Reduction of risk potential

Question 1 See full question 31s A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge? You Selected: "I can't wait to take a tub bath when I get home." Correct response: "I can't wait to take a tub bath when I get home." Explanation: The client will need to avoid extremes of motion in the hip to avoid dislocation. The hip should not be flexed more than 90 degrees, internally rotated, or legs crossed. It is not possible to safely sit in the bathtub without flexing the hip beyond the recommended 90 degrees. The client can implement the prescribed exercise program at the time of discharge home. The client should take care not to stress the hip for 3 to 6 months after surgery. An elevated toilet seat will be necessary during the recovery from surgery. Add a Note Question 2 See full question 51s A nurse is teaching the parents of a preschooler about the possibility of post-operative hemorrhage after a tonsillectomy and adenoidectomy. When should the nurse explain that the risk of bleeding is the greatest? You Selected: 7 to 10 days after surgery Correct response: 7 to 10 days after surgery Explanation: The risk of hemorrhage from a tonsillectomy is greatest when the tissue begins sloughing and the scabs fall off. This typically happens 7 to 10 days after a tonsillectomy. Add a Note Question 3 See full question 48s After teaching the parents of a child with celiac disease about diet, the nurse understands the teaching has been effective if the parents state that which foods should be avoided? Select all that apply. You Selected: bologna on rye sandwich hot dog buns Correct response: hot dog buns bologna on rye sandwich Explanation: Children with celiac disease should avoid foods containing the protein gluten, which is found in wheat, oats, rye, and barley grains. Hot dog buns, unless otherwise labeled, contain wheat. Children are allowed to eat foods containing rice, soy or corn. Add a Note Question 4 See full question 25s After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent: You Selected: depriving the client of sufficient oxygen supply. Correct response: depriving the client of sufficient oxygen supply. Explanation: After suctioning, the client should rest at least 3 minutes or until respirations return to normal before suctioning is repeated, unless secretions interfere with breathing. Intermittent suctioning prevents oxygen deprivation. Hypoxia can lead to cardiac arrhythmias and cardiac arrest. The client should receive 100% oxygen between suctionings. The nurse should not prevent stimulating the cough reflex as it helps mobilize secretions. Intermittent suction does not prevent dislodgment of the tracheostomy tube. Intermittent suction does not keep the suction catheter from becoming obstructed; clearing the catheter with normal saline will keep the catheter clear. Add a Note Question 5 See full question 58s Which statement indicates that a client with diabetes mellitus understands proper foot care? You Selected: "I'll wear cotton socks with well-fitting shoes." Correct response: "I'll wear cotton socks with well-fitting shoes." Explanation: The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury. Add a Note Question 6 See full question 1m 55s A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care? You Selected: "Keep your right leg elevated above heart level." Correct response: "Keep your right leg elevated above heart level." Explanation: The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection. Add a Note Question 7 See full question 32s A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? You Selected: Declining level of consciousness (LOC) Correct response: Declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur. Add a Note Question 8 See full question 45s A nurse is checking the laboratory results of an adult client with colon cancer admitted for further chemotherapy. The client has lost 30 lb (13.6 kg) since initiation of the treatment. Which laboratory result should be reported to the health care provider (HCP)? You Selected: albumin level of 2.8 g/dL (28 g/L) Correct response: albumin level of 2.8 g/dL (28 g/L) Explanation: The nurse must recognize that an albumin level of 2.8 g/dL (28 g/L) indicates catabolism and potential for malnutrition. Normal albumin is 3.5 to 5.0 g/dL (35 to 50 g/L); less than 3.5 (35 g/L) indicates malnutrition. The other laboratory results are normal. Add a Note Question 9 See full question 21s Which symptom should the nurse teach the client with unstable angina to report immediately to the health care provider (HCP)? You Selected: a change in the pattern of the chest pain Correct response: a change in the pattern of the chest pain Explanation: The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities. Add a Note Question 10 See full question 1m 12s Which of the following is the recommended nursing assessment to confirm placement of the nasogastric (NG) tube into the stomach of a client? You Selected: Obtain a chest X-ray and measure the pH of stomach contents. Correct response: Obtain a chest X-ray and measure the pH of stomach contents. Explanation: A chest X-ray and pH that shows acidity are the only definitive diagnostic tools to confirm placement. The other choices are not best practice. Measuring the tube or using makings do not confirm placement, only approximate distance for insertion.

