all questions i have done in March 2022

The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic. Which method of injection would be appropriate for this client? (select the correct image question)

(in this picture the answer would be 45° angle with 25gauge needle)

The practical nurse is assisting the registered nurse in caring for 4 clients in the pediatric emergency department. Which client should be seen first? 1. Adolescent with abdominal pain, heart rate 120/min, and respirations 26/min 2.Child with history of cystic fibrosis has new yellow sputum and cough today 3.Crying infant with fiery redness and moist papules in the diaper region 4.Grade-school child with swollen ecchymotic ankle after playing basketball

1. Adolescent with abdominal pain, heart rate 120/min, and respirations 26/min In prioritization, the severity of ABC (airway, breathing, and circulation) is more important than its absolute order. As a result, a severe "C" client comes before a stable "B" client. The priority principle is to save "life before limb." When care must be prioritized, young children do not automatically go first.

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? 1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity 2. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze 3. Place the tooth in water and transport the client to the nearest emergency department 4. Wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment

1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity Dental avulsion is a dental emergency. The nurse should gently rinse off debris and reinsert the tooth into the gingival socket. If reimplantation is not possible, the tooth should be placed in a commercially prepared solution, cold milk, or sterile saline. The client should see a dentist immediately.

The nurse is caring for 4 clients. Which client should the nurse see first? 1. 2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs 2. 2 days post coronary bypass graft surgery with a white blood cell count of 18,000/mm3 (18.0 × 109/L) 3.Chronic heart failure with peripheral edema and shortness of breath on exertion 4.Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

1. 2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs The nurse should palpate pulses (eg, femoral, posterior tibial, dorsalis pedis), observe skin color, and feel the temperature of the lower extremities in the client with abdominal aortic aneurysm (AAA) repair first. Pulses can be absent for 4-12 hours after surgery due to vasospasm. However, a weak pedal pulse compared to the client's baseline or an absent pulse with a painful, cool, or mottled extremity 2 days post surgery can indicate an arterial or graft occlusion. Unaddressed occlusion may cause life- or limb-threatening ischemia (eg, lower extremities, intestines, kidneys).

Which meal should the nurse recommend for a pregnant client at 13 weeks gestation? 1. Baked chicken, turnip greens, peanut butter cookie, and grape juice 2. Baked swordfish, fries, baked apples, and fat-free milk 3.Chilled ham and cheese sandwich, broccoli, orange slices, and water 4.Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water

1. Baked chicken, turnip greens, peanut butter cookie, and grape juice An appropriate diet is essential to meet the needs of the pregnant client and growing fetus. Pregnant clients should avoid deli meats and hot dogs (unless steaming hot), liver, unpasteurized milk products, unwashed fruits and vegetables, raw fish, and fish high in mercury.

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. All options must be used. 1. Clean the vial tops with alcohol swabs 5. Inject air into the regular insulin vial 3. Draw up the regular insulin solution 4. Inject air into the NPH insulin vial 2. Draw up the NPH insulin solution

1. Clean the vial tops with alcohol swabs 4. Inject air into the NPH insulin vial 5. Inject air into the regular insulin vial 3. Draw up the regular insulin solution 2. Draw up the NPH insulin solution When drawing up multiple insulins, there is a risk for contaminating the shorter-acting insulin vial with longer-acting insulin and slowing the action of later doses withdrawn from the shorter-acting insulin vial. The nurse should withdraw the shorter-acting insulin first, and then use the same syringe to withdraw the intermediate-acting insulin.

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the supervisory registered nurse? 1."I am feeling unsteady when I walk." 2."I am getting up to urinate about 4 times during the night." 3."I have a metallic taste in my mouth when I eat." 4."My gums are getting so puffy and red."

1."I am feeling unsteady when I walk." The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Phenytoin, an anticonvulsant drug, is used to treat generalized tonic-clonic seizures. Common symptoms of phenytoin drug-induced toxicity involve the central nervous system and include ataxia, nystagmus, slurred speech, and decreased alertness.

The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant notification of the supervising registered nurse? 1."I am going for repeat testing to confirm glaucoma." 2."I am not able to exercise as much as I used to." 3."I started taking esomeprazole for heartburn." 4."My bowel movements are not regular."

1."I am going for repeat testing to confirm glaucoma." Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease tremor. However, they can precipitate acute glaucoma and are therefore contraindicated.

The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on emergency use of epinephrine injection, which statements by the parent indicate understanding of the instructions? Select all that apply. 1."I will give the injection if my child has trouble breathing after a bee sting." 2."I will give the injection in the upper arm." 3."I will keep an epinephrine injection close to my child at all times." 4."I will take my child to the emergency room after giving the injection." 5."The injection can be given through clothing."

1."I will give the injection if my child has trouble breathing after a bee sting." 3."I will keep an epinephrine injection close to my child at all times." 4."I will take my child to the emergency room after giving the injection." 5."The injection can be given through clothing." Emergency self-injection of epinephrine (EpiPen) can be done through clothing into the mid-outer thigh when the client or the client's caregiver first notices any anaphylactic symptoms.

A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching? 1."I will launder recently worn clothing, sheets, and towels in hot water." 2."I will make sure all eating utensils are placed in the dishwasher." 3."I will spray the house with insecticide to control this problem." 4."I will throw away stuffed animals and toys that cannot be washed."

1."I will launder recently worn clothing, sheets, and towels in hot water." Pediculosis capitis (head lice) is a common parasitic infestation of the scalp that is typically seen in school-age children. It is spread by contact with personal items such as clothing, combs, and bedding.

