perform a weight check every morning 6. Place client on bed rest - Parenteral hydration is the best way to re-hydrate the client - Contains a plan to evaluate the status of hydration - Assessment; is an appropriate action for evaluating the client - Bed rest is ordered for the client to conserve energy

The elderly client diagnosed with Alzheimer's disease frequently wanders down the halls of the extended care facility. The client also displays restless and agitation. The HCP orders a vest restraint. When the nurse takes the restraint to the room, the client refuses to put it on. It is MOST important for the nurse to take which action? 1. Take the restraint away, and check the client frequently 2. Notify the HCP immediately that the client refused the restraint 3. Ask a coworker to hold the client and gently apply the restraint 4. Exchange the vest restraint for waist restraints

1. Take the restraint away, and check the client frequently As long as behavior is not unsafe, nurse should try other methods to engage client in activities to reduce wandering

The nurse supervises a NAP administer a soapsuds enema. The enema is prior to the client's abdominal surgery. Which action, if performed by the NAP, requires an intervention by the nurse? 1. The NAP holds the irrigation set 30 inches above the client's rectum 2. The NAP inserts the irrigation tube 3 inches into the client's rectum 3. The NAP positions the client in Sims position 4. The NAP warms the water to 105 F

1. The NAP holds the irrigation set 30 inches above the client's rectum Should be 12-18 inches; too high causes rapid distention and pressure in intestine causing rapid expulsion of solution, poor defecation, and damage to mucous membranes

The nurse cares for the 4-year-old child diagnosed w/a closed head injury. The nurse is reassured by which observation? 1. The child is able to state his name when asked who he is 2. The child reaches for a stuffed animal brought from home 3. The child maintains himself in opisthotonos 4. The child withdraws from mildly painful stimuli

1. The child is able to state his name when asked who he is Being able to state one's name demonstrates orientation to person, positive sign w/head trauma

The nurse assesses the child diagnosed with CF. The nurse is MOST concerned if which finding is observed? 1. The child is expectorating thick, yellow mucus 2. There is increased mucus production with postural drainage 3. Exertional dyspnea increases during the day 4. The child reports difficulty breathing

1. The child is expectorating thick, yellow mucus Is indicative of pneumonia

The client has taken levothyroxine sodium 0.4 mg daily for 4 days. Which finding should cause the nurse to recommend a change in the client's medication? 1. The client develops nervousness and difficulty sleeping 2. The client states that she has no energy and is "just tired" 3. The client has coarse hair and skin 4. The client has a persistent weight gain

1. The client develops nervousness and difficulty sleeping Suggests overdosage of thyroid hormone replacement therapy

The nurse evaluates care in the long-term care facility. The nurse specifically looks at self-care deficit in relation to feeding. Which finding provides the BEST evidence that the nursing intervention is effective? 1. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day 2. The client's dentures have been replaced, and the client is able to chew 3. The client will eat w/out verbalizing suspicions when a particular nurse sits at the table 4. The client appears to have increased energy to complete grooming activities

1. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day Concrete measure of the client's eating patterns indicates adequate intake of a well-balanced diet

The nurse cares for the client in a manic phase of bipolar disorder. It is MOST important for the nurse to offer which meal? 1. Tuna salad sandwich and orange slices 2. Bologna sandwich and French fries 3. Milkshake and banana 4. Fried chicken and tossed salad

1. Tuna salad sandwich and orange slices Clients with mania need nutritious finger foods; foods contain protein, carbohydrates, vitamin C, and fiber

The client undergoes peritoneal dialysis at home. The home care nurse notices the fluid outflow is inadequate. Which action should the nurse take FIRST? 1. Turn the client from side to side 2. Check for kinks in the tubing 3. Close the clamp to the drainage tubing for one half hour, and then reopen 4. Milk the drainage tubing firmly every 20 minutes

1. Turn the client from side to side Facilitates drainage

The nurse cares for a woman diagnosed with gestational HTN treated w/mag sulfate. The nurse is MOST concerned if which finding is observed? 1. UOP decreases from 70 to 30 mL/hr 2. RR increased from 14 to 18 breaths/minute 3. Hypertonic patellar reflexes 4. BP increased from 150/90 to 170/100

1. UOP decreases from 70 to 30 mL/hr Mag sulfate is metabolized and excreted by the kidneys; decrease in the UOP can lead to toxicity

