HESI Comprehensive Exit Exam 1 (And Rationale)

Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/ml. How much solution should the nurse administer? a. 0.5 ml. b. 1 ml. c. 1.5 ml. d. 2 ml.

C (To correctly solve this problem, use the formula: Desired/On Hand, or the algebraic formula: 75: x = 50 : 1. 50x = 75. x = 75/50 or reduced to 1.5 ml)

The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 ml vial is labeled "Mucomyst 20% solution (20 grams/100 ml)." What volume of medication in milliliters should the nurse administer? (Enter numeric value only.)

3 20 grams is equivalent to 20,000 mg. 20,000 mg/100 ml = 200 mg/1 ml. Using Desired/Have X Volume: 600 mg/200 mg X 1 ml = 3 ml. or (Ordered over dispensed) 600mg/20000mg =0.03mg 0.03mg x 100ml= 3ml

A child is receiving maintenance intravenous (IV) fluids at the rate of 1000 ml for the first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

61 The formula for calculating daily fluid requirements is: 0 to 10 kg= 100 ml/kg per day; 10 to 20 kg = 1000 ml for the first 10 kg of body weight +50 ml/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 ml/kg = 475 ml + 1000 ml = 1475 ml / 24 hours = 61 ml/hour

A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor? a. Liver. b. Kidney. c. Sensory. d. Cardiorespiratory.

A (Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for hepatotoxicity, so monitoring liver function is the most important assessment because the combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially fatal liver damage. Other non-narcotic analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), are more likely to promote adverse renal effects. Acetaminophen does not place the client at risk for toxic reactions related to sensory or cardiorespiratory organs.)

Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict? a. Deal with issues and not personalities. b. Require the UAPs to reach a compromise. c. Weigh the consequences of each possible solution. d. Encourage the two to view the humor of the conflict.

A (Dealing with the issues which are concrete, not personalities which include emotional reactions, is one of seven important key behaviors in managing conflict. The other choices do not resolve the conflict when diverse opinions are expressed emotionally.)

The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next? a. Mark the drainage on the dressing and take vital signs. b. Notify the healthcare provider of a potential for hemorrhage. c. Remove the dressing and assess the surgical incision site. d. Reassess dressing in one hour for increased drainage.

A (Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant changes in vital signs. To determine that the drainage on an abdominal surgical dressing is usual and not an indication of hemorrhage, marking the 6 cm drainage on the dressing assists in determining an increase in the amount which is supported with any changes in vital signs that indicates possible internal bleeding. Reporting hemorrhage is premature. Removing the initial dressing may disturb the surgical site and increase the risk of hemorrhage and infection. Reassessing the dressing is compared with the previous amount of drainage marked on the dressing.)

The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema? a. History of inflammatory bowel disorders. b. Reason for administering the enema. c. Feelings about having an enema. d. Allergies to medications.

A (Enemas should be avoided or administered with extreme caution to clients with inflammatory bowel disorders, so obtaining this historical information has the highest priority. Reason for the enema and feelings about it also provide valuable information, but are not of the same priority as history of IBS. Allergies are not necessary prior to enema administration.)

Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? a. reports decrease in pain. b. complained of pain; PRN pain medication given. c. smiling while visiting with family members. d. was talking on the phone 30 minutes after pain medication was given.

A (Evaluation of effectiveness must indicate if the drug has had the desired effect, in this case, a decrease in pain. Documenting the medication was given does not indicate whether the drug was effective, just that it was given. Observing the client smiling with family members and talking on the phone does not indicate whether the drug was effective--the client may still be in pain even while talking on the phone or visiting with family members.)

Which approach should the nurse use when preparing a toddler for a procedure? a. Demonstrate the procedure using a doll. b. Avoid asking the child to make choices. c. Plan a teaching session to last about 20 minutes. d. Show equipment but prevent child from handling it.

A (Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of a procedure on a doll enables a non-threatening, dramatic experience that can help prepare the toddler for the actual procedure. The primary developmental task in toddlerhood is acquiring a sense of autonomy, so giving choices whenever possible to a toddler is recommended, not avoiding asking the toddler to make a choice. Since the toddler's attention span is short, teaching sessions should be brief and can be repeated for reinforcement. Showing the equipment before its use helps relieve anxiety, but the child should be allowed to handle some of the equipment to prevent frustration and alleviate fear.)

