Saunders Test Yourself 1

The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply. The routine dosage The client's home address The generic medication name The length of time for the administration The route and frequency of administration

C, D, E Rationale: Medication safety is extremely important in all health care settings. The nurse should be prepared to evaluate each medication prescription to ensure that the proper information is included, and intervene when necessary to provide safe client care. The information should include: the specific dosage (rather than just the routine dosage), generic drug name, length of drug administration and route and frequency of administration. The medication prescription does not need to include the client's home address.

The nurse is caring for a client with a latex allergy. Upon entering the client's room, the nurse should plan to take which action as the priority? Perform a skin assessment Perform a physical assessment Ask if the client needs pain medication Remove the banana from the client's breakfast tray

D Rationale: A sensitivity or allergy to certain substances alerts the nurse to other possible cross allergies. The nurse should be aware of this and prevent allergic reactions whenever possible. The nurse should know that the client with an allergy to latex, may also be allergic to bananas. The priority action that the nurse should plan to take when entering the client's room, is to remove the banana from the client's breakfast tray. The other actions can be completed once the risk of allergic reaction has been removed.

A client has come to the emergency department complaining of burning with urination. What should the nurse consider a priority when providing care in order to maintain the client's psychosocial integrity? Use medical terminology when speaking to the client. Provide the client with as much privacy as possible during the examination. Explain to the client that all questions will be answered at the time of discharge. Administer medications as soon as they are prescribed by the health care provider.

B Rationale: Providing the client with as much privacy as possible during the examination is the best way to maintain psychosocial integrity and should be considered a priority by the nurse. Using medical terminology may be confusing to the client. The nurse should explain all actions and procedures to the client before they occur. Administering medications as soon as prescribed is important, but does not necessarily maintain the client's psychosocial integrity in this situation

Which manifestations are specifically noted in a client with right-sided heart failure.? Select all that apply. Wet cough Hepatomegaly Breathlessness Dependent edema Neck vein distention

B, D, E Rationale: Right ventricular failure is associated with increased systemic venous pressure and congestion. Therefore, manifestations are noted in the systemic circulation and can include ascites, hepatomegaly, dependent edema and neck vein distention. Breathlessness, a cough, and other pulmonary manifestations are often a sign of left-sided heart failure

The nurse is caring for a 55-pound child on the pediatric medical surgical unit being treated for Lyme disease. The health care provider has prescribed ceftriaxone intramuscular 50 mg/kg/day in two divided doses. The nurse should administer how many milligrams per dose? Fill in the blank. ________ mg

625

The post-operative client is experiencing moderate pain and requests pain medication from the nurse. The prescription reads: morphine 4 mg intravenous (IV) push every three hours as needed. The morphine is supplied in an ampule of 10 mg/mL. How many milliliters should the nurse administer? Fill in the blank and record your answer using the one decimal place. ________ mL

0.4

The client has been prescribed amoxiciilin 250 mg three times daily for sinusitis. The medication is supplied in a 500 mg tablet. How many tablet(s) would the nurse prepare every 8 hours to administer the correct dose? Fill in the blank. Record the answer using one decimal place. _____________ tablet(s)

0.5

The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action? [V-Tach] Check for a pulse Notify the health care provider Obtain a 12 lead electrocardiogram (ECG) Begin cardiopulmonary resuscitation (CPR)

A Rationale: Ventricular tachycardia can be stable or unstable depending on whether the client has a pulse or not. In this case, assessing the client's pulse is the initial action. Obtaining a 12 lead ECG and notifying the health care provider may be necessary but are not initial actions. Initiating CPR may be necessary of the ventricular tachycardia becomes unstable and cardiac arrest occurs.

The nurse is caring for a client on a ventilator. Which symptoms should alert the nurse to the possibility of absorption atelectasis? Select all that apply. Crackles in the lungs Diminished lung sounds Decrease in blood pressure Increase in red blood cell count High oxygen saturation readings

A, B Rationale: Nitrogen in the air helps maintain patent airways and alveoli. Making up 79% of room air, nitrogen prevents alveolar collapse because it does not cross the alveolar-capillary membranes and remains in the airways and alveoli. When high oxygen levels are delivered, nitrogen is diluted, oxygen diffuses from the alveoli into the circulation, and the alveoli collapse. Collapsed alveoli cause atelectasis (called absorption atelectasis), which is detected by auscultation. The nurse providing care to the ventilated client should be alert for signs of absorption atelectasis. These symptoms include: crackles in the lungs and diminished lung sounds. The nurse should intervene when these symptoms are present. High oxygen saturation, decreased blood pressure, and an increase in the red blood cell count are not typical signs of absorption atelectasis.

The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. After assessing the client, the nurse administers furosemide as prescribed. Which actions by the nurse are the most important after administering the medication? Select all that apply. Assess lung sounds Measure urine output Obtain and monitor vital signs Document the client's meal intake Assess the client for pitting edema

A, B , C Rationale: The client with pulmonary edema needs aggressive treatment and continuous cardiac monitoring. The most important interventions for the nurse to take after administration of the medication include: assessing the client lung sounds and vital signs and measuring the urine output. These interventions will assist in evaluating client status and response to treatment and alert the nurse to any deterioration in the client's health. Documenting the client's meal intake and assessing for pedal edema are not the most important actions to take after administering the medication.

The nurse is caring for a client who expresses an interest in alternative therapies to reduce the risk of illness and disease. What noninvasive activities should the nurse recommend to the client? Select all that apply. Yoga Meditation Biofeedback Acupuncture Herbal therapy

A, B, C Rationale: Integrative health care encompasses complementary and alternative therapies in combination with conventional Western modalities of treatment. Many popular alternative healing modalities offer human-centered care based on philosophies that recognize the value of the client's input and honor the individual's cultural beliefs, values, and desires. When caring for this client, the nurse should recommend noninvasive activities such as yoga, meditation, and the use of biofeedback. Acupuncture and herbal therapies are invasive modalities.

The nurse is caring for a malnourished client with dementia and a history of rheumatoid arthritis, and is creating a plan of care for the client's nutrition. Which nursing actions are most appropriate for increasing the client's caloric intake? Select all that apply. Provide pain medications as needed. Play soft, calming music during mealtimes. Serve the food at the appropriate temperature. Provide the client with three large meals per day. Encourage the client to eat quickly, to prevent fatigue.

A, B, C Rationale: Malnutrition results from inadequate nutrient intake, increased nutrient losses, and increased nutrient requirements. Inadequate nutrient intake can be linked to poverty, lack of education, substance abuse, decreased appetite, and a decline in functional ability to eat independently, particularly in older adults. In order to support the client, the nurse should provide pain medication as needed so that the client is comfortable during meal times. The nurse can make mealtime positive by providing a quiet environment, which is conducive to eating. Soft music may calm those with advanced dementia or delirium. It is important that the nurse serve the client's food at the appropriate temperature, in order to make the food appealing to the client. Arranging for the client to eat six small meals per day, instead of three large meals, may increase the client's desire to eat, and prevent the client from being overwhelmed by a large amount of food at each meal. It is important that the nurse avoid rushing the client through a meal, but allow as much time as needed.

