Comprehensive Exam # 1 missed ?s

The nurse is assessing a client who has been addicted to barbiturates. Which finding warrants additional action related to the barbiturate use? • sluggishness, ataxia, and irritability • suspiciousness, tachycardia, and edema • diaphoresis, twitching, and sneezing • drooling, fainting, and illusions

Correct response: sluggishness, ataxia, and irritability Explanation: Typical signs and symptoms of barbiturate abuse include sluggishness, difficulty walking, and irritability. Judgment and understanding are impaired, and speech is slurred and confused. The client acts drunk as from alcohol but does not have the odor of alcohol on her breath.Although significant, the other signs and symptoms are not effects of barbiturate use.

The nurse notices a fire in a wastebasket in a client's room. In which order of priority from first to last should the nurse perform the actions? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. -Confine the fire by closing the door to the client's room. - Extinguish the fire. -Remove the client from the room. -Pull the fire alarm at the alarm pull station.

-Remove the client from the room. -Pull the fire alarm at the alarm pull station. -Confine the fire by closing the door to the client's room. -Extinguish the fire. Explanation: The nurse uses the RACE procedure to manage a fire: Rescue, Alarm, Confine, Extinguish.

During a shift report for a client with heart failure, the nurse going off shift reports that the client had sinus bradycardia during the shift and a creatinine of 3.5 mg/dL. Which action does the nurse perform when administering digoxin to this client? • Assess the digoxin level. • Monitor the radial pulse. • Evaluate the B-type natriuretic peptide level (BNP). • Measure the urine output.

Correct response: Assess the digoxin level. Explanation: After digoxin is metabolized, the kidneys eliminate the remaining digoxin. Kidney disease will prevent elimination of digoxin causing potential toxicity; measuring the digoxin level, especially in the presence of bradycardia, a side effect of digoxin, is indicated. The nurse monitors the apical pulse when administering digoxin, as atrial fibrillation or other dysrhythmia that causes a pulse deficit may lead the nurse to hold the medication when the true pulse is above 60 beats/min. Renal impairment does not always decrease urine output; therefore, monitoring for toxicity is the priority. Although the BNP level will correlate to the client's heart failure, the most important assessment is for digoxin toxicity.

A client who survived a hemorrhagic stroke now demonstrates a speech disability. What is the best response when the home care nurse observes the spouse speaking for the client and finishing the client's sentences? • "Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." • "Remember to use a regular tone of voice when you help your spouse speak so your spouse can clearly understand the answers." • "I am wondering if you are concerned about your spouse's cognitive ability, as you seem to frequently speak for your spouse." • "Today I noticed that you are speaking for your spouse, and it would be helpful to have practice conversations with your spouse."

• "Although it takes time for your spouse to communicate to you and to others, it is important not to speak for your spouse." Explanation: When a client has a speech disability, it is important to be patient and allow the client time to speak and answer questions, rather than speak for and answer questions directed to the client. The tone of voice does not help the client better understand what is being said. Typical conversations are a part of daily interaction in a relationship, therefore practice conversations are not needed.

A 10-year-old child is taking high doses of aspirin. Which finding indicates the child is experiencing early salicylate toxicity? • chest pain • pink-colored urine • dizziness • slowed pulse rate

• dizziness Explanation: Signs and symptoms of early salicylate toxicity include tinnitus, disturbances in hearing and vision, and dizziness. Salicylate toxicity may cause nausea, vomiting, diarrhea, and bleeding from mucous membranes from long-term use.Pink-colored urine, a slowed pulse rate, and chest pain, rarely occurring in children, are not associated with salicylate toxicity.

An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply. • presence of jewelry • medications and treatments administered • identifying information when possible (such as name and age) • triage priority • next of kin

• medications and treatments administered • identifying information when possible (such as name and age) • triage priority Explanation: Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families. It is not necessary to document the presence of jewelry or next of kin.

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" • one-time order • as-needed order • stat order • standing order

Correct response: standing order Explanation: This example is a standing order. Prescribers write a one-time order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. An as-needed order doesn't indicate a specific administration time; it gives guidelines for when to administer the medication. Many pain medication orders are as-needed orders.

When explaining to parents how to reduce the risk of sudden infant death syndrome (SIDS) the nurse should teach about which measures? Select all that apply. • Place the baby on his back to sleep. • Maintain a smoke-free environment. • Use bumper pads over the bedrails. • Use a wedge for side-lying positions. • Have the baby sleep in the parents' bed. • Breastfeed the baby.

• Place the baby on his back to sleep. • Maintain a smoke-free environment. • Breastfeed the baby. Explanation: Exposure to environmental tobacco increases the risk for SIDS. Sleeping on the back and breastfeeding both decrease the risk of SIDS. The side-lying position is not recommended for sleep. It is recommended that babies be dressed in sleepers and that cribs are free of blankets, pillows, bumper pads, and stuffed animals. Co-bedding with parents is not recommended as parents may roll on the child.

A nurse is teaching a parent of a toddler diagnosed with conjunctivitis to administer the ophthalmic ointment. Which action by the mother indicates that further instruction is necessary? • The mother washes her hands before and after administration. • The mother applies the ointment to the lower conjunctival sac. • The mother holds the eyelids open with her fingers. • The mother cleans the eye prior to medication administration.