The nurse cares for the client with a sigmoid colostomy. Which statement by the adult client indicates to the nurse the need for further teaching? 1. "I hope to be able to go without a pouch soon" 2. "I will irrigate my colostomy after each meal" 3. "My stoma is looking better all the time" 4. "It is not hard to change my pouch every several days"

2. "I will irrigate my colostomy after each meal" Irrigation of sigmoid colostomy is not necessary more than once a day and sometimes every two or three days, if at all

Polyethylene glycol-electrolyte solution is ordered for the client before a colonoscopy. The HCPs office nurse explains to the client how to take the solution. Which statement, if made by the client, indicates the need for further instruction? 1. "I need to drink 4 L of the solution" 2. "If I drink it ice old, it won't taste as bad" 3. "Once I finish drinking the solution, I can drink only water" 4. " I can use tap water to reconstitute the powder"

2. "If I drink it ice old, it won't taste as bad" Can cause hypothermia d/t large quantity of solution ingested

The nurse prepares the client for an IVP. Which statement, if made by the client to the nurse, indicates teaching is effective? SELECT ALL THAT APPLY 1. "I may feel a fluttery sensation when the catheter is inserted" 2. "The test may cause spasms and shooting pain in my back" 3. "I may experience a hot feeling and my skin may become flushed" 4. "I may become light-headed and have a desire to cough" 5. "I will have to restrict my fluid intake after the procedure" 6. "I will complete the bowel prep before this procedure"

2. "The test may cause spasms and shooting pain in my back" 6. "I will complete the bowel prep before this procedure" - May be accompanied by nausea caused by dye injection - Emptying of the bowel is important for good visualization of the kidney

The nurse screens the 8-month-old girl in a well-baby clinic. The nurse correctly identifies the parent understands growth and development if the parent makes which statement? SELECT ALL THAT APPLY 1. "My daughter has almost doubled her birth weight" 2. "When I walk in the room, my child smiles at me" 3. "When she is around her grandpa, my child cries" 4. "My daughter can't quite say "mama" yet" 5. "My child should be able to do a large piece puzzle by now" 6. "I will use a pillow to support her all the time"

2. "When I walk in the room, my child smiles at me" 3. "When she is around her grandpa, my child cries" 4. "My daughter can't quite say "mama" yet" - Begins to recognize parents at 6 months of age - Begins to fear strangers at 6 months, increases until 9 months of age - Begins to say "dada" and "mama" with meaning at 10 months of age

The nurse prepares the client for a laparoscopic cholecystectomy. It is MOST important for the nurse to ask which question? 1. "Tell me about your sleep patterns" 2. "Who is going to help you at home during the next couple of days?" 3. "Have you noticed an intolerance to fatty foods?" 4. "Have you had difficulty maintaining your weight?"

2. "Who is going to help you at home during the next couple of days?" Client usually discharged the day of surgery or the next day; ensure that client has help at home for first 24-48 hours

The client is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she I afraid of having a "dry birth" Which response by the nurse is MOST appropriate? 1. "The amniotic fluid provides only minimal lubrication for the labor process" 2. "Your body will continue to produce amniotic fluid" 3. "Labor is only slightly more difficult with early rupture of the amniotic sac" 4. "Because there is limited amniotic fluid, additional fluids will be supplied"

2. "Your body will continue to produce amniotic fluid" This is a correct answer and addresses the client's concern

After abdominal surgery, the client reports abdominal gas pain. It is important for the nurse to take which action? SELECT ALL THAT APPLY 1. Offer the client fresh fruits 2. Ambulate the client frequently 3. Teach the client how to splint the abdomen during activity 4. Position the client on the right side 5. Provide bisacodyl suppositories PRN

2. Ambulate the client frequently 4. Position the client on the right side 5. Provide bisacodyl suppositories PRN - Ambulation promotes the return of peristalsis expulsion of flatus - Position to help client move gas through the bowel - Bisacodyl suppositories stimulate peristalsis and expulsion of gas

A permanent demand pacemaker, set at a rate of 72, is implanted in a client for persistent third degree block. The nurse is MOST concerned if which finding is noted? 1. Pulse rate 88 and irregular 2. Apical pulse regular at 68 3. BP 110/88, pulse at 78 4. Skin warm and dry to touch

2. Apical pulse regular at 68 Any time the pulse rate drops below the preset rate on the pacemaker, the pacer is malfunctioning; the pulse should be maintained at a minimal rate set on the pacemaker.

