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Which of the following statements by the parent of a pediatric patient would indicate that further education is needed? A. "Coughing that won't stop can be a sign of an asthma attack." B. "I should expect my child's peak expiratory flow to increase during attack." C. "My child might become restless if he is having trouble breathing." D. "I might hear my child wheezing during an asthma attack."

B. "I should expect my child's peak expiratory flow to increase during attack." Peak expiratory flow rate measures how quickly a patient can exhale. Peak expiratory flow decreases during an asthma exacerbation because of restricted airways. Restlessness is often an early sign of hypoxia, which can occur during an asthma attack. Wheezing is often heard during an acute asthma attack, but it is not always present. Early signs of an asthma attack include coughing that doesn't stop; severe wheezing on both inhalation and exhalation; rapid breathing; neck and chest retractions; difficulty talking; pale, sweaty skin; and feelings of panic or anxiety.

A male patient tells his nurse that the CIA is monitoring and recording every movement, and microphones have been planted in the walls of the unit. Which response by the nurse would be the most therapeutic? A. "Why don't you wait and bring this up at your next therapy session?" B. "This must seem frightening to you, but I believe you are safe here." C. "There is no way this is true. Let's walk around the unit and I'll prove it to you." D. "I'm going to put you in your room for a while, so you w

B. "This must seem frightening to you, but I believe you are safe here." Delusions are common in schizophrenic patients. The patient absolutely believes the delusion is true, despite any evidence to the contrary. Acknowledge the patient's feelings and offer support, but do not contradict; doing so could lead to a lack of trust by the patient. Waiting to talk about the beliefs only reinforces the delusion. Isolation increases fear and anxiety.

The nurse in the newborn nursery is performing admission vital signs on the newborn infant. Which of the following findings indicates a normal heart rate? A. 110 beats per minute B. 130 beats per minute C. 160 beats per minute D. 180 beats per minute

B. 130 beats per minute The normal heart rate for a neonate is 120 to 150 beats per minute.

Data that were obtained during the perioperative nurse is assessing a client in the preoperative holding area. Which of the following findings would indicate a need for special protection techniques during surgery? A. A stated allergy to cats and dogs B. A history of spinal and hip arthritis C. Verbalization of anxiety by the client D. Having a sip of water 2 hours previously

B. A history of spinal and hip arthritis The client with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2-3 hours before surgery are not unusual for the preoperative client. An allergy to cats and dogs will not impact the care needed during the intraoperative phase.

Which of the following statements should the nurse teach the neutropenic client and his family to avoid? A. Performing oral hygiene after every meal B. Using suppositories or enemas C. Performing perineal hygiene after each bowel movement D Using a filter mask

B. Using suppositories or enemas Neutropenic clients are at risk for infection especially bacterial infection of the gastrointestinal and respiratory tract. An incorrectly administered enema can damage tissue in your rectum/colon, cause bowel perforation and, if the device is not sterile, infections.

Situation: You are working as a nurse in a respiratory care unit. A 68-year-old patient with a long history of smoking has been admitted with severe COPD exacerbation. The patient is experiencing dyspnea and increased cough. You are responsible for providing care and education to the patient. Which of the following arterial blood gas (ABG) findings is consistent with respiratory acidosis in a patient with COPD? A. pH 7.40, PaCO2 35 mm Hg, HCO3 24 mEq/L. B. pH 7.32, PaCO2 50 mm Hg, HCO3 28 mEq/

B. pH 7.32, PaCO2 50 mm Hg, HCO3 28 mEq/L. Respiratory acidosis occurs when the patient's lungs cannot effectively remove carbon dioxide (CO2) from the bloodstream, resulting in elevated arterial PaCO2 levels. A pH of 7.32 and a PaCO2 of 50 mm Hg in option B indicate respiratory acidosis. The lower pH value (acidic) and elevated PaCO2 levels are indicative of an accumulation of CO2, which leads to respiratory acidosis in patients with COPD.

If a research study involves an intervention and "blinding," which research design is being referred to? A. Non-descriptive B. Phenomenological C. Experimental D. Descriptive

C. Experimental Experimental research designs involve the manipulation of variables, such as interventions, to determine their effects. "Blinding" is a common technique used in experimental research to ensure that both researchers and participants are unaware of certain aspects of the study, reducing bias.

A young man with newly diagnosed human immunodeficiency virus (HIV) asks the nurse if he is ready for hospice care. How should the nurse respond? A. "You have about three years before you need to worry about hospice care." B. "Hospice care is only available for cancer patients and their families." C. "Every person with HIV can request hospice services at any time. Are you ready?" D. "Hospice care is intended for people who will die in a few weeks or months."

D. "Hospice care is intended for people who will die in a few weeks or months." Hospice care is a special service for clients and families when the client's life expectancy is just a few weeks or months. According to HIV.gov, HIV+ people who do not receive antiretroviral therapy (ART) can progress to AIDS in about three years. With ART, clients with HIV can live for decades without progressing to AIDS.

What percentage of patients who survived the polio epidemic of the 1950s are now estimated to have developed post-polio syndrome? A. 10% B. 25-30% C. 50% D. 60-80%

D. 60-80% Patients who survived the polio epidemic of the 1950s, many now elderly, are developing new symptoms of weakness, fatigue and musculoskeletal pain. It is estimated that between 60% and 80% of the 640,000 polio survivors are experiencing the phenomenon known as post-polio syndrome.