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place. Answer _________(mL)

1.2 mL

The nurse has received a prescription from the health care provider to administer 80 mg of methylprednisolone IV piggyback. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered. (do the math)

1.3 mL The nurse should fill the syringe appropriately based on dosage calculation. To calculate the dose in milliliters of methylprednisolone, the nurse should first identify the prescribed dose (eg, 80 mg/dose) and available dose (eg, 125 mg/2 mL), then convert to milliliters per dose (eg, 1.3 mL).

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1.Abdominal rigidity with guarding (27%) 2.Absence of tears in crying child with IV start (10%) 3.Blood-streaked mucous stool in diaper (23%) 4.Sausage-shaped right-sided mass on palpation (38%)

1.Abdominal rigidity with guarding (27%) Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly.

The nurse is reinforcing education on child abuse and neglect to a certified home health aide. The nurse will include which statements in identifying the characteristics of the typical perpetrator of child abuse? Select all that apply. 1.Abusers often have a history of growing up in an environment of domestic violence 2.Abusers often have a history of substance abuse 3.Child abusers always present as being agitated or out of control 4.Men are much more likely to abuse children than are women 5.Most child abusers have a diagnosed mental illness 6.Teenage parents are particularly vulnerable to abusing their children

1.Abusers often have a history of growing up in an environment of domestic violence 2.Abusers often have a history of substance abuse 6.Teenage parents are particularly vulnerable to abusing their children Child abusers often have a history of growing up in an environment of domestic violence. History of substance abuse is also a risk factor. Both men and women abuse children at approximately the same rate. Teenage parents are particularly vulnerable to abusing their children.

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply. 1.Accepting a birthday gift of a gold bracelet from a client 2.Making a visit to the hospital after a client has surgery 3.Offering to pray together if a client so wishes 4.Sending a sympathy card to family after a client dies 5.Soliciting a wealthy client to invest in a company 6.Staying after work hours and drinking wine with a client

1.Accepting a birthday gift of a gold bracelet from a client 5. Soliciting a wealthy client to invest in a company 6. Staying after work hours and drinking wine with a client Professional boundaries involve maintaining a relationship that benefits the client, not the nurse, and to which the nurse would not be reluctant to admit. It is generally not appropriate to socialize with a current client after hours, ask for a financial investment/loan, or accept a valuable gift.

The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply. 1.Administration of oxygen 2.Administration of a 2nd dose of naloxone 3.Discontinuation of pain medication 4.Initiation of a rapid response or code team 5.Monitoring of respiratory rate

1.Administration of oxygen 2.Administration of a 2nd dose of naloxone 5.Monitoring of respiratory rate Naloxone is usually prescribed as needed in postoperative clients for over-sedation related to opioid use. The nurse should monitor clients who are given naloxone with the understanding that the opioid antagonist has a shorter half-life than that of most of the opioids it is meant to counteract. As a result, a second dose of naloxone may be necessary.

The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply. 1.Advising measles vaccination for susceptible family members 2.Applying calamine lotion to reduce itching 3.Placing a tracheostomy tray at the bedside 4.Placing the client in a negative-pressure isolation room 5.Using an N95 respirator mask during client contact

1.Advising measles vaccination for susceptible family members 4.Placing the client in a negative-pressure isolation room 5.Using an N95 respirator mask during client contact Clients with measles are highly contagious, and susceptible family members should receive postexposure prophylaxis (eg, measles, mumps, and rubella vaccine). Hospitalized clients require airborne precautions (eg, negative-pressure isolation room, N95 respirator mask).

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder? 1.Agoraphobia 2.Generalized anxiety disorder 3.Social anxiety disorder 4.Zoophobia

1.Agoraphobia (37%) Agoraphobia is characterized by intense anxiety about being in a situation from which there may be difficulty escaping in the event of a panic attack. A person with agoraphobia may avoid open spaces, closed spaces, riding in public or private transportation, going outside the home, bridges/tunnels, and crowds.

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The health care provider prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply. 1.Apply pads to the side rails 2.Have oxygen supplementation available 3.Prepare to insert a urinary catheter 4.Remove all linen from the bed 5.Set up bedside suction equipment

1.Apply pads to the side rails 2.Have oxygen supplementation available 5.Set up bedside suction equipment Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can help protect a client during a seizure. These precautions typically include: Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails during a seizure (Option 1). During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen equipment are set up at the bedside (Options 2 and 5). Some facilities also encourage the use of a continuous pulse oximeter

A client with borderline personality disorder says to the nurse, "You're the only one I trust around here. The others don't know what they are doing, and they don't care about anyone except themselves. I only want to talk with you." What priority action should the nurse advocate to be included in the client's nursing care plan? 1.Assign different staff members to care for the client each day 2.Continue assigning the client's stated preferred nurse to care for the client 3.Frequently reassure the client that all staff members are competent in their jobs ( 4.Reinforce unit rules and consequences of inappropriate behaviors

1.Assign different staff members to care for the client each day Clients with borderline personality disorder, in an attempt to prevent abandonment and control their environment, may flatter and cling to one staff member while making derogatory remarks about others. The best nursing action is to rotate staff members assigned to care for the client.

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration? Click the exhibit button for more information--> Medication administration recordAllergies: NoneMedicationsTimeAtenolol 50 mg by mouth daily0900Calcium acetate 667 mg by mouthWith each mealInsulin lispro, high-dose sliding-scale subcutaneous injection with meals and before bedtime0730Vitamin E 400 IU by mouth daily0900 1.Atenolol 2.Calcium acetate 3.Insulin lispro 4.Vitamin E

1.Atenolol Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and folic acid) should be held prior to dialysis.