lvL 0 to 2

Question 1 See full question 58s After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate? You Selected: Holding the infant semi-upright during feedings Correct response: Holding the infant semi-upright during feedings Explanation: Holding the infant semi-upright during feedings is appropriate because it helps prevent aspiration. The Logan bow must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on the abdomen could lead to disruption of the suture line if the infant rubs the face. Add a Note Question 2 See full question 2m 3s Nursing care for a client after electroconvulsive therapy (ECT) should include: You Selected: assessment of short-term memory loss. Correct response: assessment of short-term memory loss. Explanation: After ECT, the nurse must assess the client's short-term memory loss. The client might need to be reoriented. The client may get out of bed and eat as soon as he feels comfortable doing so. Add a Note Question 3 See full question 1m 5s Which steps should a nurse follow to insert a straight urinary catheter? You Selected: Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. Correct response: Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. Explanation: Preparing the client and equipment, creating a sterile field, putting on gloves, cleaning the urinary meatus, and inserting the catheter until urine flows are all the vital steps for inserting a straight catheter. The nurse must prepare the client and equipment before creating a sterile field. Putting on gloves before creating a sterile field and performing the other tasks is incorrect. Testing the catheter balloon describes the procedure for inserting a retention catheter, rather than a straight catheter. Add a Note Question 4 See full question 29s The nurse teaches the client with iron deficiency anemia that food sources with high iron content include: You Selected: beef. Correct response: beef. Explanation: Beef, liver, iron-fortified cereals, and spinach are iron-rich foods. Cheese, squash, and apples do not have significant sources of iron. Add a Note Question 5 See full question 1m When developing the plan of care for a toddler who has taken an acetaminophen overdose, which intervention should the nurse expect to include as part of the initial treatment? You Selected: gastric lavage Correct response: gastric lavage Explanation: Initial management of a child who has ingested a large amount of acetaminophen would include inducing vomiting or performing gastric lavage with or without activated charcoal to aid in the removal of the substance. Frequent blood level determinations may be obtained during the follow-up phase, but they are not done as part of the initial treatment. Tracheostomy is not typically part of the initial treatment for acetaminophen overdose. However, it may be necessary later if respiratory distress develops. Acetaminophen primarily affects the liver, not the heart. Therefore, an electrocardiogram would not be considered part of the initial treatment plan. Add a Note Question 6 See full question 50s A 21-year-old client undergoes bone marrow aspiration at the clinic to establish a diagnosis of possible lymphoma. Which statement made by the client demonstrates proper understanding of discharge teaching? Select all that apply. You Selected: "I will take acetaminophen for pain." "I will not be able to play basketball for the next 2 days." "I can apply an ice pack or a cold compress to the puncture site." Correct response: "I will take acetaminophen for pain." "I will not be able to play basketball for the next 2 days." "I can apply an ice pack or a cold compress to the puncture site." Explanation: Acetaminophen is a safer analgesic than aspirin in order to avoid bleeding. Contact sports or trauma to the site should be avoided. Cool compresses should limit swelling and bruising. The puncture site should be inspected every 2 hours for bleeding or bruising during the first 24 hours. Add a Note Question 7 See full question 37s A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? You Selected: Endotracheal suctioning Correct response: Endotracheal suctioning Explanation: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected. Add a Note Question 8 See full question 3m The infant with hemophilia A experiences bleeding in the elbow and is seen in the emergency department. Which nursing intervention would be most appropriate to minimize bleeding in the affected area? You Selected: Apply continuous pressure to the elbow. Correct response: Elevate the elbow above the level of the heart. Explanation: Add a Note Question 9 See full question 23s A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? You Selected: Stage 3 pressure ulcer on the left heel Correct response: Stage 3 pressure ulcer on the left heel Explanation: Add a Note Question 10 See full question 27s During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which of the following is the most appropriate nursing action? You Selected: Document this finding as on the high end of the normal range and plan to reassess. Correct response: Document this finding as on the high end of the normal range and plan to reassess.