• The mother holds the eyelids open with her fingers. Explanation: Washing hands before and after administration to an infected eye is very important to prevent the spread of conjunctivitis. Applying the ointment to the lower conjunctival sac ensures the medication will adequately cover the eye. Cleaning the eye prior to administration helps the medication be absorbed and decreases the bacteria in the eye. Holding the eyelids open will not allow application of the medication to the lower conjunctival sac.

Before the surgical repair of a detached retina, the client is placed on bed rest in a supine position. This position has been effective if it: • helps prevent further retinal detachment or tearing. • facilitates drainage from the eye. • keeps the client safe while confined to bed. • helps reduce intraocular pressure.

• helps prevent further retinal detachment or tearing. Explanation: The client's position is determined by the location of the retinal tear. The rationale for rest is the hope that the retina will fall back into place as much as possible before surgery, which will facilitate adherence of the retina to the choroid.Increased intraocular pressure is not a problem in retinal detachment.There should be no external drainage from the eye.The client is placed on bed rest to facilitate treatment of the eye, not to keep the client safe.

A client is scheduled for cardiac catheterization. The client reports being nervous because there have been incidents of people dying during this procedure. How would the nurse respond? • "All procedures carry some degree of risk and the risk with this one is very low." • "What makes you think you will die during the cardiac catheterization procedure?" • "Would you like to go over the details of the procedure with me now?" • "Do you have any history of an anxiety disorder we should be aware of?"

• "Would you like to go over the details of the procedure with me now?" The client's statements reflect anxiety about the upcoming procedure, which is normal and should not prompt the nurse to suspect the client has a history of any anxiety disorders, which is a medical diagnosis. Often fear related to procedures is related to uncertainty, so the nurse should offer to clarify the procedure with the client as a first step. The client did not state believing they would die during the procedure, only that the client is aware that others have so the nurse would be inaccurate in summarizing the client's concern in this way. Stating all procedures carry risk and this is a safe one is dismissive of the client's concerns.

The nurse is caring for a client who is lacking in Maslow's need for love and belonging. Which behaviors relate to this need? Select all that apply. • has the ability to relate to others • has a supportive network • has the ability to give and receive affection • has the ability to cope • has a good self-image

• has the ability to relate to others • has a supportive network • has the ability to give and receive affection Explanation: Maslow's hierarchy of needs progresses from the most basic to the most complex needs. Physiologic needs are the most basic human needs. Only after physiologic needs have been met can safety concerns be addressed, followed by love and belonging, which then fosters self-esteem and, finally, self-actualization. In the love and belonging need, a person is able to relate to others, love others, themselves and realize that they need others.

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? • ineffective breathing pattern related to tissue trauma • risk for vascular trauma related to pulmonary emboli • impaired circulation related to blood clot • acute pain related to tissue trauma

• ineffective breathing pattern related to tissue trauma Explanation: Although all of these nursing diagnoses are appropriate for this client, ineffective breathing pattern takes priority. According to Maslow's hierarchy of needs, air is essential to maintain life and is assigned the highest priority, along with the other physiologic needs, such as food, elimination, temperature control, sex, movement, rest, and comfort.

When educating a female client with gonorrhea, what should the nurse emphasize? In women, gonorrhea: • does not lead to serious complications. • can be treated but not cured. • is often marked by symptoms of dysuria or vaginal bleeding. • may not cause symptoms until serious complications occur.

• may not cause symptoms until serious complications occur. Explanation: Many women do not seek treatment because they are unaware that they have gonorrhea. They may be symptom-free or have only very mild symptoms until the disease progresses to pelvic inflammatory disease. Dysuria and vaginal bleeding are not present in gonorrhea. Gonorrhea can lead to very serious complications. It can be cured with the proper treatment.

A mother brings her 2-year-old adopted child from an Asian background to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child's buttocks extending into the sacral area. What should the nurse do? • Do nothing concerning this finding. • Notify social services of a case of possible child abuse. • Ask the mother in private how the bruise occurred. • Question the mother about the family's discipline style.

Do nothing concerning this finding. Explanation: This lesion is a Mongolian spot, which is common in children of Asian or African heritage.The key word in the description is pigment. A bruise results from bleeding into subcutaneous or muscle tissue; it is not a pigment change in the skin.Notifying social services is inappropriate as this is a normal finding.Asking about the family's discipline style suggests the nurse has interpreted this normal finding as a bruise and not as pigment variation.

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? • writing out the instructions and having a family member read them to the client • asking frequently whether the client understands the instructions • demonstrating the procedure and having the client return the demonstration • asking an interpreter to relay the instructions to the client

• demonstrating the procedure and having the client return the demonstration Explanation: Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Asking whether the client understands the instructions isn't appropriate because clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan? -"Another method of contraception is needed until the sperm count is 0." -"Vasectomy is easily reversed if children are desired in the future." -"Vasectomy is contraindicated in males with prior history of cardiac disease." -"Vasectomy requires only a yearly follow-up once the procedure is completed."