The nurse is evaluating a client who is four weeks post-partum. Which statement by the client would indicate a need for intervention? Select all that apply. "I feel like giving up." "My husband never helps me with the baby." "My baby will not stop crying and I can't take it anymore." "I wish I could get more than four hours of sleep at a time." "My milk has come in and my baby is nursing every 2 hours."

A, B, C Rationale: Post-partum depression is an intense and pervasive sadness with severe and labile mood swings and is more serious and persistent than postpartum blues. Intense fears, anger, anxiety, and despondency that persist in the new mother past the baby's first few weeks of life are not a normal part of postpartum blues. These symptoms rarely disappear without professional help. The nurse should be aware of statements that could place the well-being of the client and infant at risk, such as wanting to give up or reporting lack of support from a spouse. An inconsolable infant should be evaluated to determine the cause of crying. Most clients in the post-partum period struggle with sleep due to the infant waking up for feedings, which is a normal part of infant life in the first few weeks. An infant who nurses every two hours at four weeks of life is a normal finding and does not require an intervention.

The nurse is educating an older client on sources of stress. Which statements by the client indicate that the teaching has been effective? Select all that apply. "Relocating to a nursing home causes stress." "Financial hardships can be a cause of stress." "A lifestyle change such as retiring can cause stress." "A history of anxiety can be a source of stress in the older person." "The birth of a new grandchild is often a source of stress for the older person."

A, B, C Rationale: Stress can accelerate the aging process over time, or it can lead to diseases that increase the rate of degeneration. Although no period of the life cycle is free from stress, the later years can be a time of especially high risk. While educating the client on sources of stress, the nurse should evaluate the knowledge of the client. It is important that the client understand the sources of stress, so that they can be avoided when possible. Sources of stress for the older client include: relocation, financial hardships, and lifestyle changes. A history of anxiety is not often a source of stress for the older client. The birth of a new grandchild is often a joyous experience for the older client.

The nurse is creating a plan of care for a client that will undergo a total joint replacement. What should the nurse include in the client's plan of care? Select all that apply. Teach interventions to reduce client anxiety Educate the client on what to expect after surgery Complete a physical assessment before the surgery Ask the client's family to wait in the waiting room before surgery Allow time for the surgeon to address questions after the surgery

A, B, C Rationale: The client's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the client for the surgery and client safety. The nurse should include activities in the plan of care that will focus on preparing the client for surgery such as interventions that will reduce the client's level of anxiety and education on what to expect after surgery. The nurse should perform a physical assessment and alert the surgeon to any findings that would interfere with the surgery. When possible, the client's family should be with the client before surgery to reduce the client's anxiety. The nurse should allow time for the surgeon to meet with the client and family before (not after) the surgery to address any questions or concerns.

The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply. Provide the child's parents with a simple dosing schedule. Create a medication schedule that fits the parent's lifestyle. Assist the child's parents in obtaining the medication at an affordable cost. Ensure that the child's family is able to read the written discharge instructions. Refer the family to the pharmacist with questions about medication side effects.

A, B, C, D Rationale: It is important that the nurse create a medication schedule that fits the family's lifestyle and provide the family with a simple dosing chart. This helps to ensure that the child receives proper medication dosing and prevents medication errors. The nurse should consider cost of prescribed medications and providing the family with resources as needed. During the discharge process, the nurse should verify that the family can read the written discharge instructions and answer any questions about the prescribed medications, including side effects.

The nurse is caring for an older client who is being treated for malnutrition. Which actions by the nurse would be the most appropriate when providing for this client's care and comfort? Select all that apply. Ask if the client lives alone. Evaluate the fit of the client's dentures. Educate the client on how to choose healthy foods. Determine if the client qualifies for any food services. Recommend that the client choose over-the-counter medications for ailments.

A, B, C, D Rationale: Malnutrition or nutrition-related problems can occur in older adults when their nutritional needs are not met. When caring for the malnourished client, the nurse should evaluate the client's living situation. Older clients, who live alone, are more likely to become malnourished. The nurse should also evaluate the fit and comfort of dentures. The client is less likely to eat if dentures are poor fitting. The nurse should be prepared to determine the client's level of knowledge and educate as necessary. Food services, such as meals on wheels, provide food to the older client who may not be able to obtain food on their own. The nurse should assess the client to determine if this assistance would be an option. Over-the-counter medications can cause changes in taste, placing the client at a greater risk for a decreased appetite. The client should speak with the health-care provider before beginning any over-the-counter medication.

The nurse is planning care for a client who is confused. The nurse should include which actions in the client's care plan? Select all that apply. Allow a pet visit Play soft, calming music Toilet the client every 2 to 3 hours Evaluate the client for signs of pain Apply restraints as needed if the client becomes agitated

A, B, C, D Rationale: The nurse should plan care that keeps the client as comfortable and peaceful as possible. If possible, the nurse should allow a pet visit. The nurse should also ensure a comforting environment. Many times clients who are confused are unable to express the need to be toileted, which can increase agitation. It is also important that the nurse evaluate the client for pain, and treat the pain immediately. Applying restraints should be a last option. Restraints often increase agitation and lead to the client becoming violent.

A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply. Not responding to the infant's cries. Crying after talking with spouse on the phone. Stating that family was not supportive of the pregnancy. Making statements about being fat and unattractive now. Stating that the infant latched on properly during a feeding.

A, B, C, D Rationale: The weeks following the birth are a time of vulnerability to psychiatric disorders, such as depression for many women, causing significant distress for the mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional and social development. It is important that the nurse frequently assess the client for post-partum depression. Ignoring the infant's cries should alert the nurse that further assessment is needed. Crying after talking with a spouse of the phone could indicate a problem at home. Statements of non-supportive family members need to be addressed by the nurse, for the safety and well-being of the client and infant. The nurse should also address the client's statements about body image, educating the client about what is normal and what is not normal in the post-partum period. Stating that the infant latched on during a feeding is a positive action and would not indicate the need for further assessment.

The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular stent graft. What priority actions should the nurse include in the plan of care? Select all that apply. Assess for pedal pulses Monitor urinary output Administer analgesics as needed Keep the head of the bed elevated to at least 60 degrees Encourage use of an abdominal pillow when coughing or deep breathing

A, B, C, E Rationale: A priority nursing action after an AAA repair with a graft is to ensure patency of the graft. In order to do this, the nurse would monitor vital signs, pedal pulses, urinary output, and extremity color at least hourly. Pain medication is administered as needed and as prescribed and administered regularly for better pain management. The head of the bed is maintained at 45 degrees or less to prevent flexion of the graft. The client should be instructed to use an abdominal pillow when coughing or deep breathing to prevent incision splitting.

