66-70

Ref # 2294 A client is receiving digoxin 0.25 mg by mouth daily. A health care provider has written a new order to give metoprolol tartrate 25 mg twice a day by mouth. In assessing the client prior to administering the medications, which finding should the nurse report to the health care provider? Blood pressure of 94/60 Heart rate of 76 BPM Urine output of 50 mL/hour Respiratory rate of 16

1 Both medications decrease the heart rate. Metoprolol (Lopressor) affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60 to 100 BPM and systolic BP greater than 100 mm Hg) in order to safely administer both medications.

Ref # 1540 The nurse is suctioning a client's tracheostomy. During this procedure, the nurse should instill saline for what purpose? Facilitate the removal of mucus plugs Decrease the client's discomfort Reduce the viscosity of secretions Prevent client aspiration from secretions

1 According to evidence-based practice, the use of saline is no longer recommended during routine suctioning. However, if a client is suspected to have a mucous plug in the larger bronchial or in an artificial airway (such as a tracheostomy tube), the nurse can instill sterile normal saline to thin and loosen the plug or viscous secretions.

Ref # 1685 A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if the child can swim in the family pool. How best should the nurse respond? "Your child may swim in your own pool but should not dive under the water." "Your child may swim and dive if earplugs are worn when in and around the pool." "Your child should not swim in the pool while the tubes are in place." "Your child may swim anywhere without restrictions."

1 After this procedure, the child can swim in the family pool, without earplugs, as long as s/he does not dive under the water. Since lakes and oceans are not as clean as pool water, the child should not put his/her head under the surface of the water unless waterproof ear protection is used. Children should also not submerge their heads under the water in a bathtub. Unless the child develops frequent drainage after swimming or bath, routine use of earplugs are usually not recommended.

Ref # 1719 A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager implement first? Keep a time log of your day in hourly blocks for at least one week Set daily goals and establish priorities for each hour and each day Ask for additional assistance when you feel overwhelmed Complete each task before beginning another activity in selected instances

1 Apply the nursing process to time management, so the assessment of the current activities is the initial step. A baseline is established for activities and time use so that needed changes can be pinpointed.

Ref # 2113 The nurse is caring for a client taking antipsychotic drugs. Why is it important for the nurse to monitor blood pressure in this client? Orthostatic hypotension is a common side effect Rising trends in blood pressure will indicate when an antiparkinsonian drug is needed Most antipsychotic drugs cause elevated blood pressure Blood pressure will determine if dietary restriction of sodium is needed

1 Clients should be made aware of the possibility of dizziness and syncope from postural hypotension for about an hour after taking an antipsychotic medication. Clients should be advised to get up slowly from a sitting or lying position.

Ref # 1448 A nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? Formula or breast milk Room temperature fruit juice Diluted nonfat dry milk Fluoridated tap water

1 Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year-old. Juice should not be used as the main fluid.

Ref # 2346 A nurse admits a 50 year-old client with a three-day history of swelling of the face, hands and feet; foamy brown urine; fever and malaise. Which information obtained in the admission interview alerts the nurse that these findings may reflect a diagnosis of acute glomerulonephritis? Sore throat two weeks ago History of mild hypertension Type 1 diabetes since age 15 Travel to a foreign country

1 Glomerulonephritis commonly presents with proteinuria (foamy urine) that is rusty or brownish in appearance and swelling due to the systemic protein loss. In the majority of cases of acute glomerulonephritis, there is a history of an untreated streptococcal throat infection preceding the onset of symptoms by two to three weeks. The other options are not directly related to the development of acute glomerulonephritis.

Ref # 1859 A client receiving chemotherapy has developed sores in the mouth and asks the nurse why this has happened. How should the nurse respond? "The cells in the mouth are sensitive to the chemotherapy." "It is a sign that the medication is working." "This always happens with chemotherapy." "You need to have better oral hygiene."