The nurse enters the room and discovers that the client has slurred speech, right-sided paralysis, and unequal pupils. Which action should the nurse take FIRST? 1. Call the HCP 2. Assess the respiratory status 3. Determine the LOC 4. Perform a complete neurological evaluation

2. Assess the respiratory status Assessing the respiratory status and ensuring the client has an open airway is the appropriate next step

The nurse is called to a neighbor's house in the middle of a blizzard. The neighbor states that she is at 39 weeks gestation with her second baby. She has been having contractions for several hours. The woman states the baby has been in an LOA position for 3 weeks. The woman has been unable to obtain assistance because the roads are impassable. The nurse assists with the delivery of the infant. Once the head is delivered, in which order will the nurse perform the action of delivery? 1. Support the head at a slight downward angle 2. Check around the neck for the umbilical cord 3. Support the head in a slight upward angle 4. Support the head in rotation towards the maternal back 5. Place the newborn on the mother's abdomen 6. Support the newborn's body

2. Check around the neck for the umbilical cord 1. Support the head at a slight downward angle 4. Support the head in rotation towards the maternal back 3. Support the head in a slight upward angle 6. Support the newborn's body 5. Place the newborn on the mother's abdomen

The mother of a child diagnosed with type 1 diabetes calls to discuss the child's self-monitoring blood glucose home readings. The child is being tightly regulated w/a combination of intermediate-acting insulin before breakfast and supper. The past two mornings, the blood sugar readings were 220 mg/dL and 210 mg/dL. The nurse should advise the mother to take which action? 1. Continue the child's medication regime 2. Check the blood sugar during the night 3. Give the NPH insulin later in the evening 4. Serve the bedtime snack earlier in the evening

2. Check the blood sugar during the night - Assessment, may be having rebound hyperglycemia (Somogyi effect) following hypoglycemia episode while sleeping

The nurse cares for the client scheduled for surgery. Immediately before transporting the client to the surgical area, the nurse should take which action? 1. Check the client's VS 2. Check the client's ID bracelet 3. Ask the client to sign the operative permit 4. Administer the pre-op medications

2. Check the client's ID bracelet Assessment; verifying the identity of the client must be completed before anything else

The nurse cares for the client admitted three days ago w/deep partial full thickness burns over 30% of the body. It is MOST important for the nurse to report which observation to the next shift? 1. CVP reading of 12 cm water pressure 2. General muscle weakness and lethargy 3. Heart rate of 100 bpm 4. Systolic BP of 105

2. General muscle weakness and lethargy Muscle weakness and lethargy are signs of hypokalemia, which can occur on the third day after a burn, hypokalemia is c/b diuresis

The client w/urinary frequency, burning, and a temperature of 102 F is instructed by the nurse to collect a urine specimen for a culture and sensitivity. The nurse knows that teaching is successful if the client performs the procedure in which order? ARRANGE IN ORDER FROM FIRST TO LAST. ALL OPTIONS MUST BE USED. 1. Cleans the labia from front to back 2. Holds the labia open with one hand 3. Voids 30 mL into the toilet 4. Voids into the container 5. Places specimen into transfer container 6. Empties bladder into the toilet

2. Holds the labia open with one hand 1. Cleans the labia from front to back 3. Voids 30 mL into the toilet 4. Voids into the container 6. Empties bladder into the toilet 5. Places specimen into transfer container

The client diagnosed w/ALL is admitted w/SOB, anemia, and tachycardia. The nurse knows which nursing diagnosis is MOST appropriate for this client? 1. Altered protection, immunosuppresison; lukemia 2. Impaired gas exchange r/t decreased RBCs 3. Risk for infection r/t altered immune system 4. Risk of injury r/t decreased platelets

2. Impaired gas exchange r/t decreased RBCs Lukemia causes a decrease in all blood components; a gas exchange problem r/f depletion of oxygen carrying red cells

When using palpation techniques during the physical assessment of the adult client with abdominal pain, which action should the nurse take FIRST? 1. Instruct the client to take a deep breath and hold it 2. Inform the client to breathe slowly 3. Use bimanual palpation technique 4. Apply light palpation in the area