LvL 2 to 3

Question 1 See full question 1m 7s For a child with a Wilms' tumor, which preoperative nursing intervention takes highest priority? You Selected: Avoiding abdominal palpation Correct response: Avoiding abdominal palpation Explanation: Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a child with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious. Add a Note Question 2 See full question 46s A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she's in true labor, the nurse should assess for: You Selected: changes in cervical effacement and dilation after 1 to 2 hours. Correct response: changes in cervical effacement and dilation after 1 to 2 hours. Explanation: True labor is characterized by progressive cervical effacement and dilation after 1 to 2 hours, regular contractions, discomfort that moves from the back to the front of the abdomen and, possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical effacement or dilation even after 1 or 2 hours. Add a Note Question 3 See full question 57s A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects to administer which neuromuscular blocking agent? You Selected: Succinylcholine Correct response: Succinylcholine Explanation: Succinylcholine, a depolarizing blocking agent, is the drug of choice when short-term muscle relaxation is desired — for example, during ECT or intubation. Vecuronium, pancuronium, and atracurium are nondepolarizing blocking agents used for intermediate- or long-term muscle relaxation. Add a Note Question 4 See full question 1m 12s An adolescent is being prepared for an emergency appendectomy. The nurse should tell the client? Select all that apply. You Selected: The teen will be back in school in 1 week. The scar will be small. Correct response: The scar will be small. The teen will be back in school in 1 week. Explanation: Teens are very concerned about their body image and knowing about the size of the scar is important to them. Typically, teens return to school in 1 week. While hospitalized, friends can visit during visiting hours. Clients are usually hospitalized for an uncomplicated appendectomy for about 24 hours. Antibiotics are not routinely given to prevent an infection. The dressing is removed within a few days. Add a Note Question 5 See full question 2m 29s A client is scheduled for a creatinine clearance test. What should the nurse do? You Selected: Instruct the client about the need to collect urine for 24 hours. Correct response: Instruct the client about the need to collect urine for 24 hours. Explanation: A creatinine clearance test is a 24-hour urine test that measures the degree of protein breakdown in the body. The collection is not maintained in a sterile container. There is no need to insert an indwelling urinary catheter as long as the client is able to control urination. It is not necessary to force fluids. Add a Note Question 6 See full question 23s A middle-aged female with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which action should the nurse suggest? You Selected: See the health care provider (HCP) immediately. Correct response: See the health care provider (HCP) immediately. Explanation: Redness, warmth, and swelling are all signs of infection. Treatment with antibiotics is usually indicated. Infection usually increases fluid accumulation and could worsen the lymphedema. Warm compresses could also increase fluid accumulation. Elevation will not treat the infection. It is critical that the client not delay treatment. Add a Note Question 7 See full question 30s A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: You Selected: Yellow sclerae. Correct response: Yellow sclerae. Explanation: Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively. Add a Note Question 8 See full question 50s A female client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia? You Selected: Acromegaly Correct response: Acromegaly Explanation: Acromegaly, which is caused by a pituitary tumor that releases excessive growth hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this disorder. The accompanying soft tissue swelling causes hoarseness and, commonly, sleep apnea. Type 1 diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin. Hypothyroidism and growth hormone deficiency aren't associated with hyperglycemia. Add a Note Question 9 See full question 55s A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? You Selected: Declining level of consciousness (LOC) Correct response: Declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur. Add a Note Question 10 See full question 48s Which of the following statements indicates that a new graduate nurse understands central venous pressure (CVP) measurement when used on a client? You Selected: "It will assess pressure and volume changes in the right atrium." Correct response: "It will assess pressure and volume changes in the right atrium." Explanation: The best rationale for CVP measurement is to assess pressure and volume in the right atrium. CVP does not measure breathing patterns or blood pressure. Superior vena cava syndrome is usually caused by an obstruction such as a tumor or lymphoma.