The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply. Assess laboratory values. Obtain and assess vital signs. Evaluate the client's venous access. Identify the client by room number and bed. Check the health care provider's prescriptions with another nurse.

A, B, C, E Rationale: Before administering any blood product, review the agency's policies and procedures. The nurse should take care to ensure that the client is adequately prepared to receive the blood. This is accomplished by assessing the client's laboratory values, in order to determine the client's need for intervention. The nurse should also obtain and assess the client's vital signs, prior to blood administration. This is completed so that the nurse can detect any change from the client's baseline during the administration. The client's venous access should be assessed prior to the blood administration, ensuring that at least a 20 gauge IV is in place and patent. Checking the health care provider's prescription with another nurse is a crucial step that must be completed. The nurse should not simply identify the client by room number and bed.

A nurse employed at a long-term care facility is caring for a client who has recently been transferred from the hospital. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply. Encourage friends and family to visit frequently. Establish a trusting relationship with the client as soon as possible. Change rooms frequently to prevent the client from becoming bored. Ensure the client is an active part of decision making regarding their care. Allow the client to move around the halls as desired to decrease the confusion and acting-out.

A, B, D Rationale: Relocation stress can occur when a client is removed from their usual surrounding such as home. In order to provide safe and quality care, encourage friends and family to visit the client often and establish a trusting relationship with the client as soon as possible. It is important for the client to have an active role in decision-making. In order to lessen confusion, the nurse should provide the client time to become familiar with the immediate surroundings such as his or her room before allowing or encouraging ambulation to new surroundings; allowing the client to move around the halls as desired may increase confusion and acting-out behaviors. Likewise, changing the client's room frequently may increase confusion.

The client is being discharged home after the delivery of a healthy infant. The nurse is educating the client on how to prevent postpartum depression. Which activities are the most appropriate for the nurse to suggest? Select all that apply. Exercise on a regular schedule Eat a healthy, well-balanced diet Try to do housework when the baby sleeps Don't overcommit yourself to activities that will be tiring Stay home with the baby as much as possible, to promote bonding

A, B, D Rationale: The postpartum nurse must observe the new mother carefully for any signs of tearfulness and conduct further assessments as necessary. Nurses must discuss post-partum depression to prepare new parents for potential problems in the postpartum period. The nurse can provide activities and recommendations to improve the client's health and well-bring. Exercising on a regular basis will help the client feel better and maintain physical health, as well as eating a healthy diet. The nurse should also suggest avoiding over commitment to activities that will tire the new mother. The nurse should advise the client to sleep when the infant sleeps. While it is important for the client to bond with the infant, the client should not be isolated from friends and family.

The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. When creating a plan of care for the client, which interventions should the nurse include in the plan? Select all that apply. Assess the skin integrity Monitor the site frequently Place the IV at an area of flexion Educate the client about the signs and symptoms of infiltration Understand the vesicant potential before administering the infusion

A, B, D, E Rationale: It is important that the nurse take time to prepare for the IV infusion before administering any medication. The nurse should assess the client's skin integrity prior to selecting an IV site. The nurse should avoid placing the IV at an area of flexion, such as in the antecubital space, or any other space that will limit or prevent the client's range of motion. The nurse should plan to monitor the site frequently for signs of infiltration. The nurse should also educate the client about the signs and symptoms of infiltration and inform the client to alert the if any signs such as discomfort occur. Prior to administering the infusion, the nurse should understand the vesicant potential.

The nurse is obtaining the medical history from an older client with a black eye and bruising to the head. The nurse suspects that the client has been abused, and that there may be a history of abuse. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply. "Perhaps I somehow did this to myself." "I tripped over a rug and now I have a black eye." "I got into a car accident yesterday and the airbag deployed." "Well, I don't remember anything that would have caused the injuries." "Sometimes my grandson becomes angry with me when I can't give him money."

A, B, D, E Rationale: There are certain elements in the medical history that raise concern for physical abuse. Perpetrators may provide a history of events that are incomplete or inconsistent with injuries seen. Many individuals who experience interpersonal violence are unable or afraid to provide an accurate account of events. Often individuals will provide a history of trauma that is inconsistent with the physical examination. It is unlikely that these injuries were self-inflicted or the result of tripping over a rug. Having no recollection of how an injury occurred should be an alert to the nurse, as well as statements that another person caused the injury. The nurse should immediately report this to the appropriate legal authorities, a health care provider and the social worker so that proper intervention and follow-up can be arranged. A car accident with air bag deployment could reasonably cause the injuries to the client, and could be easily verifed. The nurse should continue on with assessment, treatment and arrange follow-up care for the client.

The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply. Provide culturally sensitive education. Encourage family members to obtain a tuberculosis skin test. Provide written instructions in English for the client to reference. Encourage the client and family to wash all dishes by hand to prevent the spread of infection. Urge all family and close contact community members to seek and complete treatment to enhance compliance.

A, B, E Rationale: As always, the nurse must provide culturally sensitive education. Because tuberculosis is highly contagious, all family members and close community members should have a tuberculosis skin test, seek treatment, and remain compliant. A full course of 6 to 9 months of treatment is needed to prevent re-infection. Instructions written in English are not helpful for the client with limited English skills. Washing dishes by hand is not the best way to prevent infection; rather a dishwasher should be used if available.

The nurse is presenting information to a new nursing employee regarding a thoracentesis that will take place later today. Which instructions should the nurse provide regarding signs/symptoms of a pneumothorax? Select all that apply. "Frequent coughing should be reported." "Be sure and report any bluish color to the skin." "Having air hunger is to be expected." "Discomfort on the unaffected side should be evaluated immediately." "Presents of a slanted trachea in the neck region need to be reported."

A, B, E Rationale: The nurse should explain that pneumothorax is a complication of a thoracentesis. Signs and symptoms of a pneumothorax include: cyanosis, often noticed around the lips; pain on the affected side, frequent coughing, a feeling of air hunger, and a slanted trachea. Clients with these signs and symptoms will need to be evaluated right away. Discomfort on the unaffected side is not associated with a thoracentesis or pneumothorax.

The nurse notices that an older client's skin is very dry. What actions would be appropriate for the nurse to implement into the care plan? Select all that apply. Ensure adequate hydration Wait 15 minutes after bathing to apply lotion Instruct the client to avoid caffeine and alcohol Rub skin surfaces dry in order to remove dead skin Use lavender scented lotion, which can help add moisture to the skin

A, C Rationale: Ensuring adequate hydration can help hydrate the skin from the inside out. Dehydration is avoided by eliminating substances such as caffeine and alcohol. Lotion can be beneficial if applied 2 to 3 minutes after bathing when skin still has moisture. Rubbing the skin can further dry the skin. Scented soaps, lotions, and oils can dry out the skin.