2. Inform the client to breathe slowly Breathing slowly will enhance relaxation of the abdominal muscles

The nurse cares for the client with a bleeding duodenal ulcer. The nurse is concerned if the client reports taking which medication? SELECT ALL THAT APPLY 1. Ranitidine hydrochloride 150 mg PO 2. Metoclopramide hydrochloride 15 mg PO 3. Sucralfate 1 g PO 4. Famotidine 20 mg PO 5. Naproxen 250 mg PO 6. Fluoxetine 20 mg PO

2. Metoclopramide hydrochloride 15 mg PO 5. Naproxen 250 mg PO 6. Fluoxetine 20 mg PO - Stimulates motility of upper gastrointestinal tract, contraindicated with possible hemorrhage of gastrointestinal tract; used for treating nausea of chemotherapy - NSAID medication; increases risk of GI bleeding - SSRI; increases risk of GI bleeding

The nurse performs an ice massage for the client in chronic pain. The nurse is MOST concerned if which finding is observed? 1. Redness or inflammation of the tissue 2. Mottling or graying of the tissue 3. The client states they feel a burning and tingling sensation in the area 4. The client states they feel a numbness and a cold sensation in the area

2. Mottling or graying of the tissue Site should be observed every 5 minutes for signs of tissue intolerance, including blanching, mottling or graying

The nurse cares for the client receiving parenteral nutrition. Lab values are glucose 72 mg/dL, chloride 98 mEq/L, sodium 138 mEq/L, potassium 3.0 mEq/L. Which nursing action is MOST appropriate? 1. Discontinue the PN administration 2. Notify the HCP 3. Administer IV glucose 4. Check the client's VS

2. Notify the HCP Normal plasma potassium level is 3.5-5.0 mEq/L; this client is low and needs replacement

The client awakens during the night w/dyspnea, severe anxiety, JVD, and frothy pink sputum. After the nurse begins O2 at 4 L/NC, which action is MOST appropriate? 1. Place two pillows behind the head, and elevate the legs 2. Notify the HCP about the change in the client's condition 3. Increase IV fluids to liquefy the secretions 4. Dim the lights, and provide privacy

2. Notify the HCP about the change in the client's condition Next priority is to notify the HCP, signs indicate pulmonary edema

During a non-stress test (NST), the nurse observes several late decelerations. Which nursing action is MOST appropriate? 1. Reposition the client on her right side 2. Notify the HCP for further evaluation 3. Document these results in the nurses notes 4. Stop the oxytocin immediately

2. Notify the HCP for further evaluation Appearance of any decelerations of the FHR during NST should be immediately evaluated by the HCP

The nurse cares for the client with a radium implant. It is important for the nurse to take which action? SELECT ALL THAT APPLY 1. Evaluate the position of the applicator every two hours 2. Place the client on a low-residue diet to decrease bowel movements 3. Encourage the use of the bedside commode 4. Decrease fluid intake to decrease radiation in the bladder 5. Encourage the client to conserve their energy 6. Encourage the client to take their anti-nausea medication

2. Place the client on a low-residue diet to decrease bowel movements 5. Encourage the client to conserve their energy 6. Encourage the client to take their anti-nausea medication - Implementation; bowel movements can dislodge radium implants; this diet will decrease amount of stool and number of bowel movements - Fatigue is a major side effect of radiation, conservation of energy is important - Nausea is a side effect of internal radiation. Control of the nausea helps with eating and drinking

The nurse cares for the infant admitted with fever, poor feeding, irritability, and a bulging fontanel. Which nursing action is MOST appropriate for the nurse to take? 1. Perform neurological checks every four hours 2. Place the client on droplet precautions 3. Monitor the client's UOP closely 4. Encourage fluid intake

2. Place the client on droplet precautions Implementation; classic signs of meningitis; client should be isolated from other clients

The nurse explains the use of transcutaneous electrical nerve stimulation (TENS) to the client diagnosed with sciatica. Which action, if performed by the client, indicates to the nurse that further teaching is necessary? SELECT ALL THAT APPLY 1. The client applies a conducting gel before applying the electrodes 2. The client places the electrodes on the side of the body opposite from the painful area 3. The client turns up the voltage until they feel a prickly "pins and needles" sensation 4. The client adjusts the voltage based on the relief of pain she/he experiences 5. The client turns up the voltage until milk twitching of the extremity begins 6. The client turns on the unit before applying the electrodes