A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first? 1.Auscultate breath sounds 2.Check for peripheral edema 3.Measure the client's vital signs 4.Review the client's weight log over the past several days

1.Auscultate breath sounds The nurse should follow the ABCs (airway, breathing, circulation) of assessment with a heart failure client who is short of breath and coughing. Assessment should include auscultation of breath sounds and measurement of respiratory rate and oxygen saturation.

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? 1.Auscultate breath sounds to assess for crackles (39%) 2.Monitor for >50 mL/hr urine output (20%) 3.Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 (26%) 4.Press over the tibia to assess for pitting edema (13%)

1.Auscultate breath sounds to assess for crackles (39%) Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and pulmonary edema.

A nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply. 1.Behavior appears withdrawn 2.Intelligible speech began at age 12 months 3.Monotone speech 4.Seems attentive, nods, and smiles when given directions 5.Speaks with a loud voice

1.Behavior appears withdrawn 3.Monotone speech 5.Speaks with a loud voice Hearing impairment in infants delays development of intelligible speech. As these infants become toddlers, they often have a loud voice and monotone speech that is difficult to understand. They appear shy, timid, and inattentive.

The nurse is preparing to administer 40 mg of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters? Select all that apply. 1.Blood pressure 2.Blood urea nitrogen 3.Liver enzymes 4.Potassium 5.White blood cell count

1.Blood pressure 2.Blood urea nitrogen 4.Potassium When administering furosemide, it is important to closely monitor the client's vital signs, serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury.

The nurse has received report on the following clients. Which client should be seen first? 1.Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg 2.Client receiving hospice care who has Cheyne-Stokes respiration with 20-second periods of apnea 3.Client with anemia and hemoglobin level of 7 g/dL (70 g/L) who has a pulse of 110/min after ambulation 4.Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min

1.Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion.

A client with myocardial infarction underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations. What teaching should the nurse reinforce with this client? 1.Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs 2.Client will be ready for sexual activity after completion of cardiac rehabilitation 3.It will be 6 months before the heart is healthy enough for sexual activity 4.Medications such as sildenafil or tadalafil are available as prescriptions from the health care provider

1.Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs It is important to educate clients and their partners about sexual activity after a myocardial infarction. In general, it is safe for clients to consider resumption of sexual activity when they can walk 1 block or climb 2 flights of stairs without symptoms and have the health care provider's approval.

The nurse is monitoring a newborn with skin discoloration in the lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information. 1. Check the infant's hemoglobin, hematocrit, and platelet levels (8%) 2. Measure and document the size and location of the markings (72%) 3. Notify the registered nurse of the markings immediately (10%) 4. Review the delivery record for evidence of a traumatic birth (8%)

2. Measure and document the size and location of the markings (72%) Congenital dermal melanocytosis (Mongolian spots) is a benign skin discoloration (ie, bluish-gray) typically found on the back or buttocks. It is more common in newborns of ethnicities with darker skin tones. The spots may be misidentified as bruising in future assessments and should be documented to avoid misinterpretation of findings.

On arrival in the postanesthesia care unit, the practical nurse assists the registered nurse in performing the initial assessment of a client who had surgery under general anesthesia. Which assessment finding is the most concerning? 1. Difficult to rouse 2. Muscle stiffness 3. Pinpoint pupils 4. Temperature of 96 F (35.6 C)

2. Muscle stiffness Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.

The nurse is reinforcing instructions to a parent about how to care for a newly circumcised newborn. Which statement by the parent indicates a need for further teaching? 1."Discharge and odor indicate infection of the circumcision site." 2."I will clean the area with alcohol-based wipes or soap water." 3."Infant crying during petrolatum gauze changes is expected." 4."The diaper should be changed at least every 4 hours."

2."I will clean the area with alcohol-based wipes or soap water." In a recently circumcised newborn, parents should be taught to use only warm water for cleaning and avoid soap and alcohol-based wipes. After 24 hours, a yellow exudate forms as part of the normal healing process; it should not be removed. Pain is expected, and parents can provide additional comfort measures after diaper changes to minimize discomfort.

The nurse is caring for a 7-year-old client diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for further teaching? 1."I'll provide a healthy diet without added salt for my child." 2."I'll organize playdates to keep my child's spirits up during relapses." 3."I'll restrict my child's fluids if I notice swelling or rapid weight gain." 4."I'll test for protein in my child's urine every day."

2."I'll organize playdates to keep my child's spirits up during relapses." Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-sodium diet with attractive foods; infection prevention; fluid restriction for severe edema; and monitoring of weight gain and proteinuria to detect relapse.

A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion (CSII) therapy. Which statement indicates that the client understands the advantages of using this therapy? 1."I won't need a bolus dose of insulin before my meals anymore." 2."I'm glad my blood sugars won't go way up and way down, like they did before." 3."I'm so glad I don't have to stick my finger 4 times a day to test my sugar anymore." 4."It'll finally be easier for me to lose some weight."

2."I'm glad my blood sugars won't go way up and way down, like they did before." A client prescribed CSII is taught how to self-manage the insulin pump. Key points include the importance of checking blood glucose levels at least 4 times a day, how to administer a bolus dose at mealtime to cover carbohydrate intake, how to administer a supplemental bolus dose to correct pre- and postprandial hyperglycemia, and the importance of balancing diet and exercise to avoid excess weight gain.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action? 1.Ask the client to explain the bruises on the torso 2.Assess the client's general hygiene and nutritional status 3.Report the bruises to the client's health care provider (HCP) 4.Talk to the client's child about the injuries

2.Assess the client's general hygiene and nutritional status When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

A parent calls the clinic about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? 1.Acetaminophen being given every 4 hours for fever 2.Bismuth subsalicylate being used for nausea 3.Ibuprofen being given every 6 hours for body aches 4.Popsicles and gelatin desserts being used for hydration

2.Bismuth subsalicylate being used for nausea The nurse should tell the parent not to administer any product containing aspirin or salicylates to a child with a viral infection (eg, influenza, varicella) to prevent Reye syndrome.

