EXAM MODE: Comprehensive Exam A

The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? _____ /(If rounding is necessary, round to the nearest whole drop.)/

1000 mL D5W/8 hours = 125 mL/hr × 15 gtt/60 = 31.2 gtt/min. or 31 gtt/min. 31 gtt/min

Two nurses are participating in hand off report. Which statements are best for the off-going nurse to include in report? /(Select all that apply.)/ A. "The client in 123A has been afebrile all night." B. "The client's blood pressure in 124A has been at baseline." C. "The client in 125A is on clear liquids and has taken in 1350 mL." D. "The client in 123B has slept all day." E. "The client in 124B had an output of 850 mL of clear, pale yellow urine." F. "The client in 125B is able to demonstrate insulin self-injection."

A. "The client in 123A has been afebrile all night.", C. "The client in 125A is on clear liquids and has taken in 1350 mL.", E. "The client in 124B had an output of 850 mL of clear, pale yellow urine.", F. "The client in 125B is able to demonstrate insulin self-injection." Rationale: When participating in hand-off report make objective statements. The blood pressure at baseline does not indicate what the baseline is and assumes the on-coming nurse is aware of the baseline. Slept all day needs to include the number of hours slept. The remaining statements are objective.

The client with which fasting plasma glucose level needs the most immediate action by the nurse? A. 50 mg/dL B. 80 mg/dL C. 110 mg/dL D. 140 mg/dL

A. 50 mg/dL Rationale: The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a low level, such as 50 mg/dL, requires the most immediate intervention to prevent loss of consciousness. Normal (such as 80 mg/dL) and slightly elevated levels, such as 110 or 140 mg/dL, do not require immediate intervention.

The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy surgery today C. A client who has a surgical abdominal wound with dehiscence D. A client who is 1 day postoperative following a right-sided mastectomy

A. A client who is 2 days postoperative with a right total knee replacement Rationale: Option A is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. Option B will require a high level of nursing care when returned from surgery. Option C means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. Option D requires extensive teaching and should be assigned to a more experienced nurse.

The nurse is providing care to a client newly diagnosed with asthma. Which client finding indicates that the bronchodilator treatments are effective? A. An O2 saturation reading of 98% B. Urinary output of 250 mL in 4 hours C. Apical pulse rate is 84 beats/min. D. Blood pressure reading of 102/62 mm Hg

A. An O2 saturation reading of 98% Rationale: Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation. Options B, C, and D do not indicate the desired effect of a bronchodilator.

Prior to administering an oral suspension, what is the most important nursing action? A. Assess the client's ability to swallow liquids. B. Obtain applesauce in which to mix the medication. C. Determine the client's food likes and dislikes. D. Auscultate the client's breath sounds.

A. Assess the client's ability to swallow liquids. Rationale: An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used. If a food product is used to thicken the liquid, option C would be beneficial. Option D may also be warranted, but only if the client is at risk for aspiration, determined by option A.

The nurse is providing care to a post-operative client with an indwelling Foley catheter. The client reports to the nurse the sensation of bladder fullness. What is the nurse's priority action? A. Check the tubing for kinks. B. Assure the client that feeling is expected. C. Check the color of the urine for infection. D. Assess the urinary meatus for redness.

A. Check the tubing for kinks. Rationale: Bladder fullness could indicate the drainage tube is not functioning as it is intended. Check to make sure the tube is draining. Burning, pain, and itching would be signs of infection. The client may experience a feeling of fullness with catheter placement, but assure the tubing is functioning first.

The nurse performs an assessment on a client with heart failure. Which findings are consistent with the diagnosis of left-sided heart failure? /(Select all that apply.)/ A. Confusion B. Peripheral edema C. Crackles in the lungs D. Dyspnea E. Distended neck veins

A. Confusion, C. Crackles in the lungs, D. Dyspnea Rationale: Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion. Options B and E are associated with right-sided heart failure.

After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130.

A. Ensure that the client receives breakfast within 30 minutes. Rationale: Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction. Options B, C, and D are also important nursing actions but are of less immediacy than option A.

A nurse is providing care to four clients who are all requesting to be medicated for pain. Which client prescription is the nurse's priority? A. Four mg IV of morphine sulfate every 3 to 4 hours B. Two hydrocodone bitartrate 10/325 tablets every 6 hours C. One tramadol 50 mg tablet every 4 to 6 hours. D. Two 325 mg tablets of acetaminophen every 6 hours

A. Four mg IV of morphine sulfate every 3 to 4 hours Rationale: Administer pain medication in the order of IV, IM, and po, from the most powerful to the least. Morphine IV has both the route and the strength according to this prioritization practice.