A client is going to have cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on teaching the client to report which of the following sensations during the procedure? A. Pressure at the insertion site B. Urge to cough C. Warm, flushed feeling D. Chest pain

D. Chest pain The client is taught before cardiac catheterization to report chest pain or any unusual sensations immediately. The client is taught that a warm, flushed feeling may accompany dye injection and is normal. The client may be asked to cough or breathe deeply from time to time during the procedure. Because local anesthetic is used, the client is expected to feel pressure but not pain at the insertion site.

When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care? A. Empty the drainage chamber during every shift and record the amount. B. Vigorously massage the tube every 2 hours to promote drainage. C. Change the insertion site dressing daily using aseptic technique. D. Encourage the patient to breathe deeply and cough regularly.

D. Encourage the patient to breathe deeply and cough regularly. Regular deep breathing and coughing will help re-expand the collapsed lung. The dressing is changed per protocol or as needed when it becomes soiled. Routine massage (milking) of the chest tube may excessively increase intrapulmonary pressures and may damage the lung. Tracking the amount of drainage during each shift is accomplished by marking on the collection chamber.

The nurse is positioning a client in the operating room for a transurethral resection of the prostate. Which of the following client positions should the nurse place this client in? A. Prone B. Supine C. Trendelenburg D. Lithotomy

D. Lithotomy The lithotomy position is used for genito-urinary procedures such as vaginal hysterectomy and transurethral resection of the prostate. Although supine is the most common position, it is not used for this surgery; rather it is appropriate for abdominal, cardiac, and breast surgeries. A variation of the supine is the Trendelenburg position, used in lower abdominal or pelvic surgery, for which it is necessary to see the pelvic organs. The prone position allows easy access for back surgeries (e.g., laminectomies).

Which of the following outcome measures is best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room? A. Smooth functioning of the OR team B. Effective protection of client privacy C. Rapid completion of surgical procedure D. Low incidence of perioperative infection

D. Low incidence of perioperative infection The primary focus when setting up the OR is the prevention of cross-contamination and transmission of infection to the client. Client privacy, efficient completion of procedures, and smooth functioning of the OR team are also important, but the priority is protection of the client from infection.

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The nurse is caring for a preoperative adult client who is scheduled for a routine surgery and is in the holding area. The client asks the nurse, "Will the doctor put me to sleep with a mask over my face?" Which of the following responses is most appropriate? A. "A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately." B. "Only your surgeon can tell you for sure what method of anaesthesia will be used. Should I ask your surgeon?" C.

A. "A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately." The first step in virtually all routine surgeries for general anesthesia is the injection of an intravenous (IV) induction agent, which rapidly induces sleep. The anesthesiologist (not the surgeon) determines the method of anesthesia used. Masks may still be used for inhalation, although many clients are intubated. Total IV anesthesia may be used for some clients but inhalation anesthetics also are commonly used. The client will have a face mask even if the medication is injected into client veins so telling the client that they will not have a face mask is not accurate.

The nurse is preparing a client for surgery. Which of the following actions should the nurse include in the surgical time-out procedure? (Select all that apply.) 1. Check for placement of IV lines. 2. Have the surgeon identify the client. 3. Confirm the hospital chart identification (ID) number. 4. Have the client state name and date of birth. 5. Ask the client to state the surgical procedure. 6. Verify the client ID band number. A. 3,4,5,6 B. 2,3,4,5 C. 1,3,4,5 D. 1,2,3,6

A. 3,4,5,6 These actions are included in surgical time out. IV line placement and identification of the client by the surgeon are not included in the surgical time-out procedure.

After routine patient contact, hand washing should last at least: A. 30 seconds B. 1 minute C. 2 minute D. 3 minutes

A. 30 seconds Depending on the degree of exposure to pathogens, hand washing may last from 10 seconds to 4 minutes. After routine patient contact, hand washing for 30 seconds effectively minimizes the risk of pathogen transmission.

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

A. Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Al-Anon members come to understand problem drinking as a family illness that affects everyone in the family. By listening to Al-Anon members speak at Al-Anon meetings, they can hear how they came to understand their own role in this family illness. This insight put them in a better position to play a positive role in the family's future.

Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL? A. Ataxia B. Potassium deficit C. Neglect syndrome D. Tetraplegia

A. Ataxia A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 35 mg/dl signifies toxicity. Symptoms of this level of concentration include ataxia, tremor, slurred speech, nausea, and vomiting.

Lesions in the temporal lobe may result in which of the following types of agnosia? A. Auditory B. Visual C. Tactile D. Relationship

A. Auditory Lesions in the temporal lobe (lateral and superior portions) may result in auditory agnosia.

The most common psychogenic disorder among elderly person is: A. Depression B. Sleep disturbances (such as bizarre dreams) C. Inability to concentrate D. Decreased appetite

A. Depression Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability. Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors

Which of the following are sympathetic effects of the nervous system? A. Dilated pupils B. Decreased blood pressure C. Increased peristalsis D. Decreased respiratory rate

A. Dilated pupils Dilated pupils are a sympathetic effect of the nervous system. Constricted pupils are a parasympathetic effect.

The nurse is assessing a patient with COPD who is experiencing increased sputum production. Which of the following interventions should be included in the plan of care? A. Encourage the patient to drink plenty of fluids to help thin the secretions. B. Administer antibiotics to treat the sputum production. C. Restrict the patient's fluid intake to reduce sputum production. D. Administer cough suppressants to decrease sputum production.