A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply. 1.Apical pulse 2.Capillary refill 3.Lung sounds 4.Pupillary response 5.Skin color and temperature

2.Capillary refill 5.Skin color and temperature The adequacy of blood flow to peripheral tissues is determined by measuring capillary refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock.

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? 1.Baked sweet potato, kale, yeast roll, water 2.Cheeseburger, apple, vanilla milkshake 3.Spaghetti with meatballs, fruit salad, milk 4.Vegetable soup, salad, dinner roll, iced tea

2.Cheeseburger, apple, vanilla milkshake When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal

The nurse has just received report on 4 clients. Which reported information is the most concerning? 1.Client on a heparin drip with an activated partial thromboplastin time of 60 seconds 2.Client reporting back pain 1 hour following coronary angiography 3.Client with a head injury and a Glasgow Coma Scale score of 14 4.Client with incisional pain rated 6/10 on day 2 post coronary artery bypass graft

2.Client reporting back pain 1 hour following coronary angiography Clients with any indication of compromised airway, breathing, or circulation always take priority. The onset of back pain after angiography always requires further assessment to monitor for retroperitoneal bleeding.

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1.Client on chemotherapy who started antibiotics today for cellulitis of the leg 2.Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours 3.Client with diabetes who has nausea, abdominal pain, and vomiting 4.Client with ulcerative colitis and diarrhea who has developed fever and vomiting

2.Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours In response to a local disaster, the nurse identifies clients who can be safely discharged to make room for newly admitted clients. A client with acute asthma exacerbation can be safely discharged home when respiratory status has stabilized.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? 1.Ask the health care provider to prescribe a different calcium channel blocker 2.Consult with the pharmacist to see if an alternate form of the drug is available 3.Open the capsule and sprinkle the medication in a cup of applesauce 4.Warn the client about the dangers of uncontrolled hypertension

2.Consult with the pharmacist to see if an alternate form of the drug is available Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill.

The practical nurse is caring for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply. 1.Bradypnea 2.Diaphoresis 3.Hallucinations 4.Lethargy 5.Tachycardia

2.Diaphoresis 3.Hallucinations 5.Tachycardia One of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital stay. Clients should always be screened for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable. Signs and symptoms of delirium tremens include disorientation, agitation, fever, tachycardia, hypertension, diaphoresis, and hallucinations.

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply. 1.Assist maternal pushing efforts by applying fundal pressure during each contraction 2.Document the time the fetal head was born 3.Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 4.Prepare for a forceps-assisted birth 5.Request additional assistance from other nurses immediately

2.Document the time the fetal head was born 3.Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 5.Request additional assistance from other nurses immediately Shoulder dystocia occurs when the anterior shoulder becomes wedged behind or under the maternal symphysis pubis. The nurse should document the timing of events (eg, birth of fetal head), verbalize passing time, perform McRoberts maneuver, apply suprapubic pressure, and request additional assistance.

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply. 1.Decrease fluid intake to 1 glass with each meal and at bedtime 2.Encourage the client to bear down while attempting to void 3.Inspect the perineal area for evidence of skin breakdown 4.Measure postvoid residual volumes as prescribed 5.Tell the client to wait 30 seconds after voiding and then attempt to void again

2.Encourage the client to bear down while attempting to void 3.Inspect the perineal area for evidence of skin breakdown 4.Measure postvoid residual volumes as prescribed 5.Tell the client to wait 30 seconds after voiding and then attempt to void again When caring for clients with overflow incontinence, the nurse should implement a fixed voiding schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as prescribed.

The client is scheduled to have a cardiac catheterization. Which of the following findings would cause the nurse to question the safety of the test proceeding? Select all that apply. 1.Elevated serum C-reactive protein level 2.History of previous allergic reaction to IV contrast 3.Prolonged PR interval on ECG 4.Received metformin today for type 2 diabetes mellitus 5.Serum creatinine of 2.5 mg/dL (221 µmol/L)

2.History of previous allergic reaction to IV contrast 4.Received metformin today for type 2 diabetes mellitus 5.Serum creatinine of 2.5 mg/dL (221 µmol/L) Cardiac catheterization uses IV iodinated contrast to assess for obstructed coronary arteries. IV iodinated contrast is avoided in clients who had a previous allergic reaction to contrast agents; have renal impairment; or, in some cases, who recently received metformin.

A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications? 1.How to assess blood pressure daily 2.How to prevent constipation 3.How to prevent itching 4.How to prevent nausea

2.How to prevent constipation Constipation is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant.

The clinic nurse is reinforcing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client? 1.How to transmit the readings over the phone 2.Keep a diary of activities and any symptoms experienced 3.Refrain from exercising while wearing the monitor 4.The monitor may be removed only when bathing

2.Keep a diary of activities and any symptoms experienced The nurse should instruct the client with a Holter monitor to keep a diary of activities and any symptoms that occur while wearing it. The client should also be taught not to bathe during the testing period but to continue all other normal activities.