A 95-year-old client with full mental capacity is admitted to the hospital with hemoglobin of 6 g/dL and melena. The health care provider orders a capsule endoscopy. The client refuses the treatment to evacuate the bowel. What is the nurse's best action? A. Inform the client of the risks of refusal. B. Tell the client this treatment is mandatory. C. Ask the client's family to convince the client to take the treatment. D. Call the health care provider to come and talk to the client.

A. Inform the client of the risks of refusal. Rationale: A client with capacity who at the age of consent has the right to refuse treatment. The nurse's first responsibility is to make sure the client is aware of the ramifications of the decision and to support the client's choice. The remaining options do support the client's right to refuse treatment.

The nurse is providing care to an 86-year-old admitted with generalized weakness. Dietary modifications and levothyroxine are prescribed. Which physiologic finding in an older adult could precipitate an adverse reaction to the medication? A. Reduced renal excretion B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders

A. Reduced renal excretion Rationale: During the aging process, reduced renal function is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not option C, predisposes an older adult to an increase in adverse drug reactions. Option B may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders is not increased, nor does it affect drug pharmacotherapeutics.

The nurse is providing care to a client newly diagnosed with type 1 diabetes mellitus. Which instructions for foot care will the nurse include in the client's discharge instructions? /(Select all that apply.)/ A. Use lanolin to moisturize the tops and bottoms of the feet. B. Soak the feet in warm water for at least 1 hour daily. C. Wash feet daily and dry well, particularly between the toes. D. Use over-the-counter products to remove corns and calluses. E. Wear leather shoes that fit properly and provide arch support.

A. Use lanolin to moisturize the tops and bottoms of the feet., C. Wash feet daily and dry well, particularly between the toes., E. Wear leather shoes that fit properly and provide arch support. Rationale: Options A, C, and E are therapeutic interventions for foot care in the diabetic client. Options B and D are contraindicated and could cause foot infection or injury.

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?"

B. "Tell me more about how you're feeling." Rationale: It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings. Option A is a leading response, and the client may not be feeling sad. Options C and D are closed-ended questions that do not facilitate communication.

The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. 1. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." 2. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." 3. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." 4. "Would you like to make a change in his pharmacologic regimen?" A. 3, 1, 4, 2 B. 2, 3, 1, 4 C. 1, 4, 2, 3 D. 2, 1, 3, 4

B. 2, 3, 1, 4 Rationale: SBAR S—Situation and includes introduction of the nurse and client/setting (option B). B—Background and includes the presenting complaint and relevant history (option C). A—Assessment and includes current vital signs and other information (option A). R—Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (option D).

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as ebola and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse manager to take? A. Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B. Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C. Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D. Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear.

B. Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. Rationale: Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients. Option A is too authoritarian and does not permit education to play a role in reducing fears. Option C is likely to be intrusive to the family member. Arbitrary staffing without education does not reduce staff fears, even with the provision of peer counseling.

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? A. Hearing acuity B. Immunization history C. Weight and length D. Head circumference

B. Immunization history Rationale: The Centers for Disease Control and Prevention indicates that vaccines are among the most widely used, effective, and safe medical products in use today. Assessing the infant immunization histories in clients from disadvantaged socioeconomic groups is the most effective method for determining these infants' susceptibilities to vaccine-preventable diseases. Assessment of options A, C, and D provides valuable information but does not supply information about infants' susceptibilities to vaccine-preventable diseases, which are major causes of infant mortality and morbidity.

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A. Keep the residual limb elevated during positioning. B. Instruct the client to grasp the overhead trapeze bar. C. Maintain alignment with an abduction pillow. D. Use pillow support to prevent turning to a prone position.

B. Instruct the client to grasp the overhead trapeze bar. Rationale: The client will gain upper body strength and independence by using the overhead trapeze bar for positioning. Elevation of the residual limb is controversial because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. Option C is used for alignment following some hip surgeries. A prone position should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip.

The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A. Advise the client that food from the meal tray should not be shared with others. B. Leave the room and discuss the incident privately with the staff member. C. Objectively document the situation as observed on a variance report. D. Call the nurse manager to the client's room immediately.

B. Leave the room and discuss the incident privately with the staff member. Rationale: Discussing the incident privately promotes open communication between the charge nurse and staff member. The client is free to share unwanted food with family or friends, but the employee should not ask for the client's food. Option C is not necessary, and the charge nurse can respond to this situation without implementing option D.

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse take first? A. Inspect the dressing over the puncture site and under the client for bleeding. B. Take the vital signs to determine the client's response for a potential blood loss. C. Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D. Assess the client's pain level to determine the need for analgesic medication.