The nurse is caring for a client with cancer who has a sealed implant of a radioactive source. Which actions should the nurse take to promote safety for staff and visitors? Select all that apply. Keep the client's door closed Limit each visitor to 1 hour per day Wear a lead apron while providing care Assign the client to a semi-private room Remove dressings and linens from the room as they are soiled

A, C Rationale: Solid or sealed radiation sources are implanted within or near the tumor. These sources can be temporary or permanent. Most implants emit continuous, low-energy radiation to tumor tissues. Safety for staff and visitors should be a priority for the nurse and are focused on preventing exposure to the radiation. Therefore, ways to promote safety include wearing a lead apron while providing care. The nurse should always keep the lead facing the client, never turning away from the client. The door to the client's room should be kept closed. Visitors should be limited to one-half hour a day, and should remain 6 feet (1.8 meters) from the source of radiation. The client should be assigned to a private room with a private bathroom, and not in a semi-private room. All dressings and linens should be kept in the room until the source of radiation has been removed.

A client is being discharged home after a routine hip replacement surgery. The nurse is instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply. "Limiting fiber is necessary to avoid diarrhea." "I should empty my bladder when I feel the urge." "Avoiding pain medication will prevent constipation." "I should drink plenty of liquids like iced tea or coffee." "I should continue with my physical therapy and walking."

A, C, D Rationale: Constipation is common after surgery due to pain medication, decreased movement, and anesthesia. Fiber intake should be encouraged as it promotes the prevention of stool retention. Although pain medication can cause constipation, it should not be avoided in the post-operative period. Drinking plenty of fluids is encouraged for both bowel and bladder maintenance, but the client should choose non-caffeinated options. Physical therapy, walking, and exercise will help prevent constipation. Emptying the bladder when the urge is present can help prevent urinary tract infections.

The nurse is caring for a client in the hospital and is reconciling the client's home medications. The client is taking Lactobacillus, a probiotic over-the-counter medication. The nurse is discussing the supplement with the client. What statement by the client would warrant the need for further teaching? Select all that apply. "I can take my probiotic at any time of day or night." "Probiotics can be found in yogurt and some juices." "I should take this supplement to prevent gas and bloating." "Because I'm lactose intolerant, a probiotic would not benefit me." "This supplement will help me avoid getting diarrhea from antibiotics."

A, C, D Rationale: Probiotics are live microorganisms that are similar to those found naturally occurring in the gastrointestinal tract. Probiotics should be taken as directed, usually with a meal, and can have a side effect of gas and bloating. If gas and bloating do occur, the client should be advised to try a different type of probiotic. Probiotics are recommended for those clients who are lactose intolerant. Probiotics are found in foods such as yogurts and some juices and can be helpful to treat antibiotic-associated diarrhea.

The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an understanding of a PICC? Select all that apply. "The tip of the PICC line sits in the superior vena cava." "Insertion of the PICC line occurs in the operating room." "PICCs can accommodate infusions of all types of therapy." "PICCs with a lumen size of 14 Gauge or larger can be used for blood sampling." "PICCs are the most appropriate for client's who require short-term antibiotics."

A, C, D Rationale: A peripherally inserted central catheter (PICC) is a catheter inserted through a vein of the antecubitcal fossa (inner aspect of the bend of the arm) or the middle of the upper arm. When educating the new nurse on the purpose and use of PICC lines, the nurse preceptor should discuss the placement of the PICC line, including where the PICC line is placed in the body. The nurse should explain that PICC line insertions are typically done at the client's bedside, by a nurse with specialized training. PICC lines can accommodate infusions of all types of therapy because the tip sits in the superior vena cava, where the rapid blood flow quickly dilutes the infusion. The nurse preceptor should include information about blood sampling, such as only sampling blood from a PICC line with a lumen size of a 14 Gauge or larger. The new nurse should also recognize that PICC lines are often used for client's who require long-term antibiotics, in order to protect the vein and skin tissue.

The nurse provides information to an assistive personnel (AP) about caring for a client with neutropenia. Which statements by the AP indicate that teaching has been effective? Select all that apply. "I should practice good hand washing." "The client needs mouth care at least every 24 hours." "The client may not have a high fever if infection occurs." "Any sores or skin irritations should be reported right away." "I need to take precautions to protect myself from the client's illness."

A, C, D Rationale: Monitoring for manifestations of infection is critical for the hospitalized client with neutropenia. The nurse should communicate the importance of this to the AP, and actions that can be taken to reduce infection. The AP should state the importance of taking precautions to protect the client from potential infections. The AP should be able to state the need to practice good hand washing, as well as the client's need for mouth care at least every 12 hours, not every 24 hours. The AP should understand that any rashes or open sores should be reported right away, and that the client may not have the classic signs of infection, such as a high fever, due to the decrease in white blood cells (WBCs) that occurs in neutropenia.

The nurse educator is presenting a lecture on child neglect. Which statement by one of the students indicates that the teaching has been effective? Select all that apply. "A sign of neglect are bruises on the child's body." "Neglected children show aggression after age 10." "Neglect is parental failure to meet a child's basic needs." "Neglected children often have learning problems and low self-esteem." "Neglect occurs when a parent does not seek medical attention for a sick child."

A, C, D, E Rationale: Neglect has serious consequences for children. Basically, there are 5 types of child neglect: physical neglect; psychological or emotional neglect; medical neglect; mental health neglect; and educational neglect. One sign of physical neglect is bruising on the child's body. Neglect is the parental failure to meet a child's basic needs such as: food, shelter, comfort, love, and medical attention. Consequences of neglect include: learning problems, low self-esteem, developmental delays, passivity and juvenile delinquency. Children who are neglected often show signs of aggression before the age of 2.

The nurse is working in the emergency department when a client with heat exhaustion is brought in. Which actions would be the appropriate in order to effectively treat the client? Select all that apply. Remove any restrictive clothing. Administer salt tablets to the client. Apply cool water soaks to the client. Give the client an oral rehydrating solution. Apply cool packs to the client's neck and groin.

A, C, D, E Rationale: If untreated, heat exhaustion can lead to heat stroke. The nurse should reduce the client's temperature immediately. This can be done by applying cool water soaks to the client, removing any restrictive clothing, orally rehydrating the client with a sports drink or rehydrating solution, and applying cool packs to the client's body. The nurse should avoid giving the client salt tablets, as these can cause stomach irritation, nausea, and vomiting—which can lead to further dehydration. In addition, they can alter the electrolyte balance.