1 The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover.

Ref # 1514 A nurse is planning to administer otic drops to a 6 year-old child. Which action is part of the correct procedure? Hold the pinna up and back to instill the drops Assist the child to lie on the affected side afterward Insert cotton in the outer ear after giving medication Place several drops in the outer ear

1 The external auditory canal should be straightened by gently pulling the pinna up and back for otic drop administration. In children who are under three years of age, the pinna should be pulled down and back.

Ref # 1252 The nurse is caring for a client with Legionnaire's disease. Which finding would require the nurse's immediate attention? Decreased chest wall expansion Pleuritic pain on inspiration A decrease in respiratory rate from 34 to 24 Dry mucus membranes in the mouth

1 The respiratory status of a client with this acute bacterial pneumonia known as Legionnaires' disease is critical. Note that all of these findings would be of concern, but a decrease in chest wall expansion is the priority because it reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness, including low oxygen saturation, would indicate hypoxemia. The client may need to have oxygen titrated to maintain adequate O2 saturation. Mechanical ventilation may be needed for signs of respiratory failure.

Ref # 2019 The public health nurse is reviewing data about trends in tuberculosis (TB) in the U.S. Which factor should the nurse understand about the current trends in TB? All TB clients should be counseled and tested for HIV There is no significant difference between TB rates for foreign-born and U.S.-born people The number of new cases of TB in the U.S. continues to increase each year NonHispanic Asians have the lowest TB case rate

1 There has been a steady decrease in the total number of new cases of TB in the U.S. over the last nine years. According to current statistics, non-Hispanic Asians have the highest TB case rate in the U.S. and more than half of all new TB cases were in foreign-born people. The American Thoracic Society and the Infectious Disease Society of American recommend that everyone who tests positive for TB be counseled and tested for HIV; conversely, people with HIV or AIDS should be tested for TB because the chance of having both diseases is extremely high.

Ref # 1759 During administration of medications to a client, the client says to a nurse, "I do not want to take that medicine today." Which of these statements should the nurse use as a response? "Is there any particular reason why you don't want to take your medicine?" "That's OK, its all right to skip your medication now and then." "Do you understand the consequences of refusing your prescribed treatment?" "I will have to call your doctor and report this."

1 When a new problem is identified, it is important for the nurse to collect accurate information directly from clients. This is crucial to ensure that clients' needs are adequately identified in order to select the best nursing care approaches. The nurse should pursue a conversation with the client to reveal any reasons for the medication refusal. It may be that the client has developed untoward side effects.

Ref # 4368 A client is being prepared to have a right above-the-knee amputation. Which of the following nursing measures will increase surgical safety? (Select all that apply.) Verify the informed consent form is signed Have the client confirm identify, the surgical site and procedure before administration of anesthesia Verify any allergies Explain the procedure, including any risks, and have the client sign the consent form Verify the surgical leg is marked with indelible marker over, or as close as possible to, the surgical incision site

1,2,3,5 Prior to surgery, the nurse can witness the client's signature on the consent form, but explanation of the procedure, including risks and benefits, needs to come from the health care provider. Any allergies must be noted and verified prior to surgery. The surgeon must use an indelible marker on the surgical leg to indicate the incision site; sometimes the nonsurgical leg will be marked with a "NO." In the operating room, a surgical checklist is completed with a nurse and anesthesiologist. Prior to administration of anesthesia, there is another check with the client to verify identify, the correct surgical site and procedure.

Ref # 3727 The client is being treated for complications of a chronic disease on a medical-surgical unit. Who can have access to the client's medical record? (Select all that apply.) The nursing instructor planning clinical assignments The facility researcher collecting data for a study to which the client consented The emergency department nurse who originally admitted the client and now wants to know the client's current status The certified nursing assistant documenting vital signs The client's spouse or other close family member The person who has health care power of attorney

1,2,4,6 Safeguarding client privacy requires strict adherence to the ethical standards of confidentiality and need-to-know access. Only those individuals who are directly involved in the client's care should have access to his or her information. The ED nurse is no longer directly involved in the client's care and should not have access to information about the client. Without valid authorization, such as health care power of attorney, a spouse or other family members cannot access the client's medical records.