B. Take the vital signs to determine the client's response for a potential blood loss. Rationale: After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure. Although options A, C, and D should be implemented after the procedure, the first action is to obtain a baseline assessment.

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. 1. Gently insert the catheter without suction using sterile technique. 2. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). 3. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. 4. Apply suction intermittently while withdrawing the catheter. A. 2, 3, 1, 4 B. 1, 3, 4, 2 C. 3, 2, 1, 4 D. 2, 1, 4, 3

C. 3, 2, 1, 4 Rationale: Equipment should be set up and adjusted prior to beginning the procedure. Hyperoxygenation using an MRB should be completed prior to inserting the catheter. After preoxygenation, the catheter can be inserted and suction can be applied intermittently.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing action is most important in reducing the client's stress associated with repeated hospitalizations? A. Allow the client to discuss the seriousness of the illness. B. Ensure that the client is provided with information about medications. C. Encourage as much independence in decision-making as possible. D. Include the client in planning the course of treatment.

C. Encourage as much independence in decision-making as possible. Rationale: Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible helps reduce stress experienced with repeated hospitalization. Options A, B, and D are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand and participate in the hospitalized plan of care.

When caring for a postpartum client, which nursing action will promote increased peripheral vascular activity? A. Encourage the client to turn from side to side every 2 hours. B. Elevate the foot of the client's bed at least 6 inches. C. Encourage the client to ambulate every 3 hours. D. Teach the client how to perform leg exercises while in bed.

C. Encourage the client to ambulate every 3 hours. Rationale: Ambulation is the best way to increase peripheral vascular activity. Options A, B, and D will increase peripheral vascular activity but are not as effective as ambulation.

Upon assessing a newborn male, the nurse finds the urethral meatus opens on ventral side of penis behind the glans. Which term will the nurse highlight on the infant's assessment tool? A. Cryptorchidism B. Priapism C. Hypospadias D. Epispadias

C. Hypospadias Rationale: In hypospadias, there is a congenital defect of urethral meatus in males and the urethra opens on ventral side of penis behind the glans. Answers A, B, and D are consistent with other conditions.

A client has been receiving levofloxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. What is the most important nursing action for this client? A. Perform a digital evaluation for fecal impaction. B. Administer a PRN dose of psyllium. C. Obtain a stool specimen for culture and sensitivity. D. Instruct the UAP to obtain incontinent pads for the client.

C. Obtain a stool specimen for culture and sensitivity. Rationale: Long-term use of levofloxacin can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen. Impaction is unlikely, so option A is of less priority and may not be necessary. Option B is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort are important interventions but of less priority than determining the cause of the client's diarrhea.

The nurse is preparing to administer a dose of digoxin. Which finding would indicate withholding the medication? A. Serum digoxin level is 1.5 ng/mL. B. Blood pressure is 104/68 mm Hg. C. Serum potassium level is 2.5 mEq/L. D. Apical pulse is 68/min.

C. Serum potassium level is 2.5 mEq/L. Rationale: Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥2 ng/mL). Option A is within this range. Option B would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is <60/min.

A 5-year-old is in Bryant's traction for intervention for a fractured femur. Which finding would require a nursing action? A. The parents are at the bedside reading a book with the child. B. The child's hips are in 90-degree flexion. C. The child's hips are gently resting on the bed. D. The child is consuming 120 mL of grape juice.

C. The child's hips are gently resting on the bed. Rationale: The In Bryant's traction, the buttocks should be elevated off the bed not resting on the mattress. Drinking grape juice with a volume of 120 mL is acceptable and the family should be incorporated into the child's plan of care.

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40 mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A. The client is noncompliant with taking medications. B. The client recently consumed large quantities of pears or nuts. C. The client's renal function has affected the potassium level. D. The client needs to be started on a potassium supplement.

C. The client's renal function has affected the potassium level. Rationale: The client has a normalized potassium level despite diuretic use. The kidney automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the client is noncompliant with his treatment. Pears and nuts do not affect the serum potassium level. There is no need for a potassium supplement because the client's potassium level is within the normal range.

Which assessment finding indicates to the nurse that the nystatin swish and swallow, prescribed for a client with oral candidiasis, has been effective? A. The client denies dysphagia. B. The client is afebrile with warm and dry skin. C. The oral mucosa is pink and intact. D. There is no reflux following food intake.

C. The oral mucosa is pink and intact. Rationale: Nystatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx. The ability to swallow does not indicate that the medication has been effective. Options B and D do not reflect effectiveness of the local medication.