The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? Select all that apply. 1. No sexual activity for at least 6 weeks postoperatively 2.Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site 3.Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP 4.Take a shower daily without soaking chest and leg incisions 5.Use lotion on incision sites when changing dressing if the areas are dry

2.Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site 3.Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP 4.Take a shower daily without soaking chest and leg incisions Discharge teaching for a client recovering from coronary artery bypass grafting should include instructions related to hygiene (showering instead of bathing, no soaking or applying lotions to incisions), medications, activity level (no lifting of objects >5 lb [2.26 kg], no driving for 4-6 weeks) sexual activity (resume when able to walk 1 block or climb 2 flights of stairs without symptoms), and symptoms to report to the health care provider (chest pain or shortness of breath during rest, signs of infection).

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1.Hematocrit of 30% (0.30) 2.Partial thromboplastin time of 110 seconds 3.Platelet count of 80,000/mm3 (80 x 109/L) 4.Prothrombin time of 11 seconds

2.Partial thromboplastin time of 110 seconds Heparin infusions require close monitoring by the nurse. The partial thromboplastin time is the laboratory value required to accurately monitor the therapeutic effects of heparin.

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1.Continue CPR without using the automated external defibrillator (AED) until paramedics arrive 2.Place one AED pad on the chest and the other on the back 3.Place one AED pad on the upper right chest and the other on the lower left side 4.Place one AED pad on the upper right chest and dispose of the other

2.Place one AED pad on the chest and the other on the back An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding? 1."I can smoke 1 cigarette the day of the test so that I won't have withdrawal." 2."I should eat a hearty breakfast the morning of the test to avoid nausea." 3."I should stop drinking coffee 24 hours before the procedure." 4."I should take my usual dose of insulin the day of the test."

3."I should stop drinking coffee 24 hours before the procedure." Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; they should avoid caffeinated products for 24 hours before the test and avoid taking certain cardiac medications (eg, nitrates, beta blockers) unless otherwise instructed by the health care provider.

A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. 1."I don't plan on eating any more frozen meals." 2."I plan to take my diuretic pill in the morning." 3."I will weigh myself at least every other day." 4."I'm going to look into joining a cardiac rehabilitation program." 5."Ibuprofen works best for me when I have pain."

3."I will weigh myself at least every other day." 5."Ibuprofen works best for me when I have pain." Discharge education for the client with chronic heart failure should include daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention.

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? 1. "I need for you to get rid of these bugs that are crawling under my skin." 2."Hear that? She told me to kill my father." 3."That song is a message sent to me in secret code." 4."Those Martians are trying to poison me with the tap water."

3."That song is a message sent to me in secret code." Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them.

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate? 1. "The Allen's test is done to determine if capillary refill is adequate." 2."The Allen's test is done to determine if the radial pulse is palpable." 3."The Allen's test is done to determine the patency of the ulnar artery." 4."The Allen's test is done to determine the presence of a neurologic deficit."

3."The Allen's test is done to determine the patency of the ulnar artery." The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.

The nurse has been providing care for the past month to a 7-year-old client recently diagnosed with type 1 diabetes mellitus. Initially, the family seemed devastated about the diagnosis and the client's parent stated, "Our lives will never be the same." Which statement made by the parent indicates that nursing interventions and education have been effective? 1."Our child will not be able to participate in any sporting events." 2."Our whole family will have to make sacrifices to deal with this disease." 3."We are working to manage this disease so that it cannot control our child's life." 4."We have set aside a place in the pantry for our child's special foods."

3."We are working to manage this disease so that it cannot control our child's life." The diagnosis of a chronic illness (eg, diabetes) in a child will have an impact on the entire family. When parents see themselves and the child as capable of being independent and in control of the disease, there is an increased likelihood that the disease will be managed and controlled and the child can have an independent life.

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? 1.Client has 1 emesis of green fluid 2.Client has had no bowel movement for 2 days 3.Client falls asleep while talking to the nurse 4.Client reports experiencing pruritus

3.Client falls asleep while talking to the nurse Sedation precedes respiratory depression in narcotic administration. A client (especially if on high doses) should be assessed for sedation level. Level 3 sedation on POSS requires that no additional narcotics be administered to the client.

The nurse is caring for 4 hospitalized clients. Which client should the nurse see first? 1.Client with hyperemesis gravidarum who is currently vomiting 2.Client with molar pregnancy who has dark brown vaginal discharge 3.Client with suspected ectopic pregnancy who has abdominal and shoulder pain 4.Client with threatened miscarriage who says, "I am a Jehovah's Witness."

3.Client with suspected ectopic pregnancy who has abdominal and shoulder pain Ectopic pregnancy is a serious condition that results in loss of the fetus and could be life-threatening to the mother if not treated quickly. When a fertilized egg begins to grow outside the uterus (eg, in a fallopian tube), the risk of rupture increases. Rupture of the tube will result in significant blood loss and requires surgery and possible transfusion. Shoulder pain in clients with ectopic pregnancy indicates intraabdominal bleeding.

The nurse is caring for a client diagnosed with ulcerative colitis and prescribed sulfasalazine. Which instructions should be reinforced at discharge? Select all that apply. 1.Avoid small, frequent meals 2.Consume a cup of coffee with each meal if desired 3.Continue medication even after resolution of symptoms 4.Eat a low-residue, high-protein, high-calorie diet 5.Increase fluid intake to at least 2000 mL/day

3.Continue medication even after resolution of symptoms 4.Eat a low-residue, high-protein, high-calorie diet 5.Increase fluid intake to at least 2000 mL/day Dietary management of ulcerative colitis includes eating small, frequent meals; following a low-residue, high-protein, high-calorie diet; taking supplemental vitamins and minerals; avoiding caffeine, alcohol, and tobacco; and drinking at least 2000-3000 mL/day of fluid. Continued use of sulfasalazine prevents relapse and prolongs symptom remission.