Ref # 2008 The nurse is caring for a client who has a history of asthma and is now diagnosed with gastroesophageal reflux disease (GERD). Which of these types of medications, which are all prescribed for the client, may aggravate the GERD? Histamine blocker Anticholinergic bronchodilator Corticosteroid Anti-infective

2 An anticholinergic medication will decrease gastric emptying and diminish the pressure on the lower esophageal sphincter. This will enhance gastric reflux.

Ref # 2107 A nurse is caring for a client who had a mastectomy two months ago. Which of these statements, made by a client, is incorrect and indicates a need for an additional assessment associated with the impact of an alteration in body image? "I plan to volunteer to work with others who have had mastectomies in Reach for Recovery." "I only look at myself in the mirror after I am fully dressed." "It really isn't much of a problem for me, I never had large breasts anyway." "I guess it's time for me to quit wearing a bikini at my age anyway." Submit

2 An inability to look at the incision or surgical site is associated with possible denial or anger during the process of coping with a loss. This indicates that a problem area for this client is body image. The other statements reflect movement towards acceptance of the loss of a "normal" figure.

Ref # 2032 A nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction? Explain the changes in diet necessary for pregnant women Conduct a diet history to determine her normal eating routines Question her understanding and use of the food pyramid Teach her how to meet the needs of self and her family

2 Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information. The results of this information provides the basis of the planned educational needs.

Ref # 1949 A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? Meconium was cleared from the airway at delivery The infant received mechanical ventilation for two weeks Phototherapy was used to treat Rh incompatibility Gestational age assessment suggested growth retardation

2 Bronchopulmonary dysplasia (BPD) is an iatrogenic disease caused by mechanical ventilation. When the prematurely born infant is treated with mechanical ventilation, over time the pressure from the ventilation and excess oxygen can injure the infant's lungs, causing BPD.

Ref # 1748 A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of these problems should be addressed as a priority in planning care? Esophagitis Leukopenia Fatigue Skin irritation

2 Clients being treated by radiation over the sternum, which is a bone marrow producing area, develop leukopenia due to the depressant effect of radiation therapy on the bone marrow function. With the resultant low white counts, infection is a potential outcome. The other options are possible complication outcomes of radiation therapy on this part of the body. However, they are not the priority because leukopenia is a threat to the entire body and the other options are more of a local problem.

Ref # 1811 A 23 year-old single client in the 33rd week of her first pregnancy tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? Acceptance of the pregnancy Anticipation of the birth Ambivalence about pregnancy Focus on fetal development

2 Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of appropriate emotional response in the third trimester and a part of "nesting" according to Rubin. Ambivalence about pregnancy is an expected emotion during the first trimester. Acceptance of the pregnancy with a focus on fetal development are important in the second trimester.

Ref # 1821 A mother brings her 26 month-old to the well-child clinic and expresses frustration and anger due to the child constantly saying "no" and refusing to follow directions. The nurse should explain that this is normal for the age, as negativism is an attempt to meet which developmental need? Initiative Independence Self-esteem Trust

2 In Erikson's theory of development, toddlers struggle to assert independence. They often use the word "no" even when they mean yes. This stage is called autonomy versus shame and doubt. At this stage other characteristics are "grazing" instead of eating a meal, a behavior of rituals especially at bedtime and parallel play with other children.

Ref # 2402 When admitting a client to the ambulatory surgery unit, the nurse notices the client has painted fingernails. The nurse reviews the pre-op orders and notes that pulse oximetry is prescribed. Which statement by the nurse is appropriate? "I will ask your provider if we must ruin those beautiful nails." "So that we can measure your oxygen levels, may I please remove the polish from at least two nails?" "If you do not remove all your polish, I will request a needlestick to test oxygen levels." "I am sorry. All your nail polish must be removed."