LvL 3 to 4

Question 1 See full question 3m 3s A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? You Selected: Up to 20 Correct response: Up to 20 Explanation: A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13. Add a Note Question 2 See full question 50s A physician diagnoses leukemia in a child, aged 4, who complains of being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the physiologic effects of leukemia? You Selected: Activity intolerance related to hypoxia and weakness Correct response: Activity intolerance related to hypoxia and weakness Explanation: A nursing diagnosis of Activity intolerance related to hypoxia and weakness reflects the nurse's understanding of leukemia's physiologic effects because a child with leukemia may experience weakness and lack of oxygen. The nurse's findings don't support the other diagnoses of Ineffective airway clearance related to fatigue, Imbalanced nutrition: More than body requirements related to lack of activity, or Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells. Add a Note Question 3 See full question 21s A 4-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. The nurse should suspect that the child's I.V. fluid intake is excessive if assessment reveals: You Selected: worsening dyspnea. Correct response: worsening dyspnea. Explanation: Dyspnea and other signs of respiratory distress signify fluid volume overload, which can occur quickly in a child as fluid shifts rapidly between the intracellular and extracellular compartments. Gastric distention suggests excessive oral (not I.V.) fluid intake or infection. Nausea and vomiting or an elevated temperature may indicate a fluid volume deficit, not an excess. Add a Note Question 4 See full question 12s A nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider? You Selected: Incompatibility between the child's history and the injury Correct response: Incompatibility between the child's history and the injury Explanation: Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. For example, the child may have a skull fracture but the parents state that the child fell off of the sofa. The other criteria also may suggest child abuse but are less reliable indicators. Add a Note Question 5 See full question 57s Encouraging fantasy play and participation by children in their own care is a useful developmental approach for which pediatric age-group? You Selected: Preschool age (3 to 5 years) Correct response: Preschool age (3 to 5 years) Explanation: Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation. Allow choices when possible. Add a Note Question 6 See full question 1m 30s How should a nurse prepare a suspension before administration? You Selected: By shaking it so that all the drug particles are dispersed uniformly Correct response: By shaking it so that all the drug particles are dispersed uniformly Explanation: The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form. Add a Note Question 7 See full question 28s A nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children? You Selected: Kidneys Correct response: Kidneys Explanation: The kidneys are most responsible for drug excretion in children. Less commonly, some drugs may be excreted via the lungs or liver. Drugs are never excreted by the heart in children or adults. Add a Note Question 8 See full question 11s A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention? You Selected: Heart rate less than 60 beats/minute Correct response: Heart rate less than 60 beats/minute Explanation: Bradycardia, a slow but steady heartbeat at a rate less than 60 beats/minute, is an ominous sign in children. Older children experiencing anaphylaxis initially demonstrate tachycardia in response to hypoxemia. When tachycardia can no longer maintain tissue oxygenation, bradycardia follows. The development of bradycardia usually precedes cardiopulmonary arrest. The average systolic blood pressure of children ages 1 to 7 can be determined by this formula: age in years plus 90. Thus, an average blood pressure for a 5-year-old child is 95 mm Hg. Urticaria should be treated after airway control has been established. The normal respiratory rate for a 5-year-old is 20 to 25 breaths/minute. Add a Note Question 9 See full question 1m 25s Parents of a 4-year-old with sickle cell anemia tell the nurse that they would like to have other children, but they're concerned about passing sickle cell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to? You Selected: Genetic counselor Correct response: Genetic counselor Explanation: A genetic counselor can educate the couple about an inherited disorder, as well as screening tests and treatments that can be done; the counselor can also provide emotional support. Clergy are available to provide spiritual support. A social worker can provide emotional support and help with referrals for financial problems. A nurse-midwife cares for women during pregnancy and birth. Add a Note Question 10 See full question 35s A 5-year-old child has been placed on phenytoin for tonic-clonic seizures. The child weighs 42 lb (19.1 kg), and the maintenance dose prescribed for this child is 7.5 mg/kg/day. How many milligrams should the child receive each day? Record your answer using a whole number. Your Response: 143 Correct response: 143 Explanation: Determine the dose by multiplying the child's weight by the dose ordered: 19.1 kg x 7.5 mg = 143 mg/day.