A. Encourage the patient to drink plenty of fluids to help thin the secretions. Patients with COPD often experience increased sputum production as a result of chronic inflammation and mucus hypersecretion in the airways. Encouraging the patient to drink plenty of fluids is a crucial intervention. Adequate hydration helps to thin the sputum, making it easier for the patient to expectorate and facilitating airway clearance. It is essential to promote effective mucus clearance to prevent exacerbations and complications associated with COPD.

The post-prandial serum glucose level of a pregnant woman who is at 24 week's gestation is 160 mg/dL. A nurse would expect the woman to have which of the following tests performed? A. Fasting blood glucose B. Glycosated hemoglobin C. Plasma glucagons level D. Qualitative urine glucose

A. Fasting blood glucose The normal postprandial serum glucose level for pregnant woman is 140 mg/dL or less. A fasting blood sugar evaluation is indicated next for this patient to rule out diabetes mellitus. B - In diabetes with hyperglycemia the increase in glycohemoglobin is usually caused by an increase in glycosated hemoglobin. The glucose concentration will increase when hyperglycemia caused by insulin deficiency develops. However, the fasting blood sugar would be performed before this test. C - Increased plasma glucagons levels are associated with diabetes. However, a fasting blood sugar would be performed first. D - Twenty-four hour glucose tests are not routinely ordered.

A healthcare provider is caring for a patient diagnosed with a mild cognitive impairment. Which of these would be the most effective intervention for this patient? A. Frequent reorientation B. Application of soft restraints C. Relaxation therapy D. Behavior modification

A. Frequent reorientation Frequent reorientation is the most effective intervention for a patient diagnosed with mild cognitive impairment. Behavior modification is an intervention aimed at changing undesirable behaviors. Restraints can increase agitation and should not be used unless absolutely necessary and only when certain criteria are met.

A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler (MDI), two puffs every 4 hours. The nurse instructs the client to report side effects. Which of the following are potential side effects of metaproterenol? A. Irregular heartbeat B. Constipation C. Pedal edema D. Decreased heart rate.

A. Irregular heartbeat Irregular heart rates should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on the beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

The patient complains of numbness and tingling in their feet. What term best describes this diabetes-related complication? A. Neuropathy B. Nephropathy C. Retinopathy D. Gastroparesis

A. Neuropathy The numbness and tingling in the feet experienced by the patient are indicative of diabetic neuropathy. Neuropathy is a common complication in diabetes, resulting from damage to nerves due to prolonged high blood sugar levels.

Which insulin should the nurse administer to rapidly lower the patient's blood sugar? A. Regular insulin (short-acting) B. NPH insulin (intermediate-acting) C. Insulin lispro (rapid-acting) D. Insulin glargine (long-acting)

A. Regular insulin (short-acting) In cases of hyperglycemia, it is essential to use a short-acting insulin, such as Regular insulin, to lower blood sugar rapidly. Regular insulin acts quickly and is suitable for managing acute blood sugar spikes.

A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A. Should be taken in the morning B. May decrease the client's energy level C. Must be stored in a dark container D. Will decrease the client's heart rate

A. Should be taken in the morning Levothyroxine (Synthroid) has a side effect of insomnia. Taking it in the morning could prevent interfering with the client's sleeping pattern.

Marielle, 17 years old was sexually attacked while on her way home from school. She is brought to the hospital by her mother. Rape is an example of which type of crisis: A. Situational B. Adventitious C. Developmental D. Internal

A. Situational Situational crisis is from an external source that upsets one's psychological equilibrium. These sudden and unexpected crises include accidents and natural disasters. Getting in a car accident, experiencing a flood or earthquake, or being the victim of a crime are just a few types of situational crises.

Which of the following statements describe the pathophysiology of post-polio syndrome? A. The exact cause is unknown, but aging or muscle overuse is suspected. B. The exact cause is unknown, but latent poliovirus is suspected. C. Post-polio syndrome is caused by an autoimmune response. D. Post-polio syndrome is caused by long-term intake of a low-protein, high-fat diet in polio survivors.

A. The exact cause is unknown, but aging or muscle overuse is suspected. The exact cause of post-polio syndrome is not known but researchers suspect that with aging or muscle overuse the neurons not destroyed originally by the poliovirus are unable to continue generating axon sprouts.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at A. controlling seizures and increased intracranical pressure. B. preventing renal insufficiency. C. maintaining hemodynamic stability and adequate cardiac output. D. preventing muscular atrophy.

A. controlling seizures and increased intracranial pressure. There is no specific medication for arboviral encephalitis. Medical management is aimed at controlling seizures and increased intracranial pressure.

The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for A renal complications related to acyclovir therapy. B. signs and symptoms of cardiac insufficiency. C. signs of relapse. D. signs of improvement in the patient's condition.

A. renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

A nursing student in the medical surgical unit reads that a patient has cyanosis. When the student asks the instructor what cyanosis means, the instructor's best response would be A. "Cyanosis is the blue coloring of skin and mucous membranes in the presence of highly oxygenated blood." B. "Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood." C. "Cyanosis means the patient has been exposed to cyanide poisoning." D. "Cyanosis is the primary

B. "Cyanosis is the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood." Cyanosis means that there is a blue color noted to the skin, mucous membranes, and nail beds, secondary to poorly oxygenated blood. When blood is fully oxygenated, it appears bright red; when it lacks sufficient oxygen, the blood is a dark purple or bluish red.