Correct response: "Another method of contraception is needed until the sperm count is 0." Explanation: Another method of contraception is needed until all sperm has been cleared from the body. The number of ejaculates for this to occur varies with the individual, and laboratory analysis is required to determine when that has been accomplished. Vasectomy is considered a permanent sterilization procedure and requires microsurgery for anastomosis of the vas deferens to be completed. Studies have shown that there is no connection between cardiac disease in males and vasectomy. There is no need for follow-up after verification there is no sperm in the system.

The nurse is preparing discharge instructions for a client taking lithium. What is the most important information for the nurse to give the client? • Reduce fat and calorie intake to decrease the risk for weight gain associated with lithium. • Limit sodium intake to 2 to 3 grams per day to prevent fluid retention and increased blood pressure. • Maintain a consistent fluid intake each day, avoiding great fluctuations in volumes consumed. • Include nonpharmacological treatments for depression such as vigorous cardiovascular exercise.

Correct response: Maintain a consistent fluid intake each day, avoiding great fluctuations in volumes consumed. Explanation: Clients taking lithium need to maintain a consistent fluid and sodium intake and not restrict either water or salt to avoid fluctuations that could alter lithium plasma levels. Vigorous exercise can increase water and sodium loss through perspiration and should not be done without the health care provider's guidance. Although lithium is associated with weight gain, not all clients are equally affected. Dieting can alter how lithium levels are balanced and should only be done with medical supervision.

A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When the nurse informs the client that the physician has ordered a wound care nurse to examine the wound, the client asks why should anyone other than the staff nurse care for the wound. The client states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." Which responses made by the nurse would be appropriate? Select all that apply. • "Do you want me to tell the physician you refused?" • "The wound nurse is specially trained to care for diabetic wounds." • "We're very concerned about your foot and we want to provide the best possible care for you." • "This is a big deal, and you need to recognize how serious it is." • "You could possibly lose your foot without proper care."

• "The wound nurse is specially trained to care for diabetic wounds." • "We're very concerned about your foot and we want to provide the best possible care for you." • "You could possibly lose your foot without proper care." Explanation: Since diabetics are at an increased risk for loss of lower extremities due to vascular problems, foot care specialists are warranted. Foot care nurses are specially trained to care for diabetic wounds.

A client in the first trimester of pregnancy comes to the facility for a routine prenatal visit. The client reports mixed feelings about readiness to have a baby, even though this was a planned pregnancy. Which response should the nurse offer? • "You're feeling ambivalent, which is normal during the first trimester." • "You may want to consider having an abortion." • "You need to share these feelings with your partner." • "You may want to discuss these concerns with a social worker."

• "You're feeling ambivalent, which is normal during the first trimester." Explanation: The first trimester is known as the trimester of ambivalence because the client or the couple may experience mixed feelings. During this trimester, resolution of ambivalence is the family's key psychosocial task. Discussing these feelings with a social worker or the client's partner would be inappropriate at this time. (However, if further assessment reveals there is a problem, referral to a social worker and discussion with the partner may be appropriate.) Suggesting that the client consider having an abortion is a leading statement and would be inappropriate.

A client receives 12 units of intermediate- or long-acting insulin and 6 units of fast-acting insulin each morning. Place the following actions in chronological order of how the nurse would demonstrate how to mix insulins. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. • 1 Wipe off the vials with an alcohol swab. • 2 Inject 12 units of air into the intermediate- or long-acting insulin vial. • 3 Withdraw 12 units of intermediate- or long-acting insulin . • 4 Inject 6 units of air into the fast-acting insulin vial.

• 1 Wipe off the vials with an alcohol swab. • 2 Inject 12 units of air into the intermediate- or long-acting insulin vial. • 4 Inject 6 units of air into the fast-acting insulin vial. • 5 Withdraw 6 units of fast-acting insulin. • 3 Withdraw 12 units of intermediate- or long-acting insulin . Explanation: The nurse should wipe the insulin bottles with an alcohol swab before each use to eliminate contamination. Then the nurse should inject 12 units of air into the intermediate- or long-acting insulin vial, without touching the insulin. Next, the nurse should insert 6 units of air into the fast-acting insulin and draw up the insulin into the syringe. Fast-acting insulin should be drawn into the syringe first to avoid the risk of mixing the long-acting insulin into the vial and delaying the onset of action of the regular insulin in an emergency. Lastly, the nurse should draw 12 units of intermediate- or long-acting insulin into the syringe.

The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement interventions to ensure the client's safety? All options must be used. -Contact the health care provider (HCP) and request a prescription for soft wrist restraints. -Assess the client's respiratory status, including oxygen saturation. - Review the client's medications for interactions that may cause or increase confusion. -Ensure the client does not need toileting or pain medications.

• 1. Assess the client's respiratory status, including oxygen saturation. • 2. Ensure the client does not need toileting or pain medications. • 3. Review the client's medications for interactions that may cause or increase confusion. • 4. Contact the health care provider (HCP) and request a prescription for soft wrist restraints. Explanation: The nurse should first assess the client's respiratory status to determine if there is a physiological reason for the client's confusion. Other physiological factors to assess include pain and elimination. Safety needs including medication interactions should then be evaluated. Requesting restraints in order to maintain client safety should be used as a last resort.