LvL 3 to 4

Question 1 See full question 38s A school-age child is being discharged with a diagnosis of rheumatic fever. Which instructions should be included in the teaching plan for the family? You Selected: The child should stay out of school until the source of the infection is determined. Correct response: The child should stay on penicillin and return for a follow-up appointment. Explanation: A child with rheumatic fever, which is caused by group A beta-hemolytic streptococci, should stay on penicillin — either oral daily or an injection monthly — to prevent a recurrence. A follow-up appointment is needed to determine how the child is responding to treatment. Neither bed rest nor monthly blood tests will be ordered for all children. Rheumatic fever is caused by group A beta-hemolytic streptococci, so the source of the infection is already known. Add a Note Question 2 See full question 51s A nurse is caring for a client who is experiencing alcohol withdrawal. Which assessment finding indicates the need for an as-needed dose of chlordiazepoxide? You Selected: Heart rate of 120 to 140 beats/minute Correct response: Heart rate of 120 to 140 beats/minute Explanation: Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. This finding indicates the need for a central nervous system depressant, which may prevent progression of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should carefully monitor the client's vital signs throughout the entire alcohol withdrawal process. Add a Note Question 3 See full question 37s A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding alerts the nurse to an increased risk for fetal distress? You Selected: Blood pressure of 146/90 mm Hg Correct response: Blood pressure of 146/90 mm Hg Explanation: A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus. Add a Note Question 4 See full question 34s A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored? You Selected: Blood urea nitrogen (BUN) Correct response: Blood urea nitrogen (BUN) Explanation: BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function. Add a Note Question 5 See full question 35s A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should: You Selected: monitor the client for signs of pneumothorax. Correct response: monitor the client for signs of pneumothorax. Explanation: After a bronchoscopy with a biopsy, the nurse should monitor the client for signs of pneumothorax as well as hemorrhage. The client should not gargle with oral lidocaine; this will not allow the gag reflex to return. The client should not have any mediastinal discomfort after a bronchoscopy; if pain does occur, it should be reported promptly to the health care provider (HCP). It is not necessary to tell the client not to talk until the gag reflex returns. Add a Note Question 6 See full question 38s The comatose victim of a car accident is to have a gastric lavage. Which position would be most appropriate for the client during this procedure? You Selected: lateral Correct response: lateral Explanation: An unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration. Positioning the client supine carries a major risk of airway obstruction from the tongue, vomitus, or nasopharyngeal secretions. Trendelenburg's position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema. The lithotomy position has no purpose in this situation. Add a Note Question 7 See full question 37s While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? You Selected: Platelet count, prothrombin time, and partial thromboplastin time Correct response: Platelet count, prothrombin time, and partial thromboplastin time Explanation: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, fibrinogen level, and D-dimer, as well as client history and other assessment factors. Red blood cell count and hemoglobin are not utilized in this diagnosis. Add a Note Question 8 See full question 55s Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia? You Selected: Monitoring the patency of an indwelling urinary catheter Correct response: Monitoring the patency of an indwelling urinary catheter Explanation: A full bladder can precipitate autonomic dysreflexia. The nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position cannot prevent autonomic dysreflexia. Add a Note Question 9 See full question 1m 52s The nurse is checking the laboratory results of an adult client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed? You Selected: blood glucose Correct response: blood glucose Explanation: The normal range for blood glucose is 70 to 100 mg/dL (3.9 to 5.6 mmol/L); the elevated blood glucose level indicates hyperglycemia. The hemoglobin is normal. The client's cholesterol and LDL levels are both normal. The nurse should determine if there are standing prescriptions for the hyperglycemia or notify the health care provider (HCP). Add a Note Question 10 See full question 1m 47s Which of the following actions should the nurse include in the plan of care for a client scheduled to undergo electroconvulsive therapy (ECT)? You Selected: Obtain the client's informed consent Correct response: Give nothing by mouth for at least 8 hours prior to the test Explanation: Before an ECT treatment, the nurse should ensure that the client is NPO for at least 8 hours prior to the therapy to decrease the risk of aspiration. Additionally the client should have had a medical evaluation that includes an electrocardiogram, a chest X-ray, neurologic and laboratory tests, and spinal X-rays, if indicated. The client is not routinely given antianxiety medication prior to the therapy. It is the responsibility of the physician to obtain the client's informed consent. While the nurse should be familiar with the effects of dantrolene, it is the physician or nurse anesthetist who administers this medication.