The nurse educates the patient about self-monitoring of blood glucose (SMBG). Which statement by the patient indicates understanding of SMBG? A. "I should check my blood sugar once a week." B. "I should check my blood sugar before meals and at bedtime." C. "I should check my blood sugar only when I feel unwell." D. "I don't need to check my blood sugar since I'm on insulin."

B. "I should check my blood sugar before meals and at bedtime." Proper self-monitoring of blood glucose (SMBG) involves checking blood sugar levels before meals and at bedtime, as well as at other specific times as directed by the healthcare provider. Regular monitoring helps patients manage their diabetes effectively by making informed decisions about insulin dosing, dietary choices, and physical activity. Checking blood sugar once a week or only when feeling unwell is insufficient for managing diabetes.

The nurse is performing an assessment on a newborn infant admitted to the nursery following birth. On assessment of the neonate's head, which of the following would the nurse most likely expect to note? A. A depressed anterior fontanel B. A soft and flat anterior fontanel C. An anterior fontanel measuring 1 cm D. An anterior fontanel measuring 6 cm

B. A soft and flat anterior fontanel The anterior fontanel is diamond shaped and located on the top of the head. It should be flat and soft and may range in size from almost nonexistent to 4 to 5 cm cross. It normally closes by 18 to 24 months of age. A depressed fontanel may indicate dehydration.

The nurse is caring for a client who is recovering from anesthesia in the post-anesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 and warm, dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time? A. Increase the rate of the IV fluid replacement. B. Continue to take vital signs every 15 minutes. C. Administer oxygen therapy at 1

B. Continue to take vital signs every 15 minutes. A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration

Francis who is addicted to cocaine withdraws from the drug. You should expect to observe: A. Hyperactivity B. Depression C. Suspicion D. Delirium

B. Depression There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused by the drug. When cocaine use is stopped or when a binge ends, a crash follows almost right away. The cocaine user has a strong craving for more cocaine during a crash. Other symptoms include fatigue, lack of pleasure, anxiety, irritability, sleepiness, and sometimes agitation or extreme suspicion or paranoia. Cocaine withdrawal often has no visible physical symptoms, such as the vomiting and shaking that accompany withdrawal from heroin or alcohol.

The nurse is preparing an older-adult client for discharge from the OPD surgical unit following left eye surgery. The client tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which of the following actions is the most appropriate for the nurse to implement? A. Refer the client to health center services. B. Discuss the specific concerns regarding self-care. C. Give the client written instructions regarding care. D. Assess the client's support system

B. Discuss the specific concerns regarding self-care. The nurse's initial action should be to assess exactly the client's concerns about self-care. Referral to health center and assessment of the client's support system may be appropriate actions but will be based on further assessment of the client's concerns. Written instructions should be given to the client, but these are unlikely to address the client's stated concern about self-care.

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The client is sleepy but awakens easily. Which of the following actions should the nurse take at this time? A. Place the client in a side-lying position. B. Encourage the client to take deep breaths. C. Prepare to transfer the client from the PACU. D. Increase the rate of the postoperative IV fluids.

B. Encourage the client to take deep breaths. The client's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the client and remind the client to take deep breaths. Placing the client in a lateral position is needed when the client first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The client is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate

A "full understanding" in research should be understood by the nurse researcher as ___. A. Ensuring that participants are not placed at risk. B. Explaining the study including risk and benefit. C. The right to decide voluntarily. D. Not exploiting information shared by participants.

B. Explaining the study including risk and benefit. A "full understanding" in research includes providing participants with a clear explanation of the study, including the associated risks and benefits. This ensures that participants are well-informed and can make voluntary, informed decisions about their participation without being exploited.

Which of the following statements is least descriptive of a qualitative research design? A. Researchers become involved. B. Gather data from one collection strategy. C. It is flexible and elastic. D. Strives for an understanding of the whole strategy.

B. Gather data from one collection strategy. The statement "Gather data from one collection strategy" is the least descriptive of a qualitative research design. Qualitative research often involves multiple data collection strategies, such as interviews, observations, and document analysis. Qualitative research is known for its flexibility and adaptability in data collection methods.

Situation: A 60-year-old male patient has been admitted to the orthopedic unit with a right femoral fracture after a fall. The patient has undergone surgery for internal fixation. As the nurse caring for this patient, you need to ensure effective fracture management and minimize complications. Which intervention is a priority during the immediate postoperative period for a patient with a femoral fracture who has undergone internal fixation? A. Administering pain medication. B. Monitoring for u

B. Monitoring for urinary retention. Monitoring for urinary retention is a priority to prevent complications like urinary retention, which can lead to bladder distention and possible renal damage. Pain management and antibiotics are important but come after addressing immediate postoperative concerns.

Kim and her daughter Jane went grocery shopping to only buy essential things needed at home. As they went along the different sections of the store, Jane saw a limited-edition Barbie doll. She is tempted to get it but decides not to grab it for fear of being slapped. This behavior of Jane is considered to be in what stage of Kohlberg's Moral Development? A. Conventional Stage 3: Good Boy/Nice Girl Orientation B. Preconventional Stage 1: Punishment/Obedience Orientation C. Conventional Stage 2

B. Preconventional Stage 1: Punishment/Obedience Orientation Jane is in the preconventional level stage 1 where judgment is motivated by fear of punishment. Children in this stage are responsive to rules that will affect their physical well-being.