The nurse is caring for a client with bipolar disorder. When creating a care plan for this individual, which should the nurse include as appropriate goals? Select all that apply. The client will understand what bipolar disorder is. The client will ask the nurse to refill the prescriptions each month. The client will be able to manage the symptoms of bipolar disorder. The client will perform activities of daily living (ADLs) independently. The client will state the importance of taking medications as prescribed.

A, C, D, E Rationale: While caring for the bipolar client, it is important that the nurse create a plan of care, in order for the client to have the best outcome. The nurse should ensure that the client understands important concepts such as: what bipolar disorder is, how to manage the symptoms and the importance of taking medications as they are prescribed. The nurse should also assess the client's ability to realistically solve problems of daily living, such as obtaining more medications. The client should be able to call the pharmacy to refill medications, instead of relying on the nurse.

The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply. A child with autism An infant with fetal alcohol syndrome A child with attention deficit disorder A child with generalized anxiety disorder A child with expressive language disorder

A, D Rationale: A developmental delay is defined as not meeting the expected developmental level. Social and emotional developmental delays include those affecting personality, emotion, or behaviors. Two examples are autism and generalized anxiety disorder. Attention deficit disorder and fetal alcohol syndrome are classified as cognitive developmental delays, and expressive language disorder is a communication developmental delay.

The nurse is caring for a postoperative client with a patient controlled analgesia (PCA) pump. When creating the client's plan of care, which opiate-induced side effects should the nurse monitor? Select all that apply. Sedation High blood glucose Increased appetite Nausea and vomiting Elevated cardiac enzymes

A, D Rationale: Patient-controlled analgesia (PCA) is a common way to address the problem of inadequate analgesia by allowing the client to control the dosage of opioid received. When creating the plan of care, the nurse should anticipate opiate-induced side effects, and be prepared to monitor for them and manage them. These side effects include sedation, nausea, and vomiting. High blood glucose, increased appetite and elevated cardiac enzymes are not typical opiate-induced side effects.

The nurse is attending a teaching session on communicating with the ill child. Which statement by the nurse indicates that the teaching has been effective? Select all that apply. "I will strive to maintain honesty and trust with each child." "Children frequently ask multiple questions, even when they fear the answers." "Providing as much information as possible will help ease the child's fears." "Complete honesty may cause problems for some family and staff members." "To prevent misunderstandings, I should ask the child to explain what is known."

A, D, E Rationale: After listening to the lecture on communication with the ill child, the nurse should understand the need to strive to maintain honesty and trust with each child. Lack of honesty and trust can hinder care and leave the child feeling frightened. The nurse should also understand that children often are reluctant to ask questions when they fear the answers. The nurse should keep the child informed, while clarifying any questions the child has. Clarifying questions can help the nurse avoid providing more information than the child wants or can handle emotionally. Providing too much information may be overwhelming and frightening to the child. It may also inhibit future questions and interaction with the nurse. It is important for the nurse to consider that not everyone agrees with complete honesty; at times, parents may directly ask the nurse to withhold information from the child. It is important that the nurse maintain honesty, using terms that the parents agree upon. One of the most important aspects of communicating with a child is to have the child explain what is already known to them about their illness. The nurse can then answer questions accordingly without overwhelming the child with information.

The nurse is caring for a client who has just come in to the emergency department to receive treatment. The client reports a bite from a brown recluse spider. The nurse assesses the bite mark and notes that it is possibly infected. Which actions should the nurse take? Select all that apply. Apply ice to the site. Contact a surgeon immediately. Apply a non-sterile dressing to the site. Cleanse the area with a topical antiseptic. Assess the date of the client's last tetanus immunization.

A, D, E Rationale: Brown recluse spider venom causes cell damage. The central bite site may appear as a bleb or vesicle surrounded by edema and erythema, which may expand over the course of hours as the toxin spreads to surrounding tissues. The nurse should take immediate action to prevent further damage to the bitten area. Applying ice to the site helps decrease the enzyme activity of the venom and assists in decreasing swelling of the tissue. Cleansing the area with a topical antiseptic and applying a sterile dressing can help decrease the risk of infection, and prevent a current infection from worsening. The nurse should also assess the date of the client's last tetanus immunization, and prepare to administer the vaccine if necessary. It is not necessary to contact a surgeon immediately. If necrosis is present then a surgeon may be needed for debridement.

The nurse is educating a new registered nurse (RN) about the Healthy People 2020 goals. Which statements by the RN indicate that teaching has been effective? Select all that apply. "Healthy People 2020 aims to promote healthy behaviors." "Healthy People 2020 aims to make health care more affordable." "Healthy People 2020 aims to improve the health of the geriatric population." "Healthy People 2020 aims to eliminate preventable disease, disability, injury, and preventable death." "Healthy People 2020 aims to create social and physical environments that promote good health for all."

A, D, E Rationale: Healthy People 2020 provides science-based 10-year national objectives for improving health and preventing disease in the United States. The nurse should evaluate the new RN's understanding of the information, and provide additional education as needed. The teaching has been effective when the new RN can state that Healthy People 2020 aims to promote healthy behaviors, eliminate preventable disease, disability, injury, and preventable death; as well as to create social and physical environments that promote good health for all. Healthy People 2020 strives to create a society that is healthy for all populations, however, the objectives do not include making health care affordable.

The nurse is caring for a client with a blood pressure of 80/54 mmHg. Which actions should the nurse take because of the risk of hypovolemic shock? Select all that apply. Insert a large-bore intravenous (IV) line Position the client into high Fowler's position Keep intravenous fluids to be administered cold Anticipate administering Ringer's lactate solution Perform assessments and monitor the client closely

A, D, E Rationale: Hypovolemic shock occurs when there is a decrease in the circulating blood volume in the body. When treating a client in hypovolemic shock, the nurse should insert a large-bore IV line, administer Ringer's lactate or 0.9 % normal saline solutions, perform assessments and monitor the client closely. These treatments will restore circulating blood volume to the client. Positioning the client in high Fowler's position could further decrease the blood pressure. Intravenous fluids should be warmed prior to administration to the client.

The nurse is creating a plan of care for a client with a respiratory infection. Which actions should the nurse include in the plan of care to prevent the spread of infection? Select all that apply. Clean the client's room daily Wash hands when they are soiled Wear gloves to apply fresh linen to the bed Keep fingernails short and without nail polish Place a mask on the client's face when transporting to other departments

A, D, E Rationale: Infection control within a health care facility is designed to reduce the risk for health-care associated infections (HAI). The nurse must implement measures to prevent the spread of infection. The nurse should include the following in a plan of care for the client: daily room cleaning to remove infectious material; keeping fingernails short and without nail polish because of the risk of harboring bacteria; and use of a mask when the client is transported to other departments to prevent spread. In addition, other departments that the client is being transported to should be aware of the risk of respiratory infection. The nurse should wash hands after every client contact or more frequently if needed, not just when they are soiled. Often hands may not look soiled, but can have infectious material on them. It is not necessary to use gloves to apply fresh bed linens.