2 In order to effectively measure pulse oximetry, there can be no nail polish on the finger fitted with the reading device. The client should be approached using therapeutic communication skills. The other options are inappropriate.

Ref # 1640 A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? Institute seizure precautions Initiate droplet precautions Monitor neurologic status every hour Administer cefotaxime (Claforan) IV 50 mg/kg/day divided every six hours

2 Meningococcal meningitis is a bacterial infection that can be communicated to others. The initial therapeutic management of acute bacterial meningitis includes droplet precautions, initiation of antimicrobial therapy, monitoring neurological status along with vital signs, instituting seizure precautions and, lastly, maintaining optimum hydration. The first action is to initiate any necessary precautions to protect themselves and others from the potential infection. Viral meningitis usually does not require protective measures of isolation and these clients often return home to recover

Ref # 1560 The nurse is assessing a client during a visit to a community mental health center. The client discloses that "I have been thinking about ending my life." Which statement would be the nurse's BEST response to this information? "We will help you deal with those thoughts." "Have you thought about how you would do it?" "Do you want to discuss this with your pastor?" "Is your life so terrible that you want to end it?"

2 Most experts believe that people who commit suicide don't want to die; they just want to stop hurting. When a client tells you s/he is thinking about death or suicide, you must evaluate the immediate danger the person is in. The correct option provides an opening to discuss the plan, the means (pills, gun, etc.), time set for doing it, and intent to commit suicide. Clients who have formulated a suicide plan are closer to suicidal behavior than those who have vague, nonspecific thoughts.

Ref # 1692 A nurse is giving instructions to the parents of a child with cystic fibrosis. What information should the nurse emphasize about administration of pancreatic enzymes? Once each day in the morning With each meal or snack Each time a high-carbohydrate or high-fat meal is eaten Crush the tablet and sprinkle on food three times a day

2 Pancreatic enzymes are necessary for digesting fat, starch and protein. They should be taken with each meal and most snacks to allow for the proper digestion of the food. If taken on an empty stomach, they may cause gastric irritation and possibly ulcers. Enzyme capsules should be swallowed whole, not crushed or chewed, and the microspheres should not be sprinkled on or mixed with the whole meal.

Ref # 1545 A nurse is caring for a client who was in a motor vehicle accident. Which of these findings would be the highest priority if newly identified by the nurse? Flaccid paralysis Pupils fixed and dilated Reduced sensory responses Diminished spinal reflexes

2 Pupils that are fixed and dilated indicate overwhelming injury and intrinsic damage to the upper brain stem, and would be the highest priority as it is a poor prognostic sign. The other findings are more consistent with partial dysfunction of the brain or spinal cord.

Ref # 1348 The nurse is caring for a client who is unconscious and receiving gastric tube feedings. Which assessment finding requires an immediate action from the nurse? Urine output of 250 mL in the past eight hours Decreased breath sounds in the right lower lobe Formula residual volume 100 mL Decreased bowel sounds in all quadrants

2 The most common problem associated with enteral feedings is aspiration with resulting atelectasis and pneumonia. A nursing action should be to maintain clients at a minimum of 30 degrees of head elevation during feedings and up to two hours afterwards. The nurse should verify tube placement prior to each feeding or every four to eight hours if the client receives a continuous feeding.

Ref # 1628 A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown cause. During the admission process, which of the following findings should the nurse identify as being the client's greatest risk factor for developing osteoporosis? Two glasses of red wine each day for the past 30 years History of oral corticosteroid use for 20 years to treat chronic lung problems History of menopause at age 50 Inactive lifestyle for the past 10 years

2 The use of oral corticosteroids for a long period of time increases the risk for developing osteoporosis. Being postmenopausal and physically inactivity may also contribute, but are less significant. Other factors that increase the risk for osteoporosis and fracture include low bone mass and poor calcium absorption. However, long-term steroid treatment is the most significant risk factor.