A patient diagnosed with ulcerative colitis is admitted to the medical unit. When a nurse is assessing the patient, which of these findings would be of the most concern? A. Bloody diarrhea B. Rebound tenderness C. Borborygmi D. Oral temperature of 99.0 °F (37.2 °C)

B. Rebound tenderness Rebound tenderness is a sign of peritonitis that could be the result of rupture of the colon. It is a clinical sign that occurs during physical examination, referring to pain upon removal of pressure, not during application of pressure. Bloody diarrhea is a common finding because of bleeding lesions and anal excoriation. A temperature of 99.0 °F (37.2 °C) is within the normal range, and chronic inflammation may keep temperatures within the high normal range or above. Borborygmi are the sounds made by air or fluids moving through the intestines.

While providing care for the patient with the femoral fracture, which assessment finding should the nurse be most concerned about? A. Slight ecchymosis around the incision site. B. Swelling and warmth in the calf. C. Pain rating of 3/10 with medication. D. Decreased range of motion in the hip.

B. Swelling and warmth in the calf. Swelling and warmth in the calf can be indicative of deep vein thrombosis (DVT), a potentially life-threatening complication. The nurse should be most concerned about this finding.

The nurse is reviewing the patient's laboratory results and notices an elevated D-dimer level. What does this finding indicate for a patient with a femoral fracture? A. The patient has a bleeding disorder. B. The patient is at risk for pulmonary embolism. C. The fracture is not healing properly. D. The patient has an infection at the incision site.

B. The patient is at risk for pulmonary embolism. An elevated D-dimer level in a patient with a femoral fracture is indicative of a risk for deep vein thrombosis (DVT) and potential pulmonary embolism. It is essential to monitor and manage this risk to prevent serious complications.

What should the nurse teach the patient about weight-bearing restrictions after femoral fracture surgery? A. Weight-bearing is allowed immediately after surgery. B. The patient should avoid weight-bearing for 6 weeks. C. Partial weight-bearing with assistive devices is encouraged. D. Weight-bearing restrictions are determined by pain tolerance.

B. The patient should avoid weight-bearing for 6 weeks. Patients with femoral fractures typically have weight-bearing restrictions for an extended period, often around 6 weeks, to allow proper healing. Immediate weight-bearing or pain-tolerance-based decisions can lead to complications.

Anthony is very hostile toward one of the staff for no apparent reason. He is manifesting: A. Splitting B. Transference C. Countertransference D. Resistance

B. Transference Transference is a positive or negative feeling associated with a significant person in the client's past that are unconsciously assigned to another. Transference occurs when a person redirects some of their feelings or desires for another person to an entirely different person. Transference can also happen in a healthcare setting. For example, transference in therapy happens when a patient attaches anger, hostility, love, adoration, or a host of other possible feelings onto their therapist or doctor. Therapists know this can happen. They actively try to monitor it.

The client with coronary artery diseases is scheduled to have diagnostic exercise stress testing. Which of the following items should the nurse plan to include in client teaching about this procedure? A. Avoid cigarettes for 30 minutes before the procedure B. Wear loose clothing with a shirt that buttons in front C. Eat a high snack just prior to the procedure D. Wear, firm, rigid shoes such as work boots

B. Wear loose clothing with a shirt that buttons in front The client should wear loose, comfortable clothing for the procedure. Easy ECG lead placement is enhanced if the client wears a shirt that buttons in front. The client should wear rubber-soled, supervise shoes such as sneakers. The client is NPO after bedtime, or for a minimum of 2 hours before the test. The client should avoid smoking, alcohol, and caffeine altogether on the day of the test. Inadequate or incorrect preparation can interfere with the test and possibly yield false-positive findings.

An additional Vitamin C is required during all of the following periods except: A. Infancy B. Young adulthood C. Childhood D. Pregnancy

B. Young adulthood Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress.

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as A. normal. B. decerebrate. C. flaccid. D. decorticate.

B. decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

At a routine check-up, a 17-year-old male with cystic fibrosis tells the nurse that he's tired of being sick, feels worthless, and wonders if he'd be better off dead. The nurse knows this means A. he should be prescribed an anti-depressant. B. his statement should not be ignored or challenged. C. he requires therapy to explore his feelings. D. he needs an activity to build self-esteem.

B. his statement should not be ignored or challenged. When anyone talks about suicide, they should be taken seriously and given immediate assistance. The nurse must report the patient's statement to the provider and his parents. The other options may have value at a later time.

Monro-Kellie hypothesis refers to A. unresponsiveness to the environment. B. the dynamic equilibrium of cranial contents. C. the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. D. a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.

B. the dynamic equilibrium of cranial contents. The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others.

Which of the following statements, if made by patient who has iron deficiency anemia, would indicate that the patient understands the medication instructions? A. "I will report any clay-colored stools" B. "I will keep the tablets in the refrigerator" C. "I will take the pills with orange juice D. "I will expect my urine to become red-tinged"

C. "I will take the pills with orange juice Vitamin C may increase the absorption of iron. Orange juice is high in vitamin C. A- The patient should be aware that the stools will become dark green or black. B- Iron is stored at room temperature. D- Iron discolors stool but does not cause the urine to become red-tinged.

When teaching the patient about pursed-lip breathing, which statement is correct? A. "Pursed-lip breathing is used to decrease oxygen intake." B. "You should use pursed-lip breathing during inhalation." C. "Pursed-lip breathing helps to prolong exhalation and reduce air trapping." D. "Pursed-lip breathing is only for use during exercise."