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply. 1.Avoid intake of dairy products 2.Drink large amounts of fluid with meals 3.Eat several small meals each day 4.Eliminate fried, fatty foods 5.Lie down on the left side after meals

3.Eat several small meals each day 4.Eliminate fried, fatty foods Pyrosis is common during pregnancy due to an increase of the progesterone hormone, which causes the esophageal sphincter to relax. Lifestyle changes to reduce symptoms include eating smaller meals, avoiding trigger foods (eg, fried/fatty food), maintaining an upright position after meals, and drinking fluids mostly between meals.

The clinic nurse is caring for a 3-year-old client. Which task, if not observed or reported by the parents as accomplished, will cause the nurse concern? 1.Catches a ball at least 50% of the time 2.Copies a square with a pencil or crayon 3.Eats with a spoon 4.Hops on one foot

3.Eats with a spoon Things that most children can do by a certain age are considered developmental milestones. These include the following areas of development: social/emotional, language/communication, cognitive, and physical. Each child develops in a unique pattern, and ages are considered as general guidelines for assessing development. Normally, a toddler develops the ability to use a spoon by 18 months. Therefore, a 3-year-old should be able to eat with a spoon.

The nurse is caring for a hospice client with advanced heart failure who is having trouble breathing. Which comfort intervention should the nurse implement first? 1.Administer PRN albuterol by nebulizer 2.Assist with guided imagery to relieve anxiety 3.Elevate the head of the bed 4.Give PRN sublingual morphine

3.Elevate the head of the bed The client with advanced heart failure on hospice is likely to have dyspnea associated with fluid overload. The first intervention should be to elevate the head of the bed to reduce abdominal pressure on the diaphragm. Morphine with diuretics can help alleviate persistent dyspnea.

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1.Client appears to be sleeping. Eyes closed. 2.Client reports, "I'm in pain." Medication provided. 3.Inspiratory wheezes heard in bilateral lower lung fields 4.Voided x 1

3.Inspiratory wheezes heard in bilateral lower lung fields Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement.

The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? 1. Adenosine IV 2. Dopamine IV 3. Magnesium IV 4. Metoprolol IV

3.Magnesium IV Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium (Option 3). Treatment may also include defibrillation and discontinuation of any QT-prolonging medications.

The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which findings does the nurse expect to observe? Select all that apply. 1.Absent deep tendon reflexes 2.Cold, clammy skin 3.Muscle rigidity 4.Restlessness and agitation 5.Sinus tachycardia

3.Muscle rigidity 4.Restlessness and agitation 5.Sinus tachycardia Clinical manifestations of serotonin syndrome include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).

A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection. The nurse reminds the client to observe for and notify the health care provider immediately about which of the following? 1.Brown-colored urine 2.Hearing and balance problems 3.Pain in the Achilles tendon area 4.Sunburn

3.Pain in the Achilles tendon area Use of fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin), especially ciprofloxacin (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and rupture, especially of the Achilles tendon.

A nurse is planning to test the visual acuity of a 7-year-old. Which is the best way to test visual acuity in this child? 1.Have the child focus on a bright object and follow the target 2.Have the child view a set of cards one at a time 3.Position the child at a distance of 10 ft (3 m) from a chart 4.Shine a light into the child's eyes at a distance of 16 in (40.6 cm)

3.Position the child at a distance of 10 ft (3 m) from a chart Distance visual acuity of children age 6 or older is best assessed by asking the child to read letters from the Snellen letter chart using one eye at a time. The child should be able to identify 4 out of 6 letters on the 10/15 line (equivalent to 20/30 vision) with both eyes. In infancy, visual fixation should be present by age 3-4 months and is assessed by following a target.

The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic? 1.Call the office if the toddler's temperature is higher than 100 F (37.7 C) 2.Fussiness and anorexia are common for 1 week after immunizations 3.Redness at the injection sites and a mild fever are common 4.The toddler's activity level should be restricted for 24 hours

3.Redness at the injection sites and a mild fever are common Common side effects of immunizations include a mild fever and soreness and redness at the injection site. Anorexia and fussiness can be present for the first 24 hours.

The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document? Listen to the audio clip. (Headphones are required for best audio quality.) 1.Pericardial friction rub 2.S1, S2, no adventitious sounds 3.S3 extra heart sound 4.Systolic murmur

3.S3 extra heart sound S3, the third heart sound, is a "DUB" sound that immediately follows S2. It is a normal finding in children and young adults. S3, an abnormal finding in older adults, often indicates heart failure.

The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document? Listen to the audio clip. (Headphones are required for best audio quality.) 1.Pericardial friction rub 2.S1, S2, no adventitious sounds 3.S3 extra heart sound 4.Systolic murmur

3.S3 extra heart sound S3, the third heart sound, is a "DUB" sound that immediately follows S2. It is a normal finding in children and young adults. S3, an abnormal finding in older adults, often indicates heart failure. S3 is an adventitious (extra) heart sound heard as "DUB" immediately following S2 (Option 3)

A client is admitted to the emergency department after a fall with dizziness and light-headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the exhibit. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. 1.Complete heart block 2.1st-degree heart block 3.Sinus bradycardia 4.Sinus rhythm

3.Sinus bradycardia The nurse should be able to recognize SB on the ECG and assess for clinical significance (eg, chest pain, syncope, hypotension) in the client. Initial expected treatment for symptomatic clients includes atropine and transcutaneous pacing.