2. The client places the electrodes on the side of the body opposite from the painful area 5. The client turns up the voltage until milk twitching of the extremity begins 6. The client turns on the unit before applying the electrodes - Should be over, above, or below the painful area - A "pins and needles" sensation is the max voltage, twitching would be too high - The client applies all electrodes and sets the parameters then turns on the machine

The nurse on the OB floor receives report about four pregnant women in active labor. In which order should the nurse see the woman? PLACE THE ANSWERS IN ORDER OF PRIORITY. ALL OPTIONS MUST BE USED. 1. The nullipara at 38 weeks gestation, cervical dilation of two cm, frank breech, no contractions 2. The mulitpara at 37 weeks gestation, cervical dilation of three cm, transverse lie, 0 station, mild contractions 3. The mulitpara at term, cervical dilation of 8 cm, vertex, +2 station. Strong contractions q 2 minutes 4. The nullipara at term, cervical dilation of 10 cm, LOP, Mod-Strong contractions every 2-3 minutes

3. The mulitpara at term, cervical dilation of 8 cm, vertex, +2 station. Strong contractions q 2 minutes 4. The nullipara at term, cervical dilation of 10 cm, LOP, Mod-Strong contractions every 2-3 minutes 2. The mulitpara at 37 weeks gestation, cervical dilation of three cm, transverse lie, 0 station, mild contractions 1. The nullipara at 38 weeks gestation, cervical dilation of two cm, frank breech, no contractions - End of transition phase of labor and delivery quick for multipara women - Second phase of labor nullipara women usually have a longer second stage than mulitpara women approximately 2 hours - Cesarean section for transverse presentation. Next highest priority for fetal risk - Most stable, labor has not progressed very far

The client undergoes a total laryngectomy. The nurse instructs the client and spouse how to suction the laryngectomy tube. In which order should the spouse perform the actions? ARRANGE IN ORDER FROM FIRST TO LAST. ALL OPTIONS MUST BE USED. 1. The spouse occludes the Y port 2. Has client take several deep breaths 3. The spouse selects the correct size catheter 4. Has the client take slow easy breaths 5. the spouse inserts the catheter 6. The spouse suctions the oropharynx

3. The spouse selects the correct size catheter 2. Has client take several deep breaths 5. the spouse inserts the catheter 1. The spouse occludes the Y port 6. The spouse suctions the oropharynx 4. Has the client take slow easy breaths

The client diagnosed with peripheral artery disease (PAD) talks with the nurse. The client reports leg pain frequently when walking. The nurse should advise the client to take which action? SELECT ALL THAT APPLY 1. Lie down with feet elevated above the heart when experiencing pain 2. Apply a heating pad to the legs for 15 minute before walking 3. Walk until pain begins, then rest, and then resume walking 4. Perform stretching exercises 2o minutes before starting to walk 5. Start a smoking cessation program 6. Apply cool packs before walking

3. Walk until pain begins, then rest, and then resume walking 5. Start a smoking cessation program - Exercise increases collateral circulation, should be encouraged - Smoking decreases circulation

A staff member working in the newborn nursery reports to the charge nurse, "Even though I do not feel bad, I have had loose stools for the last couple of day." Which response by the charge nurse is BEST? 1. "Make sure you wash your hands after going to the bathroom" 2. "Are you drinking plenty of fluids?" 3. "Describe to me how you are feeling" 4. "I am going to reassign you to orthopedics"

4. "I am going to reassign you to orthopedics" Restrict from care of newborn, infants or immunocompromised clients

The nurse conducts a class at a senior citizen center on the changes associated w/aging. The nurse is MOST concerned if a client makes which statement? 1. "I seem to get colds more often now than I did years ago" 2. "I'm about an inch shorter now than I was when I was working" 3. "I don't mind cooking, but eating doesn't appeal to me much anymore" 4. "I've been sleeping with fewer blankets over me lately"

4. "I've been sleeping with fewer blankets over me lately" Usually becomes intolerant to cold