C. "Pursed-lip breathing helps to prolong exhalation and reduce air trapping." Pursed-lip breathing is a breathing technique that is particularly useful for individuals with COPD. It involves inhaling through the nose for two counts and exhaling through pursed lips for four counts. The rationale behind pursed-lip breathing is to extend the exhalation phase, which allows more time for complete exhalation and reduces air trapping in the alveoli. This helps to alleviate dyspnea and improve oxygen exchange in patients with COPD.

A client has been taking flunisolide (Aerobid), two inhalations a day, for treatment of asthma. He tells the nurse that he has painful, white patches in his mouth. Which response by the nurse would be the most appropriate? A. "This is an anticipated side-effect of your medication. It should go away in a couple of weeks." B. "You are using your inhaler too much and it has irritated your mouth." C. "You have developed a fungal infection from your medication. It will need to be treated w

C. "You have developed a fungal infection from your medication. It will need to be treated with an antibiotic." Use of oral inhalant corticosteroids, such as flunisolide, can lead to the development of oral thrush, a fungal infection. Oral candidiasis (thrush) is another common complaint among users of inhaled corticosteroids. This risk increases in elderly patients and patients who are also taking oral steroids, high dose ICS, or antibiotics.

Qualitative researchers should choose their participants who can best meet the objectives of the study. Who of the following best qualifies? A. Cooperative persons in the community B. Those readily available, thus convenient for the researcher C. Able to articulate and reflect on the phenomenon that they experienced. D. Persons referred by friends.

C. Able to articulate and reflect on the phenomenon that they experienced. In qualitative research, selecting participants who can provide rich and detailed descriptions of the phenomenon being studied is essential. Participants who can articulate and reflect on their experiences help researchers gain a deeper understanding of the phenomenon.

After removal of the nasogastric (NG) tube on the second postoperative day, the client is placed on a clear liquid diet. Four hours later, the client complains of sharp, cramping gas pains. Which of the following actions should the nurse take? A. Reinsert the NG tube. B. Give the PRN IV opioid. C. Assist the client to ambulate. D. Place the client on NPO status.

C. Assist the client to ambulate. Ambulation encourages peristalsis and the passing of flatus, which will relieve the client's discomfort. If distension persists, the client may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.

The nurse is caring for a client following gallbladder surgery, and the client's T-tube is draining dark green fluid. Which of the following actions should the nurse take? A. Place the client on bed rest. B. Notify the client's surgeon. C. Document the color and amount of drainage. D. Irrigate the T-tube with sterile normal saline.

C. Document the color and amount of drainage. A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member implements which of the following actions? A. Documents all client care accurately. B. Labels all specimens to send to the laboratory. C. Keeps both hands above the operating table level. D. Takes the client to the postanaesthesia recovery area.

C. Keeps both hands above the operating table level. The scrub nurse role includes maintaining asepsis in the operating field and both hands must stay above waist level to ensure that they are above the operating table level. The other actions would be appropriate to the circulating nurse role.

A patient with COPD has been prescribed long-term oxygen therapy (LTOT). Which of the following statements is accurate regarding LTOT for patients with COPD? A. LTOT should be administered at the highest oxygen flow rate possible to maximize oxygenation. B. LTOT is typically used only during sleep to prevent nighttime hypoxemia. C. LTOT is recommended when the patient's arterial oxygen saturation (SaO2) is less than or equal to 90%. D. LTOT is not necessary for patients with COPD as they can re

C. LTOT is recommended when the patient's arterial oxygen saturation (SaO2) is less than or equal to 90%. Long-term oxygen therapy (LTOT) is indicated for patients with COPD when their arterial oxygen saturation (SaO2) remains consistently less than or equal to 88-89%. LTOT is prescribed to maintain SaO2 levels at or above 90%. Administering oxygen at the highest possible flow rate (option A) is not recommended, as it may lead to oxygen toxicity and other complications. LTOT is not limited to nighttime use (option B) and may be required 24 hours a day based on the patient's needs. COPD patients typically use inhalers for bronchodilation, not for oxygen supplementation (option D).

A male client who reportedly consumes one (1) qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. Clozapine (Clozaril) B. Thiothixene (Navane) C. Lorazepam (Ativan) D. Lithium carbonate (Eskalith)

C. Lorazepam (Ativan) The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine. Lorazepam is a benzodiazepine medication developed by DJ Richards. It went on the market in the United States in 1977. Lorazepam has common use as the sedative and anxiolytic of choice in the inpatient setting owing to its fast (1 to 3 minute) onset of action when administered intravenously. Lorazepam is also one of the few sedative-hypnotics with a relatively clean side effect profile. ff-label (non-FDA-approved) uses for Lorazepam include rapid tranquilization of the agitated patient, alcohol withdrawal delirium, alcohol withdrawal syndrome, insomnia, panic disorder, delirium, chemotherapy-associated anticipatory nausea and vomiting (adjunct or breakthrough), as well as psychogenic catatonia.

A multifarious woman delivered a 30-week's gestation stillborn infant. Which of the following actions would a nurse take initially to foster the mental health of the woman? A. Encourage the woman to seek genetic counseling B. Have a picture of the woman's other child brought to the hospital C. Offer the woman an opportunity to see and hold the infant D. Make arrangements for a member of the clergy to visit with the woman

C. Offer the woman an opportunity to see and hold the infant One of the first options to be discussed with the family is whether or not they want to see and hold the baby. A- There is no indication that genetic counseling is required. If it were, genetic counseling would be part of a long-term plan and not an immediate need. B- Having a picture of the woman's other child may provide comfort but the immediate need is to deal with the loss of the pregnancy. D- Having the clergy visit the woman is an appropriate intervention but is not the first action to be taken.