In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition? a. Increased thirst. b. Soft anterior fontanel. c. Cool, diaphoretic skin. d. Swelling around the eyes and face.

A (Increased thirst is a primary factor in monitoring effectiveness of treatment for diabetes insipidus. A child with diabetes insipidus does not want to eat, and only wants to drink; in fact he/she may even drink water from toilets and vases. The anterior fontanel usually closes at about 18 months of age; therefore, checking fontanels is not an appropriate measure of dehydration for a 3-year-old. The skin of a child with diabetes insipidus is usually warm and dry, not cool and diaphoretic. Edema is not characteristic of diabetes insipidus, but is characteristic of hypothyroidism, Cushing syndrome, or nephrotic syndrome.)

The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA). Which intervention should the nurse include in the plan of care? a. Progressive leg exercises to obtain 90-degree flexion. b. Ambulation with full weight-bearing on first postop day. c. Bed rest for three days with the left knee extended. d. Immobilization of the left knee to prevent dislocation.

A (Isometric quadriceps setting begins the first day after TKA surgery and progresses to straight-leg raises, then gentle ROM to increase muscle strength until 90-degree knee flexion is obtained. Bed rest and immobilization is contraindicated to prevent scar tissue, which limits mobility. Active flexion exercises through the use of a continuous passive motion (CPM) machine postoperatively promotes joint mobility. Postoperative exercise progresses to full weight-bearing before discharge, but not the first postoperative day. Joint mobility is a priority outcome, and dislocation is not typical with TKA.)

A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having? a. Obsessive. b. Phobic. c. Delusional. d. Paranoid.

A (Obsessive thoughts are thoughts that the client is unable to control. Phobic thoughts are irrational fears. Delusional thoughts are false beliefs. Paranoid thoughts are suspicious thoughts.)

The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem? a. Activity intolerance related to postoperative pain. b. Noncompliance with prescribed exercise plan. c. Ineffective management of treatment regimen. d. Knowledge deficit regarding impending surgery.

A (Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate in learning, so the nursing diagnosis in indicates a need to postpone teaching. the other choices indicate a need for instruction.)

The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? a. Purplish-red pinpoint lesions of the skin. b. Purple to bluish discoloration of the skin. c. Small circumscribed elevations containing purulent fluid. d. Generalized reddish discoloration of an area of skin.

A (Petechiae are described as purplish to red, non-blanchable, pinpoint lesions that are tiny hemorrhages within the dermal or submucosal layers. Purplish skin discoloration describes ecchymosis caused by trauma to the underlying blood vessels. Small elevations containing pus describes pustules. Generalize red skin area is nonspecific and incomplete.)

The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement? a. Immunizations that decrease occurrences of many contagious diseases. b. Blood pressure screenings to identify persons with high blood pressure. c. Breast self-examination (BSE) for young women instead of a mammogram. d. Home care monitoring for clients who are high-risk due to pregnancy.

A (Primary prevention involves health promotion and disease prevention activities to decrease the occurrence of illness and enhance general health and quality of life, such as immunization. Health screenings are the mainstay of secondary prevention and include interventions designed to increase the probability that disease is diagnosed early when treatment is likely to result in cure. Tertiary prevention like home monitoring of high-risk pregnancies includes interventions aimed at disability limitation from disease, injury, or disability.)

The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? a. Ptosis on the left eyelid. b. A nystagmus on the left. c. Astigmatism on the right. d. Exophthalmos on the right.

A (Ptosis is the term to describe an eyelid droop that covers a large portion of the iris, which may result from oculomotor nerve or eyelid muscle disorder. Nystagmus is characterized by rapid, rhythmic movement of both eyes. Astigmatism is a distortion of the lens of the eye, causing decreased visual acuity. Exophthalmos is a term used to describe a protrusion of the eyeballs that occurs with hyperthyroidism.)