A 19-year-old nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which information would the nurse expect to include in the client's teaching plan? • As ovulation approaches, cervical mucus is abundant and clear. • Cervical mucus disappears immediately after ovulation, resuming with menses. • About midway through the menstrual cycle, cervical mucus is thick and sticky. • During ovulation, the cervix remains dry without any mucus production.

• As ovulation approaches, cervical mucus is abundant and clear. Explanation: As ovulation approaches, cervical mucus is abundant and clear, resembling raw egg white. Ovulation generally occurs 14 days (±2 days) before the beginning of menses. During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to the influences of estrogen and progesterone. Cervical mucus is always present.

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse? • Give client paper and pencil with which to write name and birthdate. • Ask the client to state name and birthdate. • Ask two staff members to state the name of the client in the room. • Recall the client's facial features to verify the client's identity.

• Ask the client to state name and birthdate. Explanation: The nurse should ask the client to state name and birthdate and compare it to the client's records. The nurse does not need to provide a pencil and paper for the client to write the name and birthdate as the client has ataxia. Ataxia involves muscle movement, typically in the arms (making fine motor movements, such as writing, difficult) and legs, though speech may be slurred. Recalling the client's facial features to verify identity is prone to errors. Asking two staff members which client is in the room does not verify identity.

A parent calls the clinic after her 4-year-old choked on a peanut. The parent reports performing abdominal thrusts and the child is breathing normally now. What should the nurse tell the parent to do? • Test the child's urine for blood for internal bleeding. • Bring the child to the emergency department to check for airway obstruction. • Observe the child for difficulty breathing from a possible pneumothorax. • Call the primary care provider if the child begins to sweat and feels dizzy.

• Bring the child to the emergency department to check for airway obstruction. Explanation: The nurse should instruct the mother to bring the child to the emergency department. If aspirated, nuts may swell leading to an airway obstruction after the initial event; endoscopy may be required to remove remaining fragments. Bleeding from trauma to internal organs after abdominal thrusts is rare. There are no signs of shock to suggest anaphylaxis. There is no indication of the presence of a pneumothorax.

A client's blood pressure is elevated at 160/90 mm Hg. The health care provider prescribed "clonidine 1 mg by mouth now." The nurse sent the prescription to pharmacy at 0710, but the medication still has not arrived at 0800. What should the nurse do next? Select all that apply. • Use a pill from another client's box who is taking the same medication. • Go to the pharmacy to obtain the drug. • Call the pharmacy. • Check the client's blood pressure. • Check all appropriate places on the unit to which the drug could have been delivered.

• Call the pharmacy. • Check the client's blood pressure. • Check all appropriate places on the unit to which the drug could have been delivered. Explanation: The nurse should first check to see if the medication has been misplaced, check the client's blood pressure to determine the immediacy of administering the drug, and then call the pharmacy to check that the medication was delivered. Although the nurse needs to obtain and administer the medication as soon as possible, it is inappropriate for the nurse to go to the pharmacy and request the drug without first calling the pharmacy. The nurse should not use another client's medication.

The nurse is ready to administer a partial fill of imipenem-cilastatin in the IV pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. What should the nurse do? • Discard the full partial fill of imipenem-cilastatin found hanging at the client's bedside. • Determine when the client received the last dose of the imipenem-cilastatin. • Check the identifying information of the full partial fill of imipenem-cilastatin found hanging at the client's bedside. • Administer the new partial fill of imipenem-cilastatin.

• Check the identifying information of the full partial fill of imipenem-cilastatin found hanging at the client's bedside. Explanation: The nurse should first determine whether the client received the last dose of imipenem-cilastatin. If the client did not receive the last dose, the nurse should notify the health care provider (HCP) that the client did not receive the dose, receive prescriptions, document, implement the prescriptions, and complete an incident report. The nurse should not automatically discard the partial fill of imipenem-cilastatin found at the client's bedside until further investigation is done. The nurse should recognize the cost of medications such as imipenem-cilastatin and consult the pharmacist after identifying information on the partial fill bag that was found. After verifying all information, the nurse can administer the new partial fill of imipenem-cilastatin so that the client can receive the antibiotic on time.

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? • Place the mother in a knee-to-chest position. • Palpate the cord for pulsations before notifying the physician. • Restore circulation by stimulating the cord with a sterile glove. • Attempt an external cephalic rotation.

• Place the mother in a knee-to-chest position. Explanation: The knee-to-chest position helps lift the presenting part off the umbilical cord. If, upon vaginal examination, a loop of cord is discovered, the nurse should keep gloved fingers in the vagina and push on the fetal presenting part to keep the part off the cord, thus relieving cord compression until the physician or midwife arrives. It is inappropriate to attempt an external cephalic rotation. Cord pulsations may not be felt; therefore, oxygen should be administered and electronic fetal monitoring should be put in place immediately to monitor the fetal heart rate and well being.

The nurse is supervising a student nurse who is performing tracheostomy care for a client. Which action performed by the student would require nurse intervention? • Replace inner cannula and clean stoma site. • Suction tracheostomy tube before performing tracheostomy care. • Remove inner cannula and clean using universal precautions. • Change soiled tracheostomy ties and secure tube in place.