The HCP prescribes estrogen daily for the middle-aged woman. Which statement, if made by the client to the nurse, indicates further teaching is necessary? SELECT ALL THAT APPLY 1. "There may be a change in my libido b/c of this medication" 2. "I may have a change in my weight while taking this medication" 3. "I may have some difficulty wearing my contact lenses b/c of the medication" 4. "It is unnecessary for me to perform routine self-breast exams while I am taking this medication" 5. "I am glad I do not have to stop smoking"

4. "It is unnecessary for me to perform routine self-breast exams while I am taking this medication" 5. "I am glad I do not have to stop smoking" - Should continue to preform monthly self-breast exams - Smoking and this medication can increase risk of CV complications. Client should be encouraged to stop smoking

The young adult comes to the outpatient clinic reporting vaginal itching. Which recommendation, if given to the client by the nurse, is appropriate? SELECT ALL THAT APPLY 1. "Supplement your diet with yogurt and dairy products" 2. "Douche with an OTC preparation" 3. "Wash the area w/soap and water several times a day" 4. "Wear underwear that is lined w/a cotton crotch" 5. "Refrain from sexual intercourse for a week after starting treatment" 6. "You should take your medication until it is gone"

4. "Wear underwear that is lined w/a cotton crotch" 5. "Refrain from sexual intercourse for a week after starting treatment" 6. "You should take your medication until it is gone" - More absorbent; allows for better circulation of air to body; dampness aggravates itching - Decreases complications such as PID - Completion of all medications decreases risk of re-infection

The client is diagnosed with otosclerosis and is admitted for a stapedectomy. It is MOST important for the nurse to ask which question? 1. "Have you noticed fluid draining from your left ear?" 2. "Have you had problems hearing for your entire life?" 3. "Did you require speech therapy when you were a child?" 4. "When did you notice that your hearing was impaired?"

4. "When did you notice that your hearing was impaired?" Otosclerosis occurs gradually over many years; often client is not aware of it until the impairment is significant

The client is on suicide precautions asks for a razor to shave her legs. When the nurse tells the client that she must remain with the client, the client responds, "Don't you trust me?" Which response by the nurse is BEST? 1. "It is against hospital policy to allow clients on suicide precautions to have razors unsupervised" 2. "I trust you, but your HCP said a nurse has to watch you if you want to shave your legs" 3. "Wouldn't you rather wait until you are feeling better before you try to shave your legs?" 4. "You have been having thoughts about wanting to hurt yourself recently, so I will stay with you"

4. "You have been having thoughts about wanting to hurt yourself recently, so I will stay with you" Provides patient w/factual information in a caring manner

The nurse on the postpartum unit prepares four clients for discharge. It is MOST important for the nurse to refer which client for home care? 1. A 15-year-old who vaginally delivered a 7-lb male 2 days ago 2. An 18-year-old mulitpara who delivered a 9-lb female by cesarean section 2 days ago 3. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping 4. A 22-year-old who delivered by cesarean section and is reporting burning on urination

4. A 22-year-old who delivered by cesarean section and is reporting burning on urination Unstable patient, indicates UTI, requires follow-up

The nurse cares for the client who had a thoractomy three hours ago. For the past two hours, there has been 100 mL/hour of bloody chest drainage. Which action should the nurse take FIRST? 1. Increase the IV fluid rate 2. Administer O2 at 5 L/min per oxygen mask 3. Elevate the HOB 4. Advise the HCP of the amount of drainage

4. Advise the HCP of the amount of drainage Chest drainage of 100 mL/hour is abnormal; physician should be notified

The primapara is admitted in early labor, and her membranes rupture. Which assessment by the nurse is MOST important? 1. Determine the pH of the amniotic fluid 2. Evaluate the mother's BP 3. Check the monitor for decelerations 4. Assess for a prolapsed cord

4. Assess for a prolapsed cord Initial assessment is to check for a prolapsed cord

The client is treated for VTE with IV heparin. The nurse is concerned if which finding is observed? SELECT ALL THAT APPLY 1. Increased anxiety 2. Decreased HR 3. Increased aPTT 4. Decreased LOC 5. Client takes Ginkgo for memory 6. Small pinpoint red marks are noted on the client's arms

4. Decreased LOC 5. Client takes Ginkgo for memory 6. Small pinpoint red marks are noted on the client's arms - Major side effect is bleeding; decreased LOC indicates intracranial bleeding - Ginkgo is a herbal supplement that can extend clotting times - Petechiae is of concern in a client on heparin