During the physical assessment, which finding should the nurse recognize as a normal finding? a. Regular pulsation at the epigastric area when the client is supine. b. Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds. c. Jugular venous pressure palpable with the client in an upright position. d. Point of maximal impulse at the third intercostal space in the right midclavicular line.

A (Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding. All other choices are abnormal findings that require further assessment.)

The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client? a. Eat 50% of six small meals each day by the end of one week. b. Meals prepared during hospitalization will be fed by the nurse. c. Verbalize understanding of plan and of intention to eat meals. d. Demonstrate progressive weight gain toward the ideal weight.

A (Short-term goals should be realistic and attainable and should have a time line of 7 to 10 days before discharge. Eating 50% of meals meets this criteria. Feeding the client meals is a nurse-oriented goal. Verbalizing understanding may be beyond the capabilities of a confused client. Progressive weight gain is a long-term goal.)

The nurse is using the Ages and Stages Questionnaire (ASQ) to screen a 12-month-old infant during a well-child visit. When the parents ask the nurse the reason for this procedure, which response provides the best explanation? a. This tool identifies achievement of development milestones in infants and young children. b. The procedure tests cognitive, physical, and psychological areas of development. c. The examination screens for early speech difficulties so early treatment can begin. d. This test measures intellectual ability and screens for possible learning difficulties later in school.

A (The ASQ is a screening tool for children one month to 5.5 years of age to identify strengths and developmental- social-emotional delays in normal early developmental milestones. The other choices are not the focus of the ASQ.)

The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace which her healthcare provider has prescribed. Which instruction would be accurate? a. Remove the brace one hour each day for bathing only. b. Remove the brace twice daily for back range of motion exercises. c. Wear the brace against the bare skin. d. Wear the brace in order to cure the spinal curvature.

A (The brace should be worn 23 hours a day and removed a total of one hour a day for hygiene. Continuation of present activities will promote a positive self concept. There really is no such thing as back range of motion exercises. A T-shirt should be worn next to the body and the brace put on over the T-shirt. The brace should not be worn against bare skin. The brace will not cure the spinal curvature, but only slow the progression of the scoliosis.)

During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client? a. Taking medication, with community follow-up. b. Obtain housing, with possibility of returning home. c. Become familiar with public transportation. d. Begin vocational rehabilitation.

A (The most important goal for discharge is for the client to take medications, which will stabilize her mood and promote an optimum level of functioning. The other choices are important goals, but first the client needs to be stabilized on her medication.)

Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? a. Case manager. b. Nurse-manager. c. Quality manager. d. Discharge manager.

A (The role of the case manager is to assist the continuum of care for the client, and coordinate the plan of care, evaluate client needs, and collaborate with the interdisciplinary healthcare team to ensure that goals are met, quality is maintained, and progress toward discharge is made. Nurse managers focus on staffing and assigning work on client units. A quality manager reviews research and assesses opportunities for process improvement, implement changes, measure outcomes, and start the improvement process. A discharge manager is responsible for all of the discharge needs of clients at the time of discharge but would not be involved with client admission activities.)

The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder? a. Grave's disease. b. Cushing syndrome. c. Multiple sclerosis. d. Addison's disease.

A (This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease, which is an autoimmune condition affecting the thyroid. Cushing syndrome, multiple sclerosis, or Addison's disease are not associated with these symptoms.)

The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement? a. Administer the dose as prescribed. b. Withhold the drug and notify the healthcare provider. c. Give intravenous (IV) calcium gluconate. d. Recheck the vital signs in 30 minutes and then administer the dose.

A (Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so the drug should be administered, based on the client's heart rate and blood pressure. Withholding the medication or giving IV calcium are not indicated by the data presented. Rechecking vital signs delays the administration of the scheduled dose.)

The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands? a. A pregnant woman. b. A teenager beginning puberty. c. A 3-month-old infant. d. A school-aged child.

A A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other clients require only 15 to 20% more than the basic metabolic rate.

A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide? a. Are less expensive. b. Provide antiinflammatory response. c. Cause gastrointestinal bleeding. d. Increase hepatotoxic side effects.