The client has been diagnosed with valvular disease. Which interventions should the nurse be prepared to discuss with the client? Select all that apply. Surgical management Required dietary changes Encouraging oral fluid intake Placing limits on physical activity Monitoring for an irregular heart rhythm

A, D, E Rationale: Management of valvular heart disease depends on which valve is affected and the degree of valve impairment. When caring for a client with valvular disease the nurse should be prepared to discuss interventions. These include surgical and medication management, as well as placing limits on physical activity. Monitoring for an irregular heart rhythm is also a common intervention for clients with valvular disease. Required dietary changes is not specific to valvular heart disease although diet changes would be necessary for other cardiac disorders such as coronary artery disease. Valvular diseases can result in heart failure, and fluids may be restricted, not encouraged.

The nurse is meeting with an older client who was brought into the health care facility for evaluation. According to the family member, the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply. Assess the client's eyesight. Question the client about urinary habits. Review the list of the client's prescribed medications only. Determine the fit of the client's dentures. Assess the client for mental status changes.

A, D, E Rationale: Older adults in the community or in any health care setting are most at risk for poor nutrition. The nurse should review the medical history to determine the possibility of increased metabolic needs or nutritional losses, chronic disease, trauma, recent surgery of the gastrointestinal tract, drug and alcohol abuse, and recent significant weight loss. Each of these conditions can contribute to malnutrition. As part of a thorough assessment, the nurse should assess the client's eyesight. Clients with poor vision are often not able to drive to obtain groceries or cook for themselves. The nurse should also obtain a list of the client's medications, both prescription and over-the-counter. Certain medications can alter the taste perception and decrease the desire to eat. It is also important for the nurse to determine the fit of the client's dentures. Poor fitting dentures can lead to painful sores, which lead to a decrease in food intake. The nurse should also include an assessment of the client's mental status, observing for behavoir that may be abnormal for the client. Utilizing the family member's knowledge of the client's typical behavior will be important in the treatment of this client. While the client's urinary status is important to assess, it is not the most important action for the nurse to take at this time because it is not directly related to weight loss.

The nurse is completing a health history on a client who is 12 weeks pregnant. Which findings should alert the nurse to the risk of potential parenting problems? Select all that apply. The client reports feeling depressed The client has new health insurance The client states that she likes hospitals The client states that the father is not supportive The client is homeless and often stays in local shelters

A, D, E Rationale: Situational factors such as the family's ethnic and cultural background and socioeconomic status are assessed while the history is obtained. The nurse should be alert to how the client is currently feeling about the pregnancy, as well as the client's risk or actual appearance of depression. The nurse should also determine if the family is supportive of the pregnancy; lack of support can lead to parenting problems later on. The homeless client is at a high risk of parenting problems due to the lack of permanent residence; the nurse should address this problem immediately for the best outcome.

Which actions should the nurse take to adequately prepare a client for a thoracentesis? Select all that apply. Explain the procedure to the client Instruct the client to cough when asked to do so Teach the client to take slow, deep breaths during the procedure Tell the client to expect a stinging sensation from the anesthetic Inform the client that it is common to feel pressure from the needle insertion

A, D, E Rationale: Thoracentesis is the aspiration of pleural fluid or air from the pleural space. It can be used for diagnosis or treatment. In preparing the client for a thoracentesis, the nurse should thoroughly explain the procedure to the client, allowing time for the client to ask questions. The nurse should also instruct the client not to move during the procedure, and therefore the client should not cough or take deep breaths, in order to avoid puncture of the lungs or pleura. The client should be informed to expect a stinging sensation and pressure as the needle is inserted.

The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should the nurse give to the client? Select all that apply. "You may lose your hair." "It is ok to drink alcohol." "Constipation is a common side effect." "It has been shown that leflunomide can cause birth defects." "Leflunomide is a potent medication that is generally tolerated."

A, D, E Rationale: When creating and providing discharge instructions, it is important that the nurse include accurate information about leflunomide. The nurse should educate that the client that hair loss and diarrhea (not constipation) are possible. Women of child-bearing age should use a reliable method of birth control, as the medication can cause birth defects. The client should be educated that while leflunomide is a potent medication, it is generally well tolerated.

The nurse is providing discharge education to a client who was admitted for treatment with Addison's crisis and is reviewing the medication hydrocortisone. What statements made by the client would indicate teaching was effective. Select all that apply. "I should take this medication twice a day." "Weight gain is common and I should expect it." "If I forget a dose, I should take two pills the next time." "I may notice my cheeks become fat and rounded but this is okay." "If I notice any swelling or fluid retention, I should notify my healthcare provider."

A, E Rationale: Hydrocortisone is used in the treatment of Addison's disease. Adverse effects such as weight gain, moon face, and fluid retention are not expected and may indicate over-correction and a dose adjustment is needed. This medication can be taken once or twice daily, and should not be doubled if a dose is missed.

The nurse is providing care to a client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply. Cyanosis of the skin in the affected extremity Skin temperature cool to touch in the affected extremity Client complaints of stiffness in the joints of the affected extremity Complaints of sudden and severe pain in the affected extremity Bounding pulse in the affected extremity below the level of the occlusion

A,B,D Rationale: Although chronic peripheral arterial disease (PAD) progresses slowly, the onset of acute arterial occlusions may be sudden and dramatic. Acute arterial occlusion is serious and occurs when blood flow in a leg artery stops suddenly. If blood flow to the toe, foot, or leg is completely blocked, the tissue begins to die and can lead to gangrene. Intervention is needed immediately to restore blood flow. Manifestations of acute arterial occlusion are due to a lack of blood flow and include cyanosis, cool skin temperature, severe pain, problems moving the affected extremity, and a lack of a pulse. There would be no pulse as a result of the occlusion and blocked artery. Stiffness in the joints of the affected extremity is not a finding associated with acute arterial occlusion.

The nurse is caring for a client in the emergency department who is being treated for major burns and smoke exposure. What information in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to chart. Asthma Hoarse voice Blood pressure of 98/62 mmHg Blood glucose of 68 mg/dL (3.7 mmol/L)

B Rationale: Clients with major burns are at risk for respiratory compromise. A hoarse voice is an impending sign that the client may soon lose his airway due to obstruction or swelling. This would indicate the need to immediately activate the rapid response team as intubation is required. A history of asthma may impact respiratory status, however, the presence of asthma alone does not warrant a call to the rapid response team. The client's blood glucose reading is low, and should be treated, however, this can be done by the RN assigned to the client and does not warrant a rapid response team. Hypovolemia is associated with burns and would explain the low blood pressure reading.