Ref # 2222 The nurse is working to establish a therapeutic relationship with a client. Which of these approaches would be most damaging to the client's self-esteem? Fear Indifference Anger Disapproval

2 Therapeutic relationships that build or maintain self-esteem are incongruent with indifference（高まるか、自尊心を維持する治療的な関係は、冷淡に一致しません）. Positive connectedness or caring characterizes a therapeutic relationship, which will enhance self-esteem.

Ref # 2110 A client states, "People think I'm no good, you know what I mean?" Which of these responses by the nurse would be the most therapeutic? "Well people often take their own feelings of inadequacy out on others." "I'm not sure what you mean. Tell me a bit more about that." "Let's discuss this to see the reasons you create this impression on people." "I think you're good. So you see, there's one person who likes you."

2 This therapeutic communication technique elicits more information, especially when delivered in an open, nonjudgmental fashion. The use of the nursing process when a client has a problem is "further assessment" of the situation.

Ref # 2080 The nurse is working in an inpatient psychiatric unit. Which statement made by a client indicates that the client may have a thought disorder? "I'm so angry about this. Wait until my partner hears about this." "I'm a little confused. What time is it?" "I can't find my 'mesmer' shoes. Have you seen them?" "I'm fine. It's my daughter who has the problem."

3 A neologism is a word that is self-invented by a person and not readily understood by another person. The use of neologisms is often associated with a thought disorder. The other statements reflect appropriate connections between the expressed thoughts. Thought disorders are associated with schizophrenia, delusions and hallucinations of psychosis.

Ref # 1987 A nurse often works with many clients from different cultures. Which approach is a priority for the nurse? Learn about the cultures of clients who are most often encountered Have a list of persons for referral when interaction with clients from different cultures occur Recognize personal attitudes about cultural differences along with any real or expected biases Speak at least two other languages of clients in the neighborhood

3 A nurse must discover personal attitudes, prejudices and biases specific to different cultures. Awareness of these will prevent negative consequences for interactions with clients and families across various cultures.

Ref # 2097 The client has an order for benztropine. After assessing the client, which condition would contraindicate the use of this medication? Parkinson's disease Neuromalignant syndrome Glaucoma Acute extrapyramidal syndrome

3 Benztropine is an anticholinergic medication used to treat extrapyramidal disorders caused by antipsychotic medications or Parkinson's disease. Use of benztropine or other anticholinergic is contraindicated for individuals diagnosed with glaucoma, ileus and prostatic hypertrophy. Adverse effects include tachycardia, anticholinergic psychosis and heat stroke.

Ref # 1735 The hospital staff requests that parents who have a Greek heritage remove the amulet from around their infant's neck. The parents refuse. The nurse should understand that the parents may be concerned about which factor? Mental development delays Balance in body systems Evil eye or envy of others Fright from spiritual beings

3 In the Greek heritage the matiasma, "bad eye" or "evil eye, " results from the envy or admiration of others. The belief is that the eye is able to harm a wide variety of things, including inanimate objects and that children are particularly susceptible to attacks. Persons of Greek heritage employ a variety of preventive mechanisms to thwart the effects of envy. One of these is the protective charm in the form of an amulet that consists of blessed wood or incense.

Ref # 1607 An 80 year-old client on digoxin reports nausea, vomiting, abdominal cramps and halo vision. Which laboratory result should the nurse evaluate first? Magnesium levels Blood pH Potassium levels Blood urea nitrogen

3 Nausea, vomiting, abdominal cramps and halo vision are classic signs of digitalis toxicity. The most common cause of digitalis toxicity is a low potassium level. Clients are to be taught that it is important to have adequate potassium intake, especially if taking loop or thiazide diuretics that enhance the loss of potassium.