LvL 4 to 5

Question 1 See full question 2m 48s A multigravid client at 38 weeks' gestation is scheduled to undergo a contraction stress test. What should the nurse include in the explanation as the purpose of this test? You Selected: assessment of fetal ability to tolerate labor Correct response: assessment of fetal ability to tolerate labor Explanation: The purpose of a contraction stress test is to determine fetal response during labor. If late decelerations are noted with the contractions, the test is considered positive or abnormal. Fetal lung maturity is evaluated through amniocentesis to obtain the lecithin-sphingomyelin ratio. The nonstress test is part of the biophysical profile. Determining fetal response during movements is evaluated as part of the nonstress test. Add a Note Question 2 See full question 2m 9s The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which explanation should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision? You Selected: The foreskin is used to repair the deformity surgically. Correct response: The foreskin is used to repair the deformity surgically. Explanation: The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is commonly performed on the first or the second day of life. Add a Note Question 3 See full question 3m 11s Which position would be appropriate for a client with severe ascites? You Selected: Fowler's Correct response: Fowler's Explanation: Ascites can compromise the action of the diaphragm and increase the client's risk of respiratory problems. Ascites also greatly increases the risk of skin breakdown. Frequent position changes are important, but the preferred position is Fowler's. Placing the client in Fowler's position helps facilitate the client's breathing by relieving pressure on the diaphragm. The other positions do not relieve pressure on the diaphragm. Add a Note Question 4 See full question 1m 11s The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. What should the nurse do first? You Selected: Assess the client for signs of peritonitis. Correct response: Assess the client for signs of peritonitis. Explanation: The client's pain may be indicative of peritonitis, and the nurse should assess for signs and symptoms, such as a rigid abdomen, elevated temperature, and increasing pain. Reassuring the client is important, but accurate assessment of the client is essential. The full assessment should occur before pain relief measures are employed. Repositioning the client to the left side will not resolve the pain. Add a Note Question 5 See full question 1m 3s The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should: You Selected: place the client on nothing-by-mouth (NPO) status. Correct response: place the client on nothing-by-mouth (NPO) status. Explanation: The nurse should place the client on NPO status in anticipation of surgery. The nurse can initiate pain relief strategies, such as relaxation techniques, but the surgeon will likely not prescribe narcotic medication prior to surgery. The nurse can place the client in a position that is most comfortable for the client. Heat is contraindicated because it may lead to perforation of the appendix. Add a Note Question 6 See full question 1m 12s A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? You Selected: Use diaphragmatic breathing. Correct response: Use diaphragmatic breathing. Explanation: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion. Add a Note Question 7 See full question 5m 20s A client is receiving monthly doses of chemotherapy for treatment of stage III colon cancer. Which laboratory results should the nurse report to the oncologist before the next dose of chemotherapy is administered? Select all that apply. You Selected: temperature of 101.2° F (38.4° C) white blood cell count of 2,300/mm3 (2.3 X 109/L) platelet count of 40,000/mm3 (40 X 109/L) Correct response: platelet count of 40,000/mm3 (40 X 109/L) white blood cell count of 2,300/mm3 (2.3 X 109/L) temperature of 101.2° F (38.4° C) Explanation: Chemotherapy causes bone marrow suppression and risk of infection. A platelet count of 40,000/mm3 (40 X 109/L) and a white blood cell count of 2,300/mm3 (2.3 X 109/L) are low. A temperature of 101.2° F (38.4° C) is high and could indicate an infection. Further assessment and examination should be performed to rule out infection. The BUN, hemoglobin, and specific gravity values are normal. Add a Note Question 8 See full question 1m 37s An adolescent is admitted with a diagnosis of nephrotic syndrome. Which signs or symptoms would the nurse expect to see with this syndrome? Select all that apply. You Selected: Proteinuria Hypercholesterolemia Periorbital edema Hypoproteiemia Correct response: Hypercholesterolemia Hypoproteiemia Proteinuria Periorbital edema Explanation: The four classic signs and symptoms of early stage nephrotic syndrome are hypercholesterolemia, hypoproteinemia, proteinuria, and periorbital edema. Glucosuria is a sign of diabetes. Add a Note Question 9 See full question 1m 1s The nurse is caring for a client with an IV line. During care of the IV line, the nurse would be required to wear protective gloves in which of the following situations? Select all that apply. You Selected: When discontinuing the IV When spiking a new IV bag When priming the IV tubing When changing the IV site When inserting the IV Correct response: When inserting the IV When discontinuing the IV When changing the IV site Explanation: The nurse should wear protective gloves when inserting the IV, when discontinuing the IV, and when changing the IV site due to the risk of exposure to blood and bodily fluids. The nurse would not be required to wear protective gloves while spiking or hanging a new bag of solution. Add a Note Question 10 See full question 1m 26s While auscultating the apical heart rate, the nurse notes an irregular heart rhythm at a rate of 120 beats/min. Which is the nurse's next action? You Selected: Assess for a pulse deficit Correct response: Assess for a pulse deficit Explanation: The correct landmark for obtaining the apical pulse is the left fifth intercostal space in the midclavicular line. The nurse measures the apical-radial pulse for a deficit; apical rate minus radial rate. A deficit is present during atrial fibrillation, and premature ventricular contractions because some heart beats do not perfuse to distal areas. The client should not perform the Valsalva maneuver without electrocardiographic monitoring and the healthcare provider at the bedside; assessment of the underlying disorder should be made first to direct the proper intervention. Prior to calling healthcare providers, the nurse should report vital signs and presence of pulse deficit.