• Remove inner cannula and clean using universal precautions. Explanation: When tracheostomy care is performed, sterile technique is used and standard precautions are not enough. The presence of an inner cannula provides direct access to the lungs for organisms, so sterile technique must be used to decrease the risk of infection. All other steps are appropriate.

The nurse cares for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first? • Take the child's vital signs. • Switch the transfusion to normal saline solution. • Administer oxygen. • Notify the health care provider (HCP).

• Switch the transfusion to normal saline solution. Explanation: The child is having a reaction to the blood transfusion. The priority is to stop the blood transfusion but maintain an open venous access for medication or high fluid volume delivery. Thus, switching the transfusion to normal saline solution would be done first. Since the child is having difficulty breathing, applying oxygen would be the next action. Additionally, vital signs are taken to determine the extent of circulatory involvement. Then the HCP would be notified and, if necessary, the crash cart would be obtained.

What should the nurse do when suctioning a client who has a tracheostomy tube 3 days following insertion? • Protect the catheter in sterile packaging between suctioning episodes. • Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses. • Clean the catheter in sterile water after each use, and reuse for no longer than 8 hours. • Use a sterile catheter each time the client is suctioned.

• Use a sterile catheter each time the client is suctioned. Explanation: The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used. Reusing a suction catheter is not consistent with aseptic technique. The nurse does not use a clean catheter when suctioning a tracheostomy or a laryngectomy; it is a sterile procedure.

The nurse teaches the parents of an infant who has had surgery to correct imperforate anus how to position the infant to prevent tension on the perineum. The nurse determines more teaching is need when the parents put the infant in which position? • left side, with hips elevated • abdomen, with legs pulled up under the body • back, with legs suspended at a 90-degree angle • right side, with hips elevated

• abdomen, with legs pulled up under the body Explanation: When placed on the abdomen, a neonate pulls the legs up under the body, which puts tension on the perineum. Therefore, after surgery, the neonate should be positioned either supine with the legs suspended at a 90-degree angle or on either side with the hips elevated.

Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? • administering pain medication. • completing the admission history • teaching about planned diagnostic tests • maintaining hydration

• administering pain medication. Explanation: Administering pain medication would have the highest priority during the first hour after the client's admission.Completing the admission history can be done after the client's pain is controlled.Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief.It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable.

The nurse is caring for an expectant mother who asks how decisions are made if complications place both the mother and fetus at risk. What ethical principle will the nurse cite when responding to the client's question? • autonomy • justice • nonmaleficence • jurisprudence

• autonomy Explanation: The principle of autonomy informs decisions when conflicts arise between maternal and fetal rights. The woman has the right to choose for herself what she believes to be in her best interest versus the well-being of the fetus. This is the concept of self-determination, of being in charge of one's person rather than another person determining what behavior or decision represents justice. Nonmaleficence refers to doing no harm. The client has the right to make choices that align with her belief system. Jurisprudence is the actual theory or study of law.

A nurse working on a psychiatric unit is checking orders on a newly admitted client diagnosed with schizophrenia. An order reads, "thioridazine 200 mg PO qid and 100 mg PO prn." Before this drug is administered, which should be the nurse's priority action? • assessing the client's allergies • checking accuracy of the order • instructing the client about potential side effects • identifying the client by name and room number

• checking accuracy of the order Explanation: The nurse must question this order immediately. Thioridazine has an absolute dosage ceiling of 800 mg/day. Any dosage about this level places the client at high risk for toxic pigmentary retinopathy, which cannot be reversed. As written, the order allows for administering more than the maximum 800 mg/day; it should be corrected immediately before the client's health is jeopardized. This is a higher priority than assessing a client's allergies or teaching about the possible side effects, which will be done prior to medication administration. Proper client identification is necessary prior to medication administration; however, the client should be identified by name and date of birth. Accuracy of the order takes priority.

The nurse is teaching the family of a client with a psychiatric disorder about traditional antipsychotic drugs and their effect on symptoms. Which symptom would be most responsive to these types of drugs? • attention impairment • apathy • social withdrawal • delusions

• delusions Explanation: Positive symptoms such as delusions, hallucinations, thought disorder, and disorganized speech respond to traditional antipsychotic drugs. The other options belong in a category of negative symptoms, including affective flattening, restricted thought and speech, apathy, anhedonia, asociality, and attention impairment. Negative symptoms are more responsive to the new atypical antipsychotics, such as clozapine, risperidone, and olanzapine.

There has been a large disaster, and nurses from various units have been assigned to help with the large influx of clients. To which client would it be most appropriate to assign an obstetric-postpartum nurse? • male client who is three days postoperative with an indwelling urinary catheter • older adult woman who has been hospitalized for two days with herpes zoster • male admitted for hearing voices commanding him to kill himself • female in pelvic traction who is three months pregnant

• female in pelvic traction who is three months pregnant Explanation: A nurse's current experience should be considered when assignments are made. Obstetric nurses may have limited experience with traction but will be able to offer the most support to the pregnant client if she has questions about the well-being of the fetus. The next best client to assign to the nurse is the postoperative male client with an indwelling catheter as the nurse should have experience caring for postoperative cesarean clients and urinary catheters. This nurse should not care for infectious clients; this presents the risk of disease transmission to those on her regular unit. This nurse has no experience with psychiatric clients.