A graduate student, who has been studying for final exams and using energy drinks to stay awake, comes to the clinic reporting a fluttering feeling in the chest. The student is connected to the cardiac monitor that displays the rhythm in the exhibit. The nurse recognizes this as which rhythm? Click on the exhibit button for additional information. 1.Atrial fibrillation 2.Sinus rhythm with premature atrial contractions 3.Sinus rhythm with premature ventricular contractions 4.Ventricular tachycardia

3.Sinus rhythm with premature ventricular contractions Premature ventricular contractions (PVCs) are wide and distorted and occur early in the underlying rhythm. They are usually not harmful in the client with a healthy heart. PVCs in the client with myocardial infarction indicate ventricular irritability and should be assessed immediately.

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1.Black, sticky stools 2.Greasy, foul-smelling stools 3.Stools mixed with blood and mucus 4.Thin, "ribbon-like" stools

3.Stools mixed with blood and mucus (51%) The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom? 1.A temperature of 99 F (37.2 C) that occurs during the evening 2.The child cannot recall items eaten for lunch the previous day 3.The child vomits after awakening from a nap and again 1 hour later 4.The VP shunt is palpated along the posterolateral portion of the skull

3.The child vomits after awakening from a nap and again 1 hour later Increased intracranial pressure may occur with ventriculoperitoneal shunt malfunction. The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status. Early intervention by the health care provider will decrease the risk of damage to brain tissue.

What information would be most important for the nurse to obtain from a client with suspected bladder cancer who reports blood in the urine but no associated pain? 1.Family history 2.Industrial chemical exposure 3.Tobacco use 4.Usual diet

3.Tobacco use Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette smoking or other tobacco use is the primary risk factor.

The nurse working in the intensive care unit hears an alarm coming from a client's room. On entering the room, the nurse sees the rhythm displayed in the exhibit on the monitor. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. 1.Asystole 2.Atrial fibrillation 3.Ventricular fibrillation (VF) 4.Ventricular tachycardia

3.Ventricular fibrillation (VF) The nurse should recognize VF, a potentially lethal dysrhythmia. The ECG shows irregular waveforms of varying shapes and amplitudes. The client is unresponsive, pulseless, and apneic. Rapid treatment should include CPR, defibrillation, and drug therapy (eg, epinephrine, vasopressin, amiodarone).

The health care provider prescribes a continuous heparin infusion at 18 units/kg/hr for a client who has a pulmonary embolus and weighs 198 lb. The infusion bag contains 25,000 units of heparin in 500 mL of D5W. At what rate in milliliters per hour (mL/hr) does the nurse set the IV infusion pump? Record your answer using a whole number. Answer_____________ (mL/hr)

32 ml/hr (using the method on picture for solving) solve for units 1st using weight, then solve for pump To calculate the infusion rate of heparin, the nurse should first identify the prescribed dose (eg, 18 units/kg/hr) and available dose (eg, 25,000 units/500 mL) and then convert to milliliters per hour (eg, 32 mL/hr).

The nurse is assisting with community health screening. Which client is the priority to refer for further evaluation? 1. Client who is an athlete with a heart rate of 50/min 2. Client with a blood pressure of 129/79 mm Hg 3. Client with a random blood glucose of 139 mg/dL 4. Client with shiny, hairless legs that are cool to the touch

4. Client with shiny, hairless legs that are cool to the touch Peripheral artery disease (PAD) is characterized by decreased perfusion to the extremities, usually from atherosclerosis (plaque buildup in blood vessels). Poor perfusion causes shiny, cool, pale, hairless skin; poor wound healing; and ischemic pain, especially in the lower extremities (Option 4). A client with symptoms of PAD requires further evaluation as atherosclerosis is a major risk factor for coronary artery disease, myocardial infarction, stroke, and sudden cardiac death.

A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client? 1.Assess the client's risk for another suicide attempt 2.Encourage the client to express current feelings about the medical diagnosis 3.Place the client in a private room near the nurses' station 4.Provide continuous one-to-one observation with the client

4. Provide continuous one-to-one observation with the client The priority nursing action for a client who has made a recent suicide attempt is to ensure the client's safety. The best approach is to provide one-on-one contact and constant observation.

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which client statement regarding digoxin toxicity indicates that teaching reinforcement is needed? 1."I must visit my health care provider to check my drug levels." (5%) 2."I should report to my health care provider if I develop nausea and vomiting." (11%) 3."I should tell my health care provider if my heart rate is below 60 beats per minute." (15%) 4."I will need to increase my potassium intake." (66%)

4."I will need to increase my potassium intake." (66%) Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized.

The nurse is discussing child safety with the parents of a 12-month-old child who is just beginning to walk. Which statement by the parents indicates a need for further instruction? 1."Our swimming pool is fenced in with a lock on the gate." 2."We have installed childproof gates at the top and bottom of our stairs." 3."We need to lower the mattress in our child's crib." 4."When we are unable to supervise, we can put our child in a mobile walker."

4."When we are unable to supervise, we can put our child in a mobile walker." Mobile child walkers are associated with injuries such as falls and drowning because they can easily tip over. Children can also reach higher places while in a walker, enabling them to pull hot objects and dangerous substances off counters and tables.

A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse? 1. "At the moment, I would worry more about how your sibling is doing." 2."The odds are about 50-50 that you will come down with the disease as well." 3."Would you like to talk to a health care provider about this?" 4."You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."