B (Nonsteroidal antiinflammatory drugs (NSAIDs) have antiinflammatory properties, which relieves pain associated with osteoarthritis and differs from acetaminophen, a non-narcotic analgesic and antipyretic. Mentioning the price does not teach the client about the medication's actions. Although NSAIDs are irritating to the gastrointestinal (GI) system and can cause GI bleeding, instructions to take with food in the stomach to manage this as an expected side effect should be included, but this does not answer the client's question. Acetaminophen is potentially hepatotoxic, not NSAIDs.)

The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? a. Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long. b. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. c. Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube. d. Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis.

B (A soft rubber catheter with a blunt tip is preferable and deep, vigorous suctioning should be avoided. The client should not hold his breath whether he has one or two lungs and 5 seconds of suctioning is not enough to justify the trauma caused by suctioning. Having another person available for restraint is a good idea if the client is combative or confused, but having a person hold his hands is not the best answer to this question. It is important to avoid deep suctioning to avoid perforating the sutures on the bronchial stump following a pneumonectomy.)

A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was February 14. The client wants to know the expected date of birth (EDB). How should the nurse respond? a. September 17. b. November 21. c. December 17. d. October 21.

B (Using N gele's rule to calculate EDB, subtract 3 months and add 7 days to the first day of the last normal menstrual period. The client's LMP is February 14, so less 3 months + 7 days is November 21 of the next year. All other dates are inaccurate.)

The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes? a. Educate significant others about providing support for their partner during labor. b. Participants can identify at least three coping strategies to use during labor. c. Teach and practice breathing techniques to help cope with contractions during labor. d. Introduce comfort measures that are effective techniques to use during labor and delivery.

B (An expected outcome is a specific, measurable change in a client's status that occurs in response to nursing interventions. Developing coping strategies meet the criteria for an expected outcome. The other 3 choices are nursing interventions that should lead to the expected outcome.)

During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection (STI). The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women? a. Gonorrhea. b. Chlamydia. c. Candidiasis. d. Trichomoniasis.

B (Chlamydia is the most common and fastest spreading sexually transmitted infection (STI) in American women, with an estimated 3 million new cases each year. Gonorrhea and trichomoniasis are not as prevalent as Chlamydia. Although Candidiasis can be spread by sexual intercourse, it is a common vaginal infection unrelated to sexual exposure.)

A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care? a. Teach that anger will subside after two weeks on antidepressants. b. Ask client to describe triggers of anger. c. Gather more data about social support. d. Collaborate with the treatment team about revising the goal.

B (Depression is associated with feelings of anger, and clients are often not aware of these feelings. Awareness is the first step in dealing with anger (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Anger may persist after beginning antidepressant therapy, and it may not be necessary to revise the goal. Gathering data on social support systems can assist the client to cope, but it's most important to ask the client to describe triggers of anger.)

A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take? a. Talk to the colleague about what was seen. b. Report the incident to the immediate supervisor. c. Carefully observe the nurse to verify the behavior. d. Determine if other staff have observed similar behavior.

B (Even if the drugs were not narcotics, it is the nurse-manager's responsibility to report these findings to the person in charge of the unit. Talking to the colleague puts the colleague on guard and promotes denial and defensiveness. Observing the nurse is ignoring the event, which could enable the behavior to continue. Asking other staff promotes "gossip" about the colleague and is not be helpful to the colleague or to the unit.)

Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse? a. Serves as a consultant to businesses and management. b. Implements health programs for construction workers. c. Designs quality improvement methods that measure health outcomes. d. Conducts research studies that enhance health safety.

B (Implementing health programs for construction workers is an example of a competent performance criterion in management, which includes monitoring of the quality and effectiveness of vendor services. Serving as a consultant is an example of an expert performance criterion for case management. Designing quality improvement methods and conducting research studies are examples of a proficient performance criteria for management.)

A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map? a. Nurse-manager group. b. Multidisciplinary group. c. Single-discipline group. d. Surgical staff group.

B (In a multidisciplinary work group, a number of individuals from a variety of disciplines are involved in developing the care map, but each works independently to implement the care plan. Single-discipline work groups, such as nurse manager group or surgical group, are likely to focus on the aspects of the care map related only to their specific discipline.)