The psychiatric client admitted involuntarily asks the nurse to mail a letter to the President. The client states that the letter will make the President regret his action. Which response by the nurse is BEST? 1. Accept the letter and place it in the client's medical record 2. Read the client's letter and decide if it is appropriate to mail 3. Call the client's HCP to inform about the letter 4. Discourage the client from sending the letter, but mail it if the client insists

4. Discourage the client from sending the letter, but mail it if the client insists Retains the right to communicate with elected officialse

An elderly client has had a subtotal gastrectomy. The client received morphine 6 mg and hydroxyzine 50 mg IM. The nurse is MOST concerned if which finding is observed? 1. Tachypnea 2. Lethargy 3. Hypertension 4. Disorientation

4. Disorientation Elderly are prone to paradoxical reactions and can become agitated and disoriented

The client had a mitral valve replacement three days ago. It is MOST important for the nurse to take which action? 1. Maintain the client in the supine position to prevent tension on the mediastinal suture line 2. Encourage deep breathing but discourage coughing b/c of increased CVP 3. Decrease fluids to prevent fluid retention and development of CHF 4. Encourage early activity to promote ventilation and improve quality of circulation

4. Encourage early activity to promote ventilation and improve quality of circulation Post-op open heart clients should be encouraged to be out of bed and ambulating ASAP, frequently one to two days after surgery

The client at 16 weeks gestation has a blood sample drawn for rubella antibody screening. The test results reveal a low titer. The nurse discusses the results w/the client. The nurse should take which action? 1. Arrange for the client to have an MMR immunization immediately 2. Explain to the client that the results are expected and nothing needs to be done 3. Explore options w/the client about whether to terminate the pregnancy 4. Encourage the client to receive the rubella immunization after delivery

4. Encourage the client to receive the rubella immunization after delivery With a low rubella titer, the client is at risk for developing rubella; immediately after delivery, within early postpartum period, she needs to receive an immunization

The nurse performs an admission assessment for the client diagnosed with herpes zoster (shingles). Which assessment is important for the nurse to determine? 1. When the client developed this allergic reaction and how long it has lasted 2. If the client has eaten any new foods within the past 24 hours 3. If the client has a history of fever blisters or canker sores 4. If the client came into contact with anyone with chickenpox

4. If the client came into contact with anyone with chickenpox Close relationship between the virus that causes herpes zoster (shingles) and chicken pox virus

The anesthesiologist administers an epidural to the woman in labor. Which nursing action has the HIGHEST priority after the procedure is complete? 1. Decrease IV fluids 2. Assess the fetal heart monitor 3. Place the mother on her right side 4. Obtain the BP

4. Obtain the BP Assessment; side effect of an epidural is hypotension from the vasodilation that occurs

The nurse cares for the child diagnosed w/impetigo. The nurse is MOST concerned if which finding is observed? 1. White patches on the buccal mucosa 2. Hearing loss 3. Respiratory wheezes 4. Periorbital edema

4. Periorbital edema Indicative of poststreptococcal glomerulonephritis, a possible complication of impetigo

The client diagnosed w/COPD is admitted w/an acute exacerbation. The client's VS are BP 162/100 and P 78 bpm. The client's RR is 30 breaths/minute and labored. The nurse notes wheezing. The nurse should question which order? SELECT ALL THAT APPLY 1. Theophylline 0.7 mg/kg/hr IV 2. Tetracycline hydrochloride 300 mg IM BID 3. Ipratropium bramide inhaler 2 inhalations QID 4. Propranolol hydrochloride 40 mg PO BID 5. IV of NS at 200 mL/hr

4. Propranolol hydrochloride 40 mg PO BID 5. IV of NS at 200 mL/hr - Beta-blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation resulting in increased bronchoconstriction - This rate of IV fluid will increase the risk of FVO

The nurse cares for a neonate diagnosed with an infection. The nurse is MOST concerned if which is observed? 1. Heart rate of 150 bpm 2. Axillary temperature of 96 F 3. Weight increase of 4 ounces 4. RR of 65 at rest