The nurse is caring for a client in active labor. The nurse notices that the fetal heart rate pattern is demonstrating late decelerations. Which position should the nurse assist the client into? Refer to figures 1-4. Prone Lateral recumbent Knee-chest Dorsal recumbent

B Rationale: Late decelerations are a nonreassuring fetal heart rate that implies a decrease in placental sufficiency. To promote adequate oxygenation and blood flow to the fetus, the client should be assisted to a side lying position. Re-positioning may improve perfusion and the fetal heart rate. Positions such as prone and dorsal recumbent should be avoided to prevent compression of the vena cava and decreased blood flow. Knee-chest position may improve comfort, but side lying is best for perfusion.

The nurse is educating a client on how to self-manage care at home, following an admission to the hospital for heart failure. Which statements by the client indicate that teaching has been effective? Select all that apply. "I will weigh myself monthly." "I will wear my oxygen at night as prescribed." "I will follow up with my health care provider (HCP) as scheduled." "I will report new signs and symptoms to my home care nurse when she visits." "I have my medications and dosages memorized, and I recognize my pills by color."

B, C Rationale: Health teaching is essential for promoting self-management. Many clients with heart failure are readmitted to hospitals because they do not maintain their prescribed treatment plan, including lifestyle changes. The client should state the importance of daily weights, not monthly, to monitor for increases indicating fluid retention, wearing oxygen at night to prevent hypoxia, keeping follow-up appointments for monitoring status, and having medications and dosages written down and available for review and administration. The client should not wait for the home care nurse to report new signs and symptoms, but should report them immediately to the HCP in charge of care. Waiting could lead to worsening heart failure and complications such as pulmonary edema.

The nurse is caring for a client with joint pain and is educating the client on pharmacological management of pain with acetaminophen. What statements made by the client would indicate a need for further teaching? Select all that apply. "This medication is safe to take with my warfarin." "I should avoid eating grapefruit while taking this medication." "I should not take this medication more often than 3 times per day." "To prevent a stomach ache, I should take this medication with food." "I should report any skin itching or yellowing of the skin to my healthcare provider."

B, C, D Rationale: Acetaminophen works by blocking pain receptors. Grapefruit does not impact the ability of this medication and can be taken together. Dosing can occur every 4 to 6 hours as long as a daily maximum of 4000 mg is not exceeded. Gastrointestinal side effects are not common with this medication, and therefore, can be taken on an empty stomach. Acetaminophen does not inhibit platelet aggregation and can safely be taken with anticoagulants. Side effects such as liver toxicity, which include skin itching or yellowing of the skin should be reported immediately to the healthcare provider.

The nurse is caring for an older Japanese American man being treated in the oncology unit for prostate cancer. In order to provide culturally competent care, the nurse should include what actions in the care plan? Select all that apply. Address client by first name to promote a trusting relationship Routinely assess for pain, as Japanese Americans often remain stoic Provide personal space boundaries if client is in a semi-private room Allow for family to visit and participate in the decision-making process Encourage the client to verbally express their feelings and thoughts often

B, C, D Rationale: The client of Japanese descent often remains quiet and stoic, and therefore may not voice pain and should be assessed frequently. The nurse should pay attention to non-verbal signs of pain. Providing personal space boundaries may help alleviate tension and allowing family to partake in decision-making is an integral part of providing culturally competent care. Some Japanese American clients may be offended if called by their first name, and may not wish to talk frequently.

The client with heart failure is preparing to be discharged from the hospital. Which interventions should the nurse include in the client's discharge teaching plan? Select all that apply. Encourage the client to rest in bed Develop a regular exercise program Educate the client about dietary restrictions Give the client a minimal role in the self-management program Provide the client with a list of current medications and dosing times

B, C, E Rationale: Any client discharged from the hospital should be encouraged to become involved in as much self-care as possible and the client's condition allows. An exercise program is also important to maintain strength and circulation. Dietary restrictions may be necessary for the client with heart failure and may include fluid restrictions and sodium restrictions. Clients need to clearly understand how to administer prescribed medications and a written list of instructions is extremely helpful to ensure safety and compliance. It is unnecessary for the client to rest in bed.

The nurse is educating a client on how to prevent altitude sickness. Which statements indicate that the teaching has been effective? Select all that apply. "I will limit my fluid intake." "I will wear sunscreen and high quality goggles." "I will plan a quick ascent when changing to a higher altitude." "I will refrain from consuming alcohol when I am at a high altitude." "I will pay attention to the manifestations of altitude-related illnesses."

B, D, E Rationale: High altitude illness, also known as high altitude sickness or altitude sickness, cause pathophysiologic responses in the body as a result of exposure to low partial pressure of oxygen at high elevations. The nurse should educate the client on how to recognize and prevent altitude sickness and basic measures to treat sickness, until help can be obtained. The nurse can determine that teaching has been effective when the client identifies the following as being important: remaining hydrated, wearing sunscreen, using high quality goggles, refraining from alcohol use and recognizing the symptoms of altitude-related sickness. The client should prepare for a slow ascent, rather than a quick ascent. This allows the client to become acclimated to the altitude

The nurse is providing care to a client. After assessing the client, the nurse determines that the client's self ability to change position is compromised. Which actions should the nurse take to reduce the risk of skin break down? Select all that apply. Assess the skin daily Implement a turning schedule Gently massage reddened skin Keep the client's skin clean and dry Document skin breakdown prevention measures in the plan of care

B, D, E Rationale: If a client is unable to change positions the nurse should take special care in protecting skin integrity and preventing breakdown. After assessing the client, the nurse should implement a turning schedule for this client. The nurse should create a plan of care and document skin breakdown prevention measures so that other members of the health care team can continue care for this client. It is important that the nurse keep the client's skin clean and dry at all times, changing soiled linens whenever needed. Massaging reddened areas could damage fragile underlying tissues. The nurse should plan to assess the client's skin frequently to determine if there have been any changes to integrity; checking daily is too infrequent.

Which interventions should be included in the care of a client with a chest tube? Select all that apply. Change the chest tube each shift. Assess the insertion site for signs of infection. Assess the water seal chamber for a continuous, strong bubbling. Keep the drainage system lower than the level of the client's chest. Alert the health care provider (HCP) if drainage in the tube stops in the first 24 hours.

B, D, E Rationale: The chest tube site should be assessed for signs of infection and the drainage system should always be kept below the level of the client's chest to ensure adequate drainage. If drainage stops in the first 24 hours, the HCP should be notified immediately because there could be a blockage in the tube. The chest tube is not changed each shift and the system needs to remain closed and patent. A continuous strong bubbling in the water seal chamber indicates an air leak, requiring further investigation.