What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period? a. Team nursing. b. Primary nursing. c. Case management. d. Functional nursing.

B (Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing is a care delivery model that provides client care by assignment of functions or tasks. Team nursing is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management is the delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality cost-effective outcomes.)

A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? a. "There are many forms of bacteria and germs in the hospital." b. "To protect you because you can get an infection very easily." c. "After taking medication for 24 hours a gown and mask won't be needed." d. "Your condition could be spread to staff and other clients in the hospital."

B (Reverse isolation precaution implement measures to protect the client from exposure to microorganisms from others. Although microbes are prevalent in all environments, informing the child about germs in hospital does not adequately answer the child's question. Reverse isolation should be implemented until the client's white blood cell increases. Neutropenia in this child does not place others at risk for infection.)

Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach? a. Administer after an eight-hour fast. b. Give one hour before or two hours after a meal. c. Provide the dose after the client has missed a meal. d. Take with liquids, but no solid foods.

B (When administering a drug on an empty stomach, the drug should be given either one hour before a meal or two hours after a meal, which is the average transit time from the stomach to the duodenum after eating. An eight-hour fast is more time than is needed for the stomach to empty and is not necessary. The last time any food or drink has been ingested is a better indicator of an empty stomach, rather than after the client has missed a meal. Some liquids, such as grapefruit juice, can alter the drug's dilution and absorption.)

The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take? a. Ask when the healthcare provider plans to return to the office and the usual office hours. b. Tell the receptionist to have the healthcare provider return the phone call. c. Provide the receptionist with the client's name, age, and type of reaction. d. Ask the receptionist to notify the client's family if the healthcare provider cannot be contacted.

B (The best nursing action is to ask for a return call from the healthcare provider because the nurse must maintain the client's confidentiality. Asking about when they will be in their office is acceptable, but the best action is to leave a telephone number and request a return call. Leaving client information does not maintain confidentiality.)

Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa0 2 95 mmHg and PaC0 2 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time? a. Increase the oxygen flow to 6 liters/minute. b. Encourage the use of an incentive spirometer. c. Notify the healthcare provider of the crisis blood gas values. d. Encourage the client to breathe slower.

B (The blood gas reveals adequate oxygenation (Pa02 95) and hypoventilation (PaC02 > 45). The client needs to be encouraged in activities that increase the depth of breathing (e. g., use of the incentive spirometer). Increasing oxygen rate will only increase an already adequate Pa02. These are not crisis blood gas findings so no need to call healthcare provider. Asking client to breathe slower will only worsen the hypoventilation.)

A child with Tetralogy of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?" a. Remove child's constrictive clothing. b. Place child in knee-chest position. c. Have child stop all current activity. d. Administer a dose of digoxin stat.

B (The child should be placed on his or her back in the knee-to-chest position to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation. Removing tight clothing has nominal effects in hypercyanosis. Stopping current activity is self-regulating. A dose of digoxin is not indicated for immediate relief of "tet spells." It is used to improve cardiac output.)

A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide? a. Cover the ticks with oil to suffocate and kill them to prevent transmission. b. Look for early signs of a lesion that increases in size with a red border, clear center. c. See a healthcare provider if nausea, vomiting, and joint pain occur after a tick bite. d. Obtain early treatment with antiviral agents to prevent cardiac manifestations.

B (The client should look for the early signs of localized Lyme disease known as erythema migrans, a skin lesion that slowly expands to form a large round lesion with a bright red border and clear center at the site of the tick bite. A tick should be removed with tweezers by pulling straight from its insertion away from the skin, and not compressing its body or covering it with oil. Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is transmitted by the bite of an infected deer tick, and antiviral agents are ineffective. Symptoms, such as fever, chills, headache, stiff neck, fatigue, and swollen lymph nodes are more typical, not nausea and vomiting.)

The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? a. Expresses fear about the surgical procedure. b. Recalls drinking a glass of juice after midnight. c. Reports a history of hives after eating shellfish. d. States has a history of post-operative nausea.