Which of the following interventions is most appropriate for a patient with COPD to conserve energy and reduce dyspnea during activities of daily living? A. Performing all activities quickly to minimize exertion. B. Encouraging the patient to take shallow breaths during activities. C. Organizing activities to allow for rest periods between tasks. D. Avoiding the use of supplemental oxygen during activities.

C. Organizing activities to allow for rest periods between tasks. Patients with COPD often struggle with exertion and dyspnea during activities of daily living. Organizing activities to allow for rest periods between tasks is a helpful strategy to conserve energy and reduce dyspnea. It prevents overexertion and allows the patient to recover between activities, making daily tasks more manageable. Shallow breathing (option B) is not recommended as it can lead to inadequate oxygen exchange. Supplemental oxygen (option D) should be used as prescribed by a healthcare provider when necessary.

The patient is prescribed metformin for the management of type 2 diabetes. What is the primary mechanism of action of metformin? A. Increases insulin production from the pancreas B. Enhances glucose absorption in the intestines C. Reduces glucose production by the liver D. Stimulates the release of stored glucose from muscle cells

C. Reduces glucose production by the liver Metformin primarily reduces glucose production by the liver. It does this by decreasing the liver's ability to produce excess glucose, which is a common problem in patients with type 2 diabetes. Metformin does not increase insulin production but improves insulin sensitivity in peripheral tissues, helping cells to use glucose more effectively. It does not affect glucose absorption in the intestines or stimulate the release of stored glucose from muscle cells.

A nurse is monitoring a 4-year-old child for signs of increased intracranial pressure after the child fell off a bicycle, resulting in head trauma. Which of the following signs or symptoms should the nurse report immediately? A. Bulging anterior fontanel B. Falling asleep at 10 p.m. C. Repeated vomiting D. Inability to identify short words

C. Repeated vomiting Increased intracranial pressure (ICP) is caused by bleeding or swelling within the skull. Trauma is the most common cause. ICP can be life-threatening and must be monitored. Repeated vomiting can be an early sign of pressure as the vomit center within the medulla is stimulated. Other signs of ICP are headache, confusion, unresponsive pupils, double vision, increased blood pressure, shallow breathing, and seizures. The anterior fontanel is closed in a 4-year-old child. Falling asleep at 10 p.m. is normal behavior for a 4-year-old. The average 4-year-old child should not be expected to read.

In clients with a cognitive impairment disorder, the phenomenon of increased confusion in the early evening hours is called: A. Aphasia. B. Agnosia. C. Sundowning. D. Confabulation.

C. Sundowning. Sundowning is a common phenomenon that occurs after daylight hours in a client with a cognitive impairment disorder. The term "sundowning" refers to a state of confusion occurring in the late afternoon and spanning into the night. Sundowning can cause a variety of behaviors, such as confusion, anxiety, aggression, or ignoring directions. Sundowning can also lead to pacing or wandering. Sundowning isn't a disease, but a group of symptoms that occur at a specific time of the day that may affect people with dementia, such as Alzheimer's disease. The exact cause of this behavior is unknown.

A nurse is caring for a 3-month-old infant diagnosed with infectious gastroenteritis. The infant is lethargic, and the mucous membranes are dry. Which additional finding would support a diagnosis of moderate dehydration? A. Anuria B. Increased thirst C. Sunken fontanelle D. Increased capillary refill

C. Sunken fontanelle A sunken fontanelle (also spelled fontanel) is a sign of increasing dehydration. It is first noticed when dehydration progresses from mild to moderate. Mild dehydration may be evidenced by increased thirst and decreased urine output. Anuria (no urine output) is a sign of severe dehydration. Other signs of dehydration in an infant are dry mucous membranes, fewer wet diapers than normal, strong urine, no tears when crying, lethargy, rapid breathing, and mottled extremities.

Situation: A 56-year-old patient with a history of type 2 diabetes mellitus has been admitted to the hospital with uncontrolled blood sugar levels. The patient presents with hyperglycemia and multiple complications related to diabetes. The patient's fasting blood glucose level is 250 mg/dL. What does this result indicate? A. The patient's blood sugar is within the target range. B. The patient's blood sugar is below the target range. C. The patient's blood sugar is above the target range. D. Th

C. The patient's blood sugar is above the target range. A fasting blood glucose level of 250 mg/dL indicates hyperglycemia, which is above the target range (typically 80-120 mg/dL) and requires immediate intervention in diabetes management. Elevated blood sugar levels can lead to complications and should be addressed promptly.

After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions? A. Places a client in the Trendelenburg position when the blood pressure (BP) drops. B. Assists a client to the prone position when the client is nauseated. C. Turns an unconscious client to the side when the client arrives in the PACU. D. Positions a newly admitted unconscious client supine w

C. Turns an unconscious client to the side when the client arrives in the PACU. The client should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the client's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The client is placed supine with the head elevated after regaining consciousness.

Which action should the nurse take to prevent pressure ulcers in the patient with a femoral fracture who is on prolonged bed rest? A. Reposition the patient every 4 hours. B. Apply a heating pad under the patient's legs. C. Use an air mattress to reduce pressure points. D. Keep the patient's legs elevated.