A client with anxiety has just been seen by the health care provider and has been prescribed alprazolam. A week later, the client is brought to the emergency room, after consuming a large number of tablets in an attempt to overdose. The client is unresponsive and has gasping respirations. Which action should the nurse take first? Administer the antidote naloxone Administer the antidote flumazenil Assist with intubation of the client Assist with insertion of a central venous line

C Rationale: The client requires immediate intubation because of the gasping respirations and unresponsiveness. Flumazenil is the antidote for an overdose of benzodiazepines; however, the priority is securing the airway. Naloxone is the antidote for an opiate overdose. Assisting with insertion of a central venous line is not the priority and would involve a great deal of time while the client is gasping to breathe.

The nurse is caring for a client who has been diagnosed with bladder cancer. Which action should the nurse take as a priority when planning psychosocial care for this client? Assess all urine for the presence of blood Question the client about insurance coverage Assess the client's ability to cope with the diagnosis Ask the client if there is a history of cancer in the family

C Rationale: When planning care that includes the psychosocial needs, the priority action for the nurse should be to assess the client's ability to cope with the cancer diagnosis. Other important aspects of caring for this client are to assess the urine and determine the client's medical history, including family history of cancer but these are physiological aspects. Questioning the client's insurance coverage is not typically a nursing function.

The nurse is preparing to administer oral potassium chloride to a client. What should the nurse keep in mind about this medication? Select all that apply. Potassium has a generally pleasant taste. Potassium can only be mixed with water. Potassium may be taken in a liquid or solid form. Potassium chloride can cause nausea and vomiting. Potassium may be given as an intramuscular (IM) injection.

C, D Rationale: When preparing to administer potassium to the client, the nurse should keep in mind that potassium has a strong, unpleasant taste that is often difficult to mask. The client should be made aware of this beforehand. Oral potassium may be taken as either a liquid or a solid. The nurse should be aware that potassium chloride can cause nausea and vomiting, therefore it is recommended that the client take the medication with food. Potassium can be mixed with a variety of liquids, in order to make the medication more pleasant for the client. Potassium should never be administered IM, because it is a severe tissue irritant.

The nurse is caring for a client with heat stroke, who is being cooled with a cooling blanket. Which actions should the nurse take to ensure that the intervention is effective? Select all that apply. Administer antipyretics Gradually lower the core temperature Monitor temperature continuously until it is stable Monitor for patency of the airway and prepare for intubation if necessary Prepare to insert an intravenous line for administration of fluids as needed

C, D, E Rationale: Victims of heat stroke have a profoundly elevated body temperature (above 104° F [40° C]) and need to be treated immediately with cooling measures to rapidly, not gradually, lower the body temperature. The nurse would monitor the temperature continuously using a rectal thermometer or other acceptable temperature measuring method. An intravenous line is inserted to administer fluids such as 5% dextrose in the event of hypoglycemia that can occur as a complication. The nurse should not administer antipyretics. Antipyretics can interrupt the change in the hypothalamic set point and are not expected to work on a healthy hypothalamus that has been overloaded, as in the case of heatstroke. In addition, they can be harmful in some situations.

A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply. Age Race Income Chronic illness Low birth weight Environmental exposure to toxins

C,D, E, F Rationale: Developmental delays can occur at any age; however, it is most commonly seen in infancy through adolescence. Developmental delays can occur regardless of race. Children living in poverty, those with chronic illnesses, low birth weight, or exposure to environmental exposure to toxins are at a higher risk for developmental delays.

The nurse is educating a child's parents on using the behavior modification technique of discipline. Which statement should the nurse make to the parents? "All behaviors should be acknowledged." "Rewards are given at the end of the training period only." "Negative behaviors are recorded where the child can see them." "Corporal punishment should not be used to encourage good behaviors."

D Rationale:The behavior modification technique of discipline rewards positive behavior and ignores negative behavior. This technique requires parents to choose selected behaviors, preferably only one at a time, that they desire to stop. They choose others that they want to encourage. The basic technique is useful for any age from toddlerhood through adolescence. Corporal punishment can lead to child abuse if the disciplinarian loses control. When educating the paents, the nurse should provide accurate information such as: ignoring negative behaviors, giving rewards throughout and at the end of the training period and recording negative behaviors out of the client's view.

A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT). The client will be discharged home on oral anticoagulants. What information in the client's medical record would warrant the need for teaching? Refer to chart. Sodium result D-Dimer result Vitamin D 400 IU daily 10 pack year history of smoking

D Rationale: A deep vein thrombosis (DVT) is the most common type of venous thromboembolism (VTE). DVTs occur most often in the legs, but can also occur in the upper arms. Smoking increases the risk of DVT formation, and clients should educated on the importance of quitting. The sodium result is within normal limits. The positive d-dimer result is expected, as it is a marker for DVTs. Vitamin D supplementation does not impact DVTs or anticoagulation therapy.

The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40 mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart. Expiratory rales Atorvastatin prescription Peripheral vascular disease Potassium level of 3.5 mEq/L (3.5 mmol/L)

D Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5 mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should anticipate that the potassium level would drop with the administration of furosemide. Therefore, the nurse should verify continuing the prescription if this potassium level was noted. Expiratory rales are an expected finding with fluid overload and furosemide would be an appropriate treatment. Atorvastatin and peripheral vascular disease are not impacted by the administration of furosemide.

When conducting the preoperative interview with the client, the client reports an allergy to shellfish. Which agent is most likely to cause an allergic reaction in this client? Latex Penicillin Medical tape Providone-Iodine

D Rationale: The nurse should anticipate this client to have an allergic reaction to providone-iodine, also known as betadine. It is important that the nurse report the allergy to shellfish to the surgeon right away so that another method of skin cleansing can be chosen. Latex, penicillin, and medical-tape are not considered cross allergens for shellfish.

The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first? Prepare the medication Verify the dosage of meperidine Assess the client's pain score before administration. Clarify the medication prescription with the health care provider.

D Rationale: The nurse should immediately recognize that meperidine is contraindicated for the older client because it has toxic metabolites that can cause seizures and other complications. The first step the nurse should take is to clarify the prescription with the health care provider. The other steps should not be done.Test-Taking Strategy: Focus on the strategic word, "first," and focus on the data in the question and that the client is an older client. Determine which step the nurse should take first when receiving the medication order. Eliminate the options of preparing the medication, verifying the dosage and assessing the pain score, because this medication should not be given to an older client.

The nurse is educating a client on obesity. Which statements by the client indicate a need for further teaching? Select all that apply. "Type 2 diabetes is a complication of obesity". "I will likely develop obstructive sleep apnea". "Physical inactivity is one of the causes of obesity". "My heart and lungs are mildly affected by obesity". "It is unlikely that I will develop peripheral artery disease".

D, E Rationale: After receiving education from the nurse, the client should be able to state that complications and risks of obesity such as type 2 diabetes and peripheral artery disease and other cardiovascular and respiratory system complications such as obstructive sleep apnea. It is also important that the nurse discuss the causes of obesity, which include physical inactivity. Encouraging the client to exercise 20 minutes per day can decrease the risk of obesity and life threatening illnesses.