B (The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice after midnight should be reported the healthcare provider. Preoperative fear and anxiety are common and should be further explored by the nurse. Allergy to shellfish should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. Post-op nausea is a common and expected side effect of perioperative medications.)

During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first? a. Choose the most successful approach. b. Identify the problem. c. Consider alternatives. d. Predict the likelihood of the outcome.

B (The sequential steps in problem-solving are to first identify the problem, then consider alternatives, consider outcomes of the alternatives, predict the likelihood of the outcomes occurring, and choose the alternative with the best chance of success.)

The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is in the first trimester of pregnancy. Which action should the nurse prepare the client for? a. Repeating the triple marker test. b. Preparing for other diagnostic testing. c. Counseling about possible fetal defects. d. Securing permission for pregnancy termination.

B (The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal defects. An elevated result may be a false indicator, so other tests are indicated. Repeating the triple marker screening is not necessary or helpful. Elevated results warrant further testing with ultrasound or amniocentesis before initiating counseling for birth defects or discussing termination of pregnancy.)

Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first? a. Massage the uterine fundus. b. Palpate above the symphysis for the bladder. c. Perform bi-manual massage. d. Inspect the perineum for excessive bleeding.

B (Two hours after giving birth, the uterus should be firm, in the midline, and below the umbilicus. If the fundus is high, dextroverted and boggy, urinary retention is likely distending the bladder, so palpating for a full bladder above the symphysis should be implemented first. The other choices should be implemented after the client voids or the bladder is emptied by catheterization.)

A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide? a. "You should have minimal withdrawal symptoms." b. "Headache and hyperirritability are common " c. "A common withdrawal response is hypertension." d. "Expect to have a loss of appetite and tachycardia."

B (Withdrawal from nicotine cause cravings, restlessness and hyperirritability, headache, insomnia, depression, decreased blood pressure, and increased appetite. Nicotine is a highly addictive substance that precipitates an intense withdrawal syndrome, not mild ones. Nicotine causes vasoconstriction which increases peripheral resistance and blood pressure, but withdrawal is likely to relax peripheral blood vessels and reduce blood pressure. Many individuals experience an increased appetite during withdrawal, not anorexia.)

Which information should the nurse give a client with chronic kidney disease (CKD)? a. Restrict calcium-rich foods. b. Obtain monthly B12 injections. c. Avoid salt substitutes. d. Increase daily intake of fiber.

C (A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so they should avoid using them. Hypocalcemia is a complication of CKD and calcium supplements are often needed. Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not B12 injections. Although increasing fiber is a common dietary recommendation, it not an essential part of client teaching for CKD.)

A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take? a. Elevate the legs and medicate for pain. b. Apply firm pressure to the femoral artery. c. Keep the client in bed in the supine position. d. Encourage the client to exercise the leg.

C (A common postoperative complication after valve replacement is arterial occlusion from a clot, which requires anticoagulant therapy to prevent further enlargement of the thrombus and reduce the risk of embolization. Recently formed thrombi can also be effectively treated with an intraarterial infusion of a thrombolytic agent, followed by bed rest and periodic angiography to monitor the dissolution of the clot. All other choices are contraindicated due to the risk of vascular occlusion and embolization.)

What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies? a. Focuses on the pathogenesis of the disease of an individual. b. Replaces the conventional Western modality treatments. c. Recognizes the value of a client's input into their own health care. d. Continues to be used by a limited number of Americans.

C (Alternative and complementary therapies offer human-centered care based on philosophies that recognize the value of the client's input and honor cultural and individual beliefs, values, and desires. These therapies do not subscribe to which is the primary focus of traditional Western medicine. Alternative therapies are a part of an integrative approach to health care, not replace traditional therapy. An increasing number of Americans are using alternative and complementary therapies as options to traditional Western modalities.)

Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple? a. Counselling about advantages and disadvantages of termination should be helpful. b. There is limited value in diagnostic testing if termination of pregnancy is not an option. c. Diagnostic testing may indicate a fetal problem that could be treated prior to delivery. d. Many states legally require prenatal testing as a means of protecting the fetus.