C. Use an air mattress to reduce pressure points. Using an air mattress can help reduce pressure points and prevent pressure ulcers in patients on prolonged bed rest. Frequent repositioning is essential, but an air mattress complements this care.

Which of the following actions by a member of the surgical team requires rapid intervention by the charge nurse? A. Wearing street clothes into the nursing station B. Wearing a surgical mask into the holding room C. Walking into the hallway outside an operating room without the hair covered D. Putting on a surgical mask, cap, and scrubs before entering the operating room

C. Walking into the hallway outside an operating room without the hair covered The corridors outside the OR are part of the semi restricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR.

The client recovering from pulmonary edema is preparing for discharge. The nurse plans to teach the client to do which of the following to manage or prevent recurrent symptoms after discharge? A. Take a double of diuretic if peripheral edema is noted B. Withhold digoxin (Lanoxin) is slight respiratory distress occurs C. Weigh self on a daily basis D. Sleep with the head of the bed flat

C. Weigh self on a daily basis The client can best determine fluid status at home by weighing self on a daily basis. Increases of 2 to 3 pounds in a short time are reported to the physician. The client should sleep with the head of the bed elevated on a 6- to 10-inch foam wedge. During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify drug dosages without consulting the physician.

Which of the following actions should the scrub nurse use to maintain aseptic technique during surgery? A. Use waterproof shoe covers. B. Wear personal protective equipment. C. Insist that all operating room (OR) staff perform a surgical scrub. D. Change gloves after touching the thigh of a surgeon's sterile gown.

D. Change gloves after touching the thigh of a surgeon's sterile gown. Once gloved, a nurse's hands are not to go below his or her waist; therefore, touching the surgeon's thigh would contaminate the nurse's gloves. Hands are always to be kept above waist level. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the client, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR.

The nurse is using a professional interpreter to obtain a medical-social history from a client who is not proficient in English. Which of the following is the correct way to interview the client with an interpreter? A. Tell the client to speak slowly and clearly. B. Look at the interpreter when asking questions. C. Limit the interview to one hour. D. Face both the client and the interpreter.

D. Face both the client and the interpreter. According to the US Census Bureau, more than 25 million Americans speak English "less than very well," and more than 60 million speak a language other than English at home. Title VI of the Civil Rights Act mandates that interpreter services be provided for patients with limited English proficiency who need this service. Untrained interpreters, such as family members, are more likely to make errors and violate confidentiality, and increase the risk of poor outcomes. Children should never be used as interpreters except in emergencies. When using an interpreter, the nurse should address the patient directly and seat the interpreter next to or slightly behind the client. The nurse should observe the client's nonverbal cues. Statements should be short, and the discussion should be limited to three major points. In addition to acting as a conduit for the discussion, the interpreter may also serve as a cultural liaison between the staff and cl

An eight-year-old boy who has hemophilia A falls in the classroom injuring his ankle and is brought to the school nurse. Immediate first-aid actions by the nurse should include A. Applying warm compresses B. Dispensing ibuprofen (Pediaprofen) C. Administering Factor VIII D. Immobilizing the joint

D. Immobilizing the joint The nurse should first control bleeding by immobilizing and elevating the area. A - Applying warm compresses will increase bleeding. Cold compresses promote vasoconstriction. B. The first action by the nurse should be to control bleeding. C - Factor VIII replacement therapy should be instituted according to established medical protocol. The first aid priority for this patient is control of bleeding through immobilization and elevation.

When planning care for a 14-year-old female who is pregnant, a nurse should recognize that the adolescent is at risk of A. Glucose intolerance B. Fetal chromosomal abnormalities C. Incompetent cervix D. Iron deficiency anemia

D. Iron deficiency anemia Adolescents tend to have inadequate diets that are especially lacking in iron and folic acid has been linked to neural tube defects but not fetal chromosomal abnormalities. A- Pregnant adolescents are not at risk for glucose intolerance. B- A diet deficient in folic acid has been linked to neural tube defects but not fetal chromosomal abnormalities. C- Pregnant adolescents are not at risk for incompetent cervix.

Situation - Research is a vital endeavor nurses must engage in to contribute to nursing science. When the nurse researcher collects data at more than one point over an extended period, which design is applied? A. Cross-sectional B. Time-related C. Time-sequenced D. Longitudinal

D. Longitudinal A longitudinal design involves collecting data at multiple points over an extended period to track changes or developments over time. This design is particularly useful when researchers want to study the same subjects or variables over an extended duration to observe changes.

A 6-year-old child is scheduled to have measles, mumps, and rubella (MMR) vaccine. Which of the following routes will you expect the nurse to administer the vaccine? A. Intramuscularly in the vastus lateralis muscle. B. Intramuscularly in the deltoid muscle. C. Subcutaneously in the gluteal area. D. Subcutaneously in the outer aspect of the upper arm.

D. Subcutaneously in the outer aspect of the upper arm. (MMR) the vaccine is administered subcutaneously in the outer aspect of the upper arm.

A client in surgery receives a neuro-muscular blocking agent as an adjunct to general anaesthesia. At completion of the surgery, it is most important that the nurse monitor the client for which of the following adverse effects? A. Nausea B. Confusion C. Bronchospasm D. Weak chest-wall movement

D. Weak chest-wall movement The most serious adverse effect of the neuro-muscular blocking agents is weakness of the respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are as great a concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm and bronchospasm are not concerns.