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion? • fetal heart rate variability within 5 to 10 beats/minute • persistent fetal bradycardia • variable decelerations and sinusoidal pattern • late decelerations

• fetal heart rate variability within 5 to 10 beats/minute Explanation: Fetal heart rate variability most reliably indicates uteroplacental and fetal perfusion; an average variability of 5 to 10 beats per minute is considered normal. Persistent fetal bradycardia may signal hypoxia, arrhythmias, or fetal cord compression. Late decelerations indicate decreased blood flow and oxygen to the intervillous spaces during uterine contractions — an abnormal pattern. Variable decelerations suggest umbilical cord compression; a sinusoidal pattern signals severe fetal anemia or asphyxiation. -normal fetal HR range is 115-150 BPM -normal speeding up or slowing down during labor during contractions (variable deceleration or late deceleration"

A nurse is conducting a teaching session with a group of parents on infant care and safety to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints made by one of the parents would indicate to the nurse that learning has taken place? • "Infants should ride in a rear-facing car seat until they weigh 20 lb (9.1 kg) or are 1 year old." • "Infants should ride in a rear-facing car seat until they weigh 25 lb (11.3 kg) or are 1 year old." • "Infants should ride in a rear-facing car seat until they weigh 30 lb (13.6 kg) or are 2 years old." • "Infants should ride in a rear-facing car seat until they have reached the maximum weight allowed by the car seat manufacturer or are 2 years old."

Correct response: "Infants should ride in a rear-facing car seat until they have reached the maximum weight allowed by the car seat manufacturer or are 2 years old." Explanation: The American Academy of Pediatrics recommends that infants should ride in a rear-facing car seat until they have reached the maximum weight or height allowed by the car seat manufacturer or until they are at least 2 years old.

The nurse is caring for a client with graduated compression stockings. The nurse removes the stockings and assessment findings include a blister on the right heel. What is the next action by the nurse? • Apply antibiotic ointment to the blister and reapply the stockings. • Cover the blister with a sterile dressing and reapply the stockings. • Reapply the stockings and make a referral to the skin care team. • Discontinue the graduated compression stockings and notify the healthcare provider.

Correct response: Discontinue the graduated compression stockings and notify the healthcare provider. Explanation: When a client has prescribed graduated compression stockings, the nurse would remove the stockings and inspect the skin at least every 8 hours. If the client has discoloration, markings, or blisters on the heel, the nurse would discontinue the stockings and notify the healthcare provider because sequential compression devices may be used instead to prevent deep vein thrombosis. Applying antibiotic ointment or sterile dressings would require a healthcare provider's order, therefore the healthcare provider should be notified before proceeding with the reapplication of the stockings. Reapplying the stockings may cause further damage to the heel, therefore the healthcare provider should be notified before making a referral to the skin care team.

The nurse develops a plan of care for a client with a t-tube. Which nursing intervention should be included? • Keep the t-tube clamped except during meal times. • Irrigate the t-tube every 4 hours to maintain patency. • Inspect skin around the t-tube daily for irritation. • Maintain client in a supine position while the t-tube is in place.

Correct response: Inspect skin around the t-tube daily for irritation. Explanation: Bile is erosive and extremely irritating to the skin. Therefore, it is essential that skin around the t-tube be kept clean and dry.T-tubes are not routinely irrigated; they are irrigated only on prescription of the health care provider.There is no need to maintain the client in a supine position; assist the client into a position of comfort.T-tubes are never clamped without a health care provider's prescription. If prescribed to be clamped, however, t-tubes are typically clamped 1 to 2 hours before and after meals.

The nurse is admitting a client to the hospital and fails to implement a turning and positioning schedule for the client identified as a high risk for impaired skin integrity. What are the legal actions that the nurse can be accountable for? Select all that apply. • battery • unintentional tort • intentional tort • defamation of character • negligence

Correct response: unintentional tort negligence Explanation: Negligence is an unintentional tort and applies because the nurse failed to implement proper skin care such as a turning schedule. Battery is an assault and did not occur with the failure to implement the turning schedule. Defamation of character is an intentional tort making derogatory remarks about the client, which did not occur with this scenario.

After undergoing a liver biopsy, a client should be placed in which position? • Semi-Fowler's position • right lateral decubitus position • prone position • supine position

• right lateral decubitus position Explanation: After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.

A client with alcohol dependence states, "I feel so bad because of what I've done to my wife and kids. I'm just no good." Which response by the nurse is most appropriate? • "Why do you think you're no good?" • "Alcoholism is painful for everyone involved." • "They've stayed with you so far." • "Alcohol dependence is a disease that can be treated."

• "Alcohol dependence is a disease that can be treated." Explanation: The most appropriate response is "Alcohol dependence is a disease that can be treated" because it conveys hope. It also emphasizes that the client has a treatable illness, which is helpful in reducing denial and guilt and encouraging the client to seek and comply with treatment. Clients often cannot answer "why" questions. While saying that the family has stayed with the client so far may be true, there is no guarantee that they will continue to do so especially if the client does not enter into treatment. Saying alcoholism is painful for everyone is guilt producing, possibly leading to denial and furthering the need for alcohol.