4."You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia." Information regarding the potential for development of a serious illness, such as schizophrenia, needs to be provided to clients in a realistic manner that allows for discussion and exploration of the client's feelings. The exact cause of schizophrenia is unknown and is probably a combination of genetic, biochemical, structural, and developmental factors.

The practical nurse is collecting data on several clients waiting to be seen in the prenatal clinic. Which client situation is most important to report to the registered nurse? 1.18 weeks gestation client taking ceftriaxone and reporting mild diarrhea 2.22 weeks gestation client with twins who is taking acetaminophen twice a day 3.28 weeks gestation client taking metronidazole who has dark-colored urine 4.32 weeks gestation client taking ibuprofen for moderate back pain

4.32 weeks gestation client taking ibuprofen for moderate back pain Nonsteroidal anti-inflammatory drugs must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor in the client. Prior to 30 weeks gestation, they may be taken only under the close supervision of a health care provider.

There has been a large-scale community disaster and clients must be roomed together at the hospital. Who are appropriate roommates in light of infection risk principles? Select all that apply. 1.A client diagnosed with varicella and a client with pertussis 2.A client placed in an airborne infection isolation room (AIIR) and a client with heart failure 3.A client receiving chemotherapy and a client with chronic obstructive pulmonary disease (COPD) coughing yellow sputum 4.A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5.Two clients diagnosed with tuberculosis

4.A client with pelvic inflammatory disease (PID) and a client with coffee ground emesis 5.Two clients diagnosed with tuberculosis PID is an acute infection of the upper genital tract. The most common organisms are Chlamydia and Neisseria gonorrhea; PID would not be contagious by being in the same room. There is no infection risk for a client with gastrointestinal bleeding (Option 4). Clients with the same organism can room together (Option 5).

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first? 1.Client after a colonoscopic polypectomy today with abdominal cramping and a small amount of rectal bleeding 2.Client after a laparoscopic inguinal hernia repair yesterday who reports urinary hesitancy while voiding 3.Client after a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement 4.Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)

4.Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C) Postoperative infection of an arteriovenous graft may result in thrombosis (clotting), graft failure, or systemic infection. The nurse should immediately assess the client with signs of postoperative infection (eg, fever) and notify the health care provider.

The nurse responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the nurse handle this situation? 1.Call security to escort the family member to the waiting room 2.Have the family member stand or sit in an area that is not in the staff's way 3.Inform the family member that relatives are not allowed in rooms during emergency situations 4.Let the family member stay and assign a staff person to explain what is happening

4.Let the family member stay and assign a staff person to explain what is happening The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention? 1.Ask if the client needs to use the bedpan 2.Assess the client's fluid intake 3.Assess the client's skin turgor 4.Palpate the client's suprapubic area

4.Palpate the client's suprapubic area Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications.

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client? 1.Diet recall for this current week 2.Fluid intake for the past 2 days 3.Medications and dosages taken over the past 2 days 4.Presence of shortness of breath, coughing, or edema

4.Presence of shortness of breath, coughing, or edema The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.

The nurse is reviewing the telemetry strips of assigned clients. The rhythm strip displayed in the exhibit is given to the nurse by the telemetry technician. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. 1.Atrial fibrillation 2.First-degree atrioventricular block 3.Sinus bradycardia 4.Sinus rhythm

4.Sinus rhythm To analyze electrocardiogram (ECG) strips, the nurse should measure the R-R interval to determine regularity and heart rate and then analyze the PR interval, QRS complex, and QT interval. A heart rate of 60-100/min and normal PR intervals, QRS complexes, and QT intervals indicate a normal sinus rhythm.

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1.The client has been admitted to the facility without the client's consent 2.The client is becoming delirious and should be assessed for infection 3.The client is concerned that someone might steal possessions 4.The client wants to take care of business before imminent death

4.The client wants to take care of business before imminent death The client with a limited life expectancy will have concerns about completing personal business, such as ensuring that possessions go to the appropriate people. The nurse should assess the client's needs and ensure that the plan of care will facilitate the client's life closure activities (eg, legacy building).

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1.Color of sputum 2.Lung sounds 3.Saturation level 4.White blood cell count (WBC)

4.White blood cell count (WBC) Indicators of treatment effectiveness for HAP include decreased WBC on complete blood count with differential and improvement of infiltrates on chest-x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production).

The practical nurse is performing a cardiac assessment in collaboration with the registered nurse. Where does the nurse expect to feel the client's point of maximal impulse?

Educational objective:The nurse should palpate the point of maximal impulse (PMI) medial to the midclavicular line at the 4th or 5th intercostal space. Palpation of the PMI below the 5th intercostal space or to the left of the midclavicular line may indicate cardiac enlargement.

The nurse is checking for a murmur in a client with severe mitral valve stenosis. Identify the area on the image where the nurse would best auscultate a murmur in this client. Left-clicking the mouse will put an X to show the answer before submitting the question.

Mitral valve stenosis often produces a diastolic murmur best heard at the apex of the heart (5th intercostal space, midclavicular line) with a stethoscope. Educational objective:When auscultating for a murmur associated with mitral valve stenosis, the nurse should place the stethoscope at the 5th intercostal space, midclavicular line.

The nurse is teaching a client to self-administer enoxaparin subcutaneously for the outpatient treatment of deep-vein thrombosis (DVT). The client points to the site of planned injection. Which site indicates that the client understands the instructions? (this is new-generation questions where you "click" the area of body as the ANSWER)

right or left side of the abdomen at least 2 in from the umbilicus The nurse can teach a client or caregiver to inject subcutaneous enoxaparin. The appropriate site of injection is on the right or left side of the abdomen at least 2 in from the umbilicus.