LvL 5 to 6

Question 1 See full question 1m 34s An 8-year-old child is receiving moderate sedation for a medical procedure. The nurse is assessing the child's level of sedation. His gag reflex is intact, he's breathing comfortably on his own, and he opens his eyes on verbal request. The nurse recognizes that the child is: You Selected: appropriately sedated. Correct response: appropriately sedated. Explanation: Moderate sedation is an induced state of depressed consciousness. While under moderate sedation, the child should maintain protective reflexes (such as the gag reflex), maintain a patent airway independently, and respond to physical stimuli or verbal commands such as, "Open your eyes." In this scenario, the nurse assesses that the child is under moderate sedation. An undersedated child would likely be anxious and would complain of pain. In deep sedation, the child isn't as easily aroused and doesn't have protective reflexes or the ability to maintain a patent airway; this type of sedation is closer to general anesthesia. With oversedation, the child is difficult to rouse; however, he is able to maintain a patent airway independently. Add a Note Question 2 See full question 33s A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest? You Selected: Neuroleptic malignant syndrome Correct response: Neuroleptic malignant syndrome Explanation: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue, mouth, and muscles of the face, arms, and legs. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness. Add a Note Question 3 See full question 37s A primigravid client at 30 weeks' gestation has been admitted to the hospital with premature rupture of the membranes without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is most important for the nurse to assess next? You Selected: temperature. Correct response: temperature. Explanation: Add a Note Question 4 See full question 3m 4s A loading dose of digoxin is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring his heart rate. An expected outcome of this instruction is: You Selected: a return demonstration of how to take the medication. Correct response: a return demonstration of palpating the radial pulse. Explanation: The goal of the education program is to instruct the client to take the pulse; therefore, the expected outcome would be the ability to give a return demonstration of how to palpate the heart rate. Add a Note Question 5 See full question 38s A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: You Selected: turning the client's head suddenly while holding the eyelids open. Correct response: turning the client's head suddenly while holding the eyelids open. Explanation: To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III function; normally, the client's pupil responds by constricting. Add a Note Question 6 See full question 1m 6s A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base her response on the fact that the: You Selected: skin test doesn't differentiate between active and dormant tuberculosis infection. Correct response: skin test doesn't differentiate between active and dormant tuberculosis infection. Explanation: The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the tuberculin skin test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis. Add a Note Question 7 See full question 2m 23s A nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding would indicate impairment in the affected extremity? You Selected: inability to move Correct response: inability to move Explanation: Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise. Add a Note Question 8 See full question 44s Which of the following demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion? You Selected: Use sterile gloves during the procedure. Correct response: Use sterile gloves during the procedure. Explanation: The tracheotomy site is a portal of entry for microorganisms. Sterile technique must be used within the first 24-48 hours because the site is a new source of infection. Monitoring the client's temperature is not reflected in application of this question. Povidone-iodine destroys new cellular growth, so it is not to be use on open wounds. The client should be in high Fowler's, not semi-Fowler's position. Add a Note Question 9 See full question 33s The nurse is assessing the client's bowel sounds (see the accompanying image). The nurse should: You Selected: listen for 2 minutes in each area of the abdomen. Correct response: expect to hear 5 to 35 sounds in 1 minute for normal bowel sounds. Explanation: Normal bowel sounds occur at a rate of 5 to 35 sounds per minute. The nurse should use the diaphragm of the stethoscope and listen for 5 minutes, moving the stethoscope in all four quadrants. The client should empty the bladder prior to auscultation, and not drink water, which might increase the frequency of the sounds. Add a Note Question 10 See full question 3m 26s The nurse is making a postpartum visit at the home of a client who delivered 14 days earlier. After assessing the vital signs (temperature, 99° F [37.2° C]; pulse, 88 bpm; respiration rate, 20 breaths/min; and blood pressure, 112/60 mm Hg), the nurse records the other assessments. (See exhibit.) Which finding indicates delayed involution? You Selected: edema of the ankles Correct response: fundus Explanation: The fundus descends at the rate of one to two cms per day and by 2 weeks is no longer a pelvic organ. The vital signs, breasts, heart, lungs, abdomen (with exception of fundus), lochia, perineum, and extremities are within normal limits.