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A. Administer a nonsteroidal anti-inflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B. Perform passive range of motion exercises every evening before bed. C. Warm the child with an electric blanket prior to getting the child out of bed. D. Immobilize swollen joints during acute exacerbations until function returns.

C. Warm the child with an electric blanket prior to getting the child out of bed. Rationale: Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. Option A on an empty stomach is likely to cause gastric discomfort. Passive range of motion exercises keeps the joints mobile. Option D is contraindicated, because joints should be exercised, not immobilized.

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? A. "Let's play some dominoes for a few minutes." B. "I don't think the violence means the world is ending." C. "The news makes you have upsetting thoughts." D. "Listening to the news seems to be frightening you."

D. "Listening to the news seems to be frightening you." Rationale: A client's delusional statements are best addressed by identifying the feeling associated with the delusion. Option A may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief system. The client is unlikely to understand the relationship between the news and the thoughts experienced.

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A. "What makes you think we did anything to your baby?" B. "Are you or any of your blood relatives of Asian descent?" C. "Those are stork bites and will go away in about 2 years." D. "Those are Mongolian spots and will gradually fade in 1 or 2 years."

D. "Those are Mongolian spots and will gradually fade in 1 or 2 years." Rationale: Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African descent or dark-skinned babies. Option A is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African descent, option B does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the face or head and neck area.

A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A. A primigravida who is 8 cm dilated after 14 hours of labor B. A client scheduled for a repeat cesarean birth at 38 weeks' gestation C. A client being induced for fetal demise at 20 weeks' gestation D. A multiparous client who is dilated 5 cm and 50% effaced

D. A multiparous client who is dilated 5 cm and 50% effaced Rationale: The new nurse should be assigned the least complicated client to gain experience and confidence, as well as protect client safety. Of the clients available for assignment, option D is progressing well and is the least complicated. Options A, B, and C have actual or potential complications and should be assigned to a more experienced nurse.

A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A. Review the plan and the steps in performing the procedure with another nurse. B. Look up the specific procedure in a medical-surgical nursing text on the unit. C. Discuss the client's prescribed procedure with an available health care provider. D. Consult the agency's policies and procedures manual and follow the guidelines.

D. Consult the agency's policies and procedures manual and follow the guidelines. Rationale: The agency's policies and procedures manual should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. Options A and B may be resources, but client care should be implemented according to the agency's published policies and procedures. Option C is not practical.

The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received.

D. Continue with current assignments until more instructions are received. Rationale: When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received. Evacuation is typically a response of last resort that begins with clients who are most able to ambulate. Option B is premature and is likely to increase the chaos if incoming casualties are anticipated. Option C is poor utilization of personnel.

A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A. Ask the client to describe the symptoms of the vaginal infection. B. Assess if the client has been sexually active recently. C. Tell the client to reschedule the examination in 1 week. D. Inform the client that the scheduled Pap test cannot be done today.

D. Inform the client that the scheduled Pap test cannot be done today. Rationale: The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed. Although options A, B, and C are indicated, the client needs further teaching for the return visit to perform the Pap smear test.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A. Clients' names are not used while they are in a public waiting room. B. Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C. Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D. Old medical records are kept in a locked file cabinet in the department.

D. Old medical records are kept in a locked file cabinet in the department. Rationale: Past medical records must be "secured" and "reasonably protected" from inadvertent viewing. A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without his or her diagnosis or treatment) is not considered confidential or PHI. Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous, but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions.

The nurse is providing care to a client with head trauma with the most recent intracranial pressure reading of 22 mm Hg. The health care provider has prescribed morphine for pain control. What is the best rationale for the nurse to question this prescription? A. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B. Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D. Opioids suppress respirations, which increases PCO2 and contributes to an elevated ICP.

D. Opioids suppress respirations, which increases PCO2 and contributes to an elevated ICP. Rationale: The greatest risk associated with opioids such as morphine is respiratory depression that causes an increase in PCO2, which increases ICP and masks the early signs of intracranial bleeding in head injury. Options A, B, and C do not support the risks associated with opioid use in a client with increased ICP.

A client has been on a mechanical ventilator for several days. What assessment data should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client-initiated respirations

D. The ventilator setting for respiratory rate and the client-initiated respirations Rationale: The nurse should count the client's respirations and document both the respiratory rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on option A. Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client.

A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a fast-food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A. French toast sticks and orange juice B. Sausage egg muffin and grape juice C. Canadian bacon slices and hot chocolate D. Toasted oat cereal and low-fat milk

D. Toasted oat cereal and low-fat milk Rationale: A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is option D. Option A is high in fat and sugar. Options B and C are high in fat and sodium.