4. RR of 65 at rest Normal RR of a neonate is 30-60 breaths/min; tachypnea is a sign of sepsis or hypoxia in a neonate

The nurse learns that a staff member providing care to the client diagnosed w/cytomegalovirus is in early pregnancy. Which action, if taken by the nurse, is BEST? 1. Ensure that the staff member follows standard precautions 2. Instruct the staff member to contact her HCP 3. Ask the staff member how she is feeling about her pregnancy 4. Reassign the pregnant staff member to care for other clients

4. Reassign the pregnant staff member to care for other clients Make pregnant personnel aware of the risks: CMV is fetotoxic

The nurse cares for clients at the student health clinic. Which sign and/or symptom should cause the nurse to suspect current cocaine use in the college student? SELECT ALL THAT APPLY 1. Frequent sneezing 2. Paranoia 3. Fatigue 4. Reports insomnia 5. Rhinorrhea 6. Tachycardia

4. Reports insomnia 5. Rhinorrhea 6. Tachycardia - Cocaine stimulates w/current users insomnia occurs - Associated w/cocaine use by inhalation; nose is most common route for administration - Cardiac stimulant

The client has received cimetidine 300 mg QID for several weeks. During an office visit, the HCP gives the client an additional prescription for aluminum hydroxide 600 mg QID. Which instruction, if given by the nurse, is BEST? 1. Take both medications together after meals and hs for combined effect 2. Take the aluminum hydroxide with meals and before bed, and take the cimetidine one hour after meals and before bed 3. Take the cimetidine two hours before meals and before bed, and take the aluminum hydroxide two hours after meals and at bedtime 4. Take the cimetidine with meals and one hour before bed, and take the aluminum hydroxide two hours after meals and at bedtime

4. Take the cimetidine with meals and one hour before bed, and take the aluminum hydroxide two hours after meals and at bedtime Give cimetidine with meals (causes more consistent therapeutic effect) and hs; antacids interfere with absorption; separate administration by one hour, give aluminum hydroxide one hour after meals and at bedtime (separate administration by one hour)

The nurse in the newborn nursery receives report from the previous shift. In which order should the nurse see the infants? PLAC THE ANSWERS IN ORDER OF PRIORITY. ALL OPTIONS MUST BE USED. 1. The 1-day-old infant, sleeping, and the anterior fontanel is bulging 2. The 2-day-old infant, lying quietly alert, HR of 185 bpm 3. The 5-hour-old infant, sleeping, hands and feet are blue bilaterally 4. The 12-hour-old infant held by the mother, respirations 65 and deep

4. The 12-hour-old infant held by the mother, respirations 65 and deep 2. The 2-day-old infant, lying quietly alert, HR of 185 bpm 1. The 1-day-old infant, sleeping, and the anterior fontanel is bulging 3. The 5-hour-old infant, sleeping, hands and feet are blue bilaterally - Unstable, unexpected, respiratory. Newborn respiratory rates while quiet are 30-50 breaths/min and abdominal. Requires immediate assessment. - Unstable, unexpected, cardiac. Infant has tachycardia; normal resting HR is 120-160 bpm. Requires further investigation - Unstable, unexpected, neurological. The anterior fontanel should be flat when the infant is at rest. May indicate increased fluid in the cranium. The fontanel may bulge w/crying as a normal finding. - Stable. Acrocyanosis for two to six hours post delivery

The nurse evaluates care for the client diagnosed with depression. Which observation MOST concerns the nurse? 1. The LPN/LVN reinforces deep breathing and relaxation techniques to the client 2. The staff allows the client to verbalize thoughts when trying to sleep 3. The staff encourages the client to express his feelings more clearly 4. The LPN/LVN administers flurazepam hydrochloride 15 mg at bedtime

4. The LPN/LVN administers flurazepam hydrochloride 15 mg at bedtime Medication that produces dependence should be a last resort; used only if other nursing measure and antidepressant medications have not worked and the client is exhausted

The nurse makes a follow-up visit to the home of the client recently diagnosed with AIDS. Which activities, if performed by the client, indicates that teaching has been effective? 1. The client uses a firm toothbrush once a day to brush their teeth 2. The client eats a large lunch at noon and a small dinner at 6 pm 3. The client changes the liter in the cat's liter box every day 4. The client takes docusate sodium 300 mg once a day

4. The client takes docusate sodium 300 mg once a day Bowel programs, stool softners, and laxatives reduce intestinal stasis and bacterial overgrowth