LvL 6 to 7

Question 1 See full question 55s A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? You Selected: Taking vital signs every 4 hours and obtaining daily weight Correct response: Taking vital signs every 4 hours and obtaining daily weight Explanation: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation — can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation. Add a Note Question 2 See full question 3m 32s A 13-year-old adolescent may have appendicitis. Which finding is a reliable indicator of appendicitis? You Selected: The severity, location, and movement of pain Correct response: The severity, location, and movement of pain Explanation: The pattern of pain is a reliable indicator of acute appendicitis. It begins with a severe colicky abdominal pain that gets progressively worse. The pain starts in the midabdominal (periumbilical) region and moves to the right lower quadrant after 6 to 12 hours. The degree of fever, a history of vomiting and diarrhea, and a history of irritability and lethargy are also clinical manifestations of acute appendicitis; however, these conditions can also be present in a number of other childhood illnesses so they aren't as reliable as the pattern of pain. Add a Note Question 3 See full question 5m 43s A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? You Selected: Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Correct response: Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Explanation: The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Explaining what the fetal scalp electrode is, how it's applied, and that bedrest is required after application provides correct information about fetal scalp electrode application; however, these statements don't address the client's clinical situation, which prevents fetal scalp electrode application. The fetal scalp electrode helps monitor fetal heart rate, but it doesn't shorten labor. Add a Note Question 4 See full question 11s Which client is at greatest risk for Buerger's disease? You Selected: a 29-year-old male with a 14-year history of cigarette smoking. Correct response: a 29-year-old male with a 14-year history of cigarette smoking. Explanation: Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men less than 40 years of age, and there is a very strong relationship with tobacco use. Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus. Add a Note Question 5 See full question 27s A child received a local anesthetic before a cardiac catheterization. Following the procedure, the child has a pressure dressing on the right extremity and an IV line in place. He is slightly drowsy. What should the nurse do first? You Selected: Compare the color in the right and left legs. Correct response: Compare the color in the right and left legs. Explanation: Comparing the involved and uninvolved extremities in terms of color, temperature, pedal pulses, and capillary filling time is the highest priority following a cardiac catheterization to ensure adequate circulation to the involved extremity. Vital signs, including blood pressure, are checked as often as every 15 minutes after the procedure to detect arrhythmias and hypotension. The priority following a cardiac catheterization is assessing the circulatory status. Because the child received local anesthesia, the gag reflex would be normal. However, fluids should be encouraged after the procedure because the dye used during the catheterization procedure causes osmotic diuresis. Pulses, especially those below the catheterization site, are checked for equality and symmetry. Checking the temperature is only one aspect of assessing the circulatory status of the extremities. Additionally, the involved and uninvolved extremities must be compared to identify any differences that could indicate a compromise in circulation of the involved extremity. Add a Note Question 6 See full question 1m 29s A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? You Selected: Head of the bed elevated 45 degrees Correct response: Head of the bed elevated 45 degrees Explanation: After a myelogram, positioning depends on the dye injected. When a water-soluble dye such as metrizamide is injected, the head of the bed is elevated to a 45-degree angle to slow the upward dispersion of the dye. The prone and supine positions are contraindicated when a water-soluble contrast dye is used. The client should be positioned supine with the head lower than the trunk after an air-contrast study. Add a Note Question 7 See full question 40s The health care provider (HCP) prescribes a maternal blood test for alpha fetoprotein for a nulligravid client at 16 weeks' gestation. When developing the teaching plan, the nurse bases the explanations on the understanding that this test is used to detect which condition? You Selected: neural tube defects Correct response: neural tube defects Explanation: A blood test for alpha fetoprotein is recommended at 15 to 20 weeks' gestation to screen for certain chromosomal abnormalities and neural tube defects such as spina bifida. Chorionic villi sampling is used to detect chromosomal anomalies. Amniotic fluid amino acid determination is used to detect inborn errors of metabolism such as phenylketonuria. An amniocentesis is used to determine the lecithin-sphingomyelin ratio for fetal lung maturity, indicated by a ratio of 2:1, or chromosomal abnormalities. Rh incompatibilities are predicted with blood type testing measured with antigen tests. Add a Note Question 8 See full question 54s The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for a client? You Selected: Pneumonia Correct response: Pneumonia Explanation: By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis. Add a Note Question 9 See full question 36s A nurse notes that the client's PR interval is .17 and the QRS complex is .10. What action should the nurse take next? You Selected: Document the findings. Correct response: Document the findings. Explanation: These are normal findings. The nurse should document the findings. A 12-lead ECG would be ordered if the client needs further evaluation in the event of an abnormal finding. Administering nitroglycerin is a routine intervention and not related to the measured PR and QRS intervals. Oxygen administration is not indicated in the presence of normal findings. Add a Note Question 10 See full question 25s A client prescribed an antipsychotic medication develops a high fever, muscle rigidity, and hypertension. The nurse immediately notifies the health care provider with concerns that the client is experiencing which life threatening condition? You Selected: neuroleptic malignant syndrome Correct response: neuroleptic malignant syndrome Explanation: High fever, muscular rigidity, and altered consciousness are symptoms of neuroleptic maligany syndrome, a potentially fatal complication of antipsychotic medications and major tranquilizers. Malignant hyperthermia has similar symptoms but is associated with anesthesia. Extrapyramidal side effects involve movement disorders, including rigidity, but do not include a fever and are not considered to be life threatening. Hypertensive crisis refers to a systolic blood pressure over 180 or diastolic blood pressure over 110.

LvL 7 to 8