C (Although the couple is opposed to abortion, prenatal testing may reveal a fetal disorder that is treatable in utero or immediately after birth with favorable results. Counseling about terminating the pregnancy is not an option due to the couple's stated opposition. Prenatal testing has value beyond termination because it provides knowledge and time for the couple to prepare for various possibilities. Prenatal testing is voluntary.)

A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide? a. Report any uncomfortable symptoms after stopping the medication. b. Stop the medication and keep an accurate record of blood pressure. c. Ask the healthcare provider about tapering the drug dose over the next week. d. Obtain another antihypertensive prescription to avoid withdrawal symptoms.

C (Although the healthcare provider discontinued the propranolol, measures to prevent rebound cardiac excitation, such as progressively reducing the dose over one to two weeks, should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias. Abrupt cessation of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual weaning should be recommended. Prescribing a new BP medication is not indicated.)

A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next? a. Notify the healthcare provider. b. Measure the blood pressure. c. Administer the medication. d. Reassess the apical pulse.

C (Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered because the client's apical pulse is greater than 60. The other interventions [choices] are not indicated at this time.)

A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem? a. Confusion related to recent death of loved one. b. Delayed grief reaction related to death of husband. c. Denial related to the loss of a loved one. d. Unresolved anger related to death of husband.

C (Based on the data provided, denial of the loss is the best nursing diagnosis. This client is exhibiting symptoms of anxiety and the pain is too great for her to acknowledge, so she is denying the situation. Although she may seem confused, she is actually trying to deal with the pain through the defense mechanism of denial. Delayed grief occurs after one year or longer following the loss. The client's husband died one month ago. Unsresolved anger and depression are often related, and depression is sometimes described as unexpressed anger. However, this client has not acknowledged her loss (denial) and the anger is not yet realized.)

When documenting assessment data, which statement should the nurse record in the narrative nursing notes? a. Hair is within normal limits. b. Most all permanent teeth are present. c. S1 murmur auscultated in supine position. d. Slight tenderness in the left upper quadrant.

C (Documentation of subjective and objective data obtained from the physical assessment should be communicated using precise, descriptive, clear, and accurate information, such as auscultated heart sounds while the client is in a specified position. The other choices do not demonstrate specific documentation.)

An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client? a. Insulin. b. Antacids. c. Tricyclic antidepressants. d. Nonsteroidal antiinflammatory agents.

C (Drugs with anticholinergic properties, such as tricyclic antidepressants, can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of insulin or antacids with opioids do not. Nonsteroidal antiinflammatory agents can increase the risk for bleeding, but do not increase urinary retention with opioids.)

The nurse is planning care for a client who is having abdominal surgery. To achieve desired postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include? a. Explain the rationale for each postoperative exercise and intervention. b. Praise client when actively participating in postoperative exercises. c. Administer analgesics prior to encouraging progressive activities and ambulation. d. Advise client about complications related to inactivity in the postoperative period.

C (Effective pain management in the postoperative period promotes the client's participation in exercises that promote optimal healing and prevent complications, so the client should be given an analgesic prior to mobilization. Although explaining reason for moving promotes client understanding, it is more important that the client's pain is managed to promote cooperation and compliance in the care plan. Giving positive feedback is helpful but is not as useful if the client is in pain. Talking about complications may unduly scare the client.)

The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis? a. Batting practice at a batting cage. b. Soccer practice at an outdoor field. c. Swimming lessons in an indoor pool. d. Roller skating at an indoor rink.

C (External otitis is commonly caused by exposure to bacteria while swimming. In addition, chlorine tends to alter the normal flora of the external ear canal, increasing the risk for infection. Participation in the other sports may increase the child's risk for trauma, and families should be instructed to use protective equipment to reduce this risk.)

Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia? a. Mental retardation. b. Rigid extension of all extremities. c. Lethargy or irritability. d. Increased or unstable temperature.

C (Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that results from the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations of central nervous system involvement include decreased activity, a loss of interest in feeding, and lethargy or irritability. Without treatment, progressive signs of neurologic damage include mental retardation, rigid extremities and unstable temperature.)

The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture? a. Blood urea nitrogen 40 m and creatinine 1.0. b. Cloudy, amber