Ref # 1892 The nurse manager uses a block scheduling plan for staffing. However, because staff have asked for many changes and exceptions to the schedule over the past few months, the nurse manager is considering self-scheduling. What type of effect does the nurse manager anticipate with self-scheduling? Decreased staff turnover Reduced overtime payouts Improved team morale Improved quality of care

3 Nurses in direct care positions are more satisfied when opportunities exist for autonomy and control. The nurse manager becomes the facilitator rather than the decision maker of the schedule for unit needs when self-scheduling exists. Peer pressure and team work are the driving forces during self-schedule approaches.

Ref # 1330 The nurse is planning care for a 6 month-old infant. What must the nurse provide to assist in the development of trust? Comfort Food Security Warmth

3 Social and emotional development is based on trust, love and security. The best way to help infants develop trust is to give them warm and consistent care so they can form secure attachments. Providing food, comfort and/or warmth are components of care and are required to develop a secure and trusting relationship.

Ref # 2277 A nurse is assigned to care for a comatose client. The client is diagnosed with type 1 diabetes and has an IV infusion of insulin running. Which task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)? Obtain a peripheral blood glucose reading Determine if special skin care is needed when reddened areas are identified Measure and document the hourly output in a urine collection bag Answer questions from the client's spouse about the plan of care

3 The UAP perform tasks, including measuring and recording urine output. In long term care and other health care settings, UAPs are not allowed to obtain blood glucose readings. You should be aware that a national license exam has to subscribe to the lowest level of practice, which is why obtaining a blood glucose reading is an incorrect response.

Ref # 1300 The client has decreased adrenal function. What should the nursing care plan for this client include? Encourage physical activity Place the client in reverse isolation Prevent constipation Limit the number of visitors

4 Any stress, either physical or emotional, places additional stress on the adrenal glands, which could precipitate an Addisonian crisis in this client. The plan of care should protect the client from stress by avoiding the emotional stress of (too many) visitors and by reducing physical activity until the client's condition stabilizes.

Ref # 1510 A nurse is planning to give a 3 year-old child oral digoxin. Which action is the best approach by the nurse? "Do you want to take this pretty red medicine?" "You will feel better if you take your medicine." "This is your medicine, and you must take it all right now." "Would you like to take your medicine from a spoon or a cup?"

4 At 3 years of age a child often feels a loss of control when hospitalized. Giving a choice about how to take the medicine allows the child to express an opinion and have some control.

Ref # 1882 Which of these statements best describes the characteristic of an effective reward-feedback system? Performance goals should be higher than what is attainable Staff are given feedback in equal amounts over time Positive statements should precede a negative statement Specific feedback is given as close to the event as possible

4 Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.

Ref # 1809 A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? Talk with the father and help him accept the wife's decision Discuss with the mother sharing parenting responsibilities Arrange for the parents to attend infant care classes Set time aside to get the mother to express her feelings and concerns

4 Nonjudgmental support for expressed feelings may lead to resolution of competitive feelings in a new family. Cultural influences may also be clarified.

Ref # 1854 A 72 year-old client is admitted for possible dehydration. The nurse knows that older adults are particularly at risk for dehydration due to which physiologic change? An increased need for extravascular fluid An increase in diaphoresis Higher metabolic demands A decreased sensation of thirst

4 Older adults have a reduction in thirst sensation and this causes them to consume less fluids. Other risk factors may include fear of incontinence, inability to drink fluids independently, increased frequency to void with increased fluid intake, and lack of motivation.

Ref # 1391 The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? Solid foods should be mixed with formula in a bottle A variety of ground meat should be started early to provide iron Egg white is added early to increase protein intake Solid foods are to be introduced one at a time beginning with cereal

4 Solid foods should be added, one at a time, between 4 to 6 months. If the infant is able to tolerate the food, another is then added each week. Iron-fortified cereal is the recommended first food; rice cereal is recommended due to the low risk of food allergies. Teach parents to mix the cereal flakes with either breast milk or formula. After the baby is eating cereal, pureed meat, vegetables and fruits can be introduced. Egg whites and wheat products should not be given before the baby is at least a year old because these foods are more commonly associated with allergies.