The nurse is evaluating a client who is at risk for skin breakdown. Which characteristics would the nurse observe to determine there is a Stage I pressure ulcer? Select all that apply. • blister • intact skin • non-blanchable redness over a bony prominence • partial thickness loss of dermis • slough • eschar

• intact skin • non-blanchable redness over a bony prominence Explanation: The client with a Stage I pressure ulcer would still have intact skin that may be reddened if over a bony prominence; the redness would not be able to be blanched and usually involves a localized area. A blister, whether intact or ruptured, would be an indication of a Stage II pressure ulcer, along with partial thickness loss of dermis. Eschar and slough may be present in Stage III, IV, or unstageable pressure ulcers.

A nurse is caring for a client with diabetes insipidus. The nurse should anticipate administering • vasopressin. • furosemide. • potassium chloride. • insulin.

• vasopressin. Explanation: Vasopressin is given subcutaneously to manage diabetes insipidus. Insulin is used to manage diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia.

When assessing a client withdrawing from alcohol, the nurse notes that the client is anxious, experiencing nausea, is restless, and has a tremor when both arms are extended. What should the nurse should do next? • Move the client to a quieter room. • Administer a benzodiazepine as prescribed. • Transfer the client to an acute care psychiatric unit. • Continue to assess the client.

Correct response: Administer a benzodiazepine as prescribed. Explanation: The client is exhibiting signs and symptoms of withdrawal, and the nurse should administer the benzodiazepine to manage the anxiety, nausea, and restlessness and to prevent seizures. After administering the medication, the nurse will continue to assess the client and ensure the client is in a quiet environment. There is no need to transfer this client to the psychiatric unit based on the information provided.

An 8-year-old child has been admitted to the oncology unit with a suspected diagnosis of acute lymphoblastic leukemia. The nurse is obtaining a health history from the parents. During the interview, the parents ask the nurse if any of the factors discussed would make their child more at risk for this type of leukemia. What information about potential risk factors is correct for the nurse to share with the parents? • the X-rays that the child had at age 6 for a broken leg • the diagnosis of Down's syndrome at birth • a diet that includes a large proportion of dairy products • a weight that is above the limit for the child's age

Correct response: the diagnosis of Down's syndrome at birth Explanation: Children with Down's syndrome and other genetic conditions have an increased risk of developing acute lymphoblastic leukemia. Prenatal exposure to X-rays is actually a higher concern than postnatal exposure with respect to increasing the risk of developing ALL. The exception would be postnatal exposure to high doses of therapeutic radiation used as a treatment modality, which was not indicated here. Diet would have little impact on risk factors at this stage in the child's life.

A client presents to the emergency department with the following symptoms: nausea, vomiting, a sudden headache, and a stiff neck. Vital signs are: temperature 98.8 F (37.1 C); pulse 120 bpm; respirations 12 breaths/min; and blood pressure 220/148 mm Hg. The client states that they are currently taking an antidepressant. Which should the nurse assess first? • toxicology screen • type of antidepressant • nuchal rigidity • 24-hour recall of diet

Correct response: type of antidepressant Explanation: The nurse must recognize that the symptoms indicate a hypertensive crisis because the blood pressure is dangerously high. The type of antidepressant the client is taking is important because if it is a monoamine oxidase inhibitor (MAOI) such as phenelzine it could be the cause. MAOI's do have food and drug interactions that result in hypertensive crisis, and a 24 hour recall would then be important. The appearance of a sudden headache and stiff neck are also signs of the hypertensive crisis, but the type of antidepressant would take priority. The symptoms could be related to cocaine overdose but are more likely related to the antidepressant.

A nurse is administering sublingual nitroglycerin to a client. Immediately after administering nitroglycerin, the nurse should expect to administer • insulin. acetaminophen • prednisone. • alprazolam.

acetaminophen. Explanation: In the early stages of therapy, nitroglycerin commonly causes headache and dizziness. Acetaminophen usually helps decrease nitroglycerin-induced headaches. Although the client may be anxious, lorazepam usually isn't given after nitroglycerin. There is no indication that the client would need insulin or prednisone.

The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response? • "The fetal heart rate dropped during the contractions, so we may need to induce you." • "It is too early to tell, we will need to repeat the test in 2 weeks." • "The fetal heart rate went up twice during the test, so your fetus is doing well." • "I'm sorry, your provider will have to inform you of the results of the test."

• "The fetal heart rate went up twice during the test, so your fetus is doing well." Explanation: During a nonstress test, an electronic fetal monitor provides a tracing of the fetal heart rate (FHR). Normally, the FHR accelerates with movement, indicating that the fetus has an intact autonomic nervous system that is not affected by uterine hypoxia. A reactive (normal) nonstress test with two accelerations going up 15 beats per minute and lasting 15 seconds in 20 minutes is a sign of fetal well-being. A nonstress test may be performed anytime after 32 weeks' gestation. Contractions are stimulated for a contraction stress test (CST); a positive CST is indicative of a fetus that may not handle the stress of labor well.