Ref # 1325 The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? "You might want to "sneak out" of the room once the child falls asleep." "Oh, that behavior will stop in a few days with patience from you." "I think you or your partner needs to stay with the child while in the hospital." "Keep in mind that for the age this is a normal response to being in the hospital."

4 The protest phase of separation anxiety is a normal response for a child this age. In toddlers, ages one to three, separation anxiety is at its peak. After three years of age it begins to diminish until the adolescent years, when the behavior is minimal.

Ref # 1586 A couple experience the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? To plan for another pregnancy within two years and maintain physical health To seek causes for the fetal death and come to some safe conclusion To focus on the other healthy children and move through the loss To discuss feelings with each other and use grief resources

4 To communicate in a therapeutic manner, the nurse's goal is to help the couple begin the grief process by suggesting they talk to each other, seek family, friends and support groups to listen to their feelings. To look for causes or set a time to plan another pregnancy is inappropriate.

Ref # 1631 Prior to discharge home, a treatment plan is being developed for a client with severe arthritis. What is the most important part of the treatment plan? Ensure compliance with medications Anticipate side effects of therapy Support coping with limitations Maintain and preserve functional status

4 To maintain quality of life and to ensure safety, the treatment plan must emphasize maintaining functional status. The client's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) should be assessed; if needed, referrals for physical and/or occupational therapy can be made. All clients should understand the purpose of any prescribed medications, as well as how and when to take them, expected side effects and possible adverse effects.

Ref # 4354 The nurse is caring for a client admitted to the hospital with severe left-sided flank pain and hematuria. Diagnostic tests indicate a kidney stone partially obstructing the left ureter. Which of the following outcomes is the most important for this client? Verbalizes understanding of the disease process Pain controlled with medication Tolerates diet without nausea and vomiting Adequate urinary elimination is maintained

4 While all options are appropriate to the care of this client, urinary elimination is the nursing priority. A stone that completely obstructs the ureter can cause hydronephrosis and potential kidney damage. Remember Maslow - physiologic needs are more important than nutritional needs. Pain control and teaching are lower priorities.

Ref # 4454 Following craniotomy surgery the client develops a cardiac arrhythmia, and the provider orders lidocaine (Xylocaine) infusion at 3 mg/minute. The label states the 500 mL IV bag contains 2 grams of lidocaine. What is the flow rate setting (milliliter/hour)? (Round to the nearest whole number and write only the number.) mL/hour.

Correct response: 45 Using dimensional analysis to solve, because the final answer will be in mL/hour, begin the equation with milliliters on top. Multiply by known factors to cancel out unwanted units until only mL/hour remains. (500 mL/2 gram) X (1 gram/1000 mg) X (3 mg/min) X (60 min/hr) = 90,000/2,000 = 45 mL/hour.

Ref # 4458 A 187-pound client with a subdural hematoma and findings of increased intracranial pressure has been prescribed 25% solution mannitol (Osmitrol) 0.25 g/kg to be administered by intravenous push right away. The pharmacy has sent up four 50 milliliter bottles (12.5 g/50 mL is written on the label). How many milliliters should the nurse prepare to give the client? (Write the answer using whole numbers.) mL.

Correct response: 85 Submit Click 'NEXT PAGE' below to continue...... Learning Objective: Lesson 6 Convert pounds to kilograms, calculate the dose this client requires based on his weight. Convert from pounds to kilograms: 187 lbs/2.2 = 85 kg 0.25 g x 85 kg = 21.25 g (12.5 g/50 mL) = (21.25 g/x mL) x = 1062.50/12.5 = 85 mL An alternate method for solving the problem is to use dimensional analysis. Because the answer will be milliliters, begin the equation with milliliters on top, then multiply to cancel unwanted units until only the milliliters remain. (50 mL/12.5 g) X (0.25 g/kg) X (1 kg/2.2 lbs) X (187 lb/1) = 85