Which client cannot sign out against medical advice? • a client who drank a bottle of vodka 1 hour ago • a minor who has been emancipated by court order • an adult client with ST elevation on the electrocardiogram • a pregnant 15-year old with vaginal spotting

• a client who drank a bottle of vodka 1 hour ago Explanation: A client who is intoxicated is not competent to sign out against medical advice. A pregnant teen is considered an adult. A competent adult client can discharge against medical advice for any reason. A legally emancipated minor is considered an adult.

A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained: • during the acute disease stage and as long as the virus is shed (up to 30 days). • during the acute disease stage and up to 48 hours after diarrhea stops. • until three fecal cultures are negative for Shigella. • for 24 to 48 hours after anti-infective therapy begins.

• until three fecal cultures are negative for Shigella. Explanation: The nurse should explain that enteric precautions are required until three fecal cultures are negative for Shigella. Absence of diarrhea doesn't indicate absence of Shigella. Shigellosis is a bacterial infection, so no virus is shed. Shigella still may be present 48 hours after anti-infective therapy begins.

Which assessment provides the best information about the client's physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal? • evidence of tremors • vital signs • sleep pattern • nutritional status

• vital signs Explanation: Monitoring vital signs provides the best information about the client's overall physiologic status during alcohol withdrawal and the physiologic response to the medication used. Vital signs reflect the degree of central nervous system irritability and indicate the effectiveness of the medication in easing withdrawal symptoms. Although assessment of nutritional status and sleep pattern and assessment for evidence of tremors are important, they provide only indirect information about single aspects of the client's physiologic status.

The nurse reviews a client's lab values and implements which intervention to help with maintenance of skin integrity? • Place the client on cardiac monitoring. • Begin infusion of intravenous fluids. • Order the client a calorie controlled diet. • Monitor the client's oral temperature.

Begin infusion of intravenous fluids. Explanation: A client with an increased sodium level potentially has dehydration, which can impact skin integrity as a risk factor. Beginning rehydration through the infusion of intravenous fluids will help with restoring fluid volume, and preventing dry skin. The WBC count is still within normal limits, so monitoring the temperature is not indicated. While the potassium level is decreased and the client may need cardiac monitoring, this does not have an effect on skin integrity. Nutrition does have an effect, but there is no indication of the client being malnourished with a glucose level of 111 mg/dL.

A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can • count and sing with the child. • hold and rock the child and give the child a security object. • establish a time limit to get ready for the procedure. • prepare the child by positive self-talk.

• hold and rock the child and give the child a security object. Explanation: The toddler with Down syndrome may have difficulty coping with painful procedures and may regress during illness. Holding, rocking, and giving the child a security object is helpful because it may be comforting to the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing; however, the success of these tactics depends on the child.

A child diagnosed with Wilms' tumor undergoes successful surgery for removal of the diseased kidney. When the child returns to the room, the nurse should place the child in which position? • semi-Fowler's • supine • modified Trendelenburg • Sims'

• semi-Fowler's Explanation: The child who has undergone abdominal surgery is usually placed in a semi-Fowler's position to facilitate draining of abdominal contents and promote pulmonary expansion. The modified Trendelenburg position is used for clients in shock. The Sims' position is likely to be uncomfortable for this child because of the large transabdominal incision. The supine position, without the head elevated, puts the child at increased risk for aspiration.

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention? • partial pressure of arterial oxygen (PaO2) of 69 mm Hg • bicarbonate (HCO3-) of 28 mEq/L • pH of 7.29 • partial pressure of arterial carbon dioxide (PaCO2) of 51 mm Hg

• partial pressure of arterial oxygen (PaO2) of 69 mm Hg Explanation: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

A nurse is caring for a school-age client who is in the second percentile of height and weight for age as a result of an endocrine disorder. Which pharmacological intervention should the nurse anticipate? • treatment with desmopressin acetate (DDAVP) • treatment with testosterone or estrogen • replacement with biosynthetic growth hormone • replacement with antidiuretic hormone (ADH)

• replacement with biosynthetic growth hormone Explanation: The definitive treatment of growth hormone deficiency is the replacement of growth hormone (somatotropin) with biosynthetic somatotropin. This treatment is successful in 80% of affected children. Desmopressin acetate is used to treat diabetes insipidus. A deficiency of antidiuretic hormone causes diabetes insipidus, and isn't related to hypopituitarism. Testosterone or estrogen may be given during adolescence for normal sexual maturation, but neither is the definitive treatment for hypopituitarism.

The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following topics would be important for the nurse to include in the teaching plan? • increased risk for urinary tract infections • decreased plasma volume • increased hemoglobin levels • increased peripheral vascular resistance

Correct response: increased risk for urinary tract infections Explanation: During pregnancy, urinary tract infections are more common because of urinary stasis. Clients need instructions about increasing fluid volume intake. Plasma volume increases during pregnancy. The increase in plasma volume is more pronounced and occurs earlier than the increase in red blood cell mass, possibly resulting in physiologic anemia. Peripheral vascular resistance decreases during pregnancy, providing a relatively stable blood pressure. Hemoglobin levels decrease during pregnancy even though there is an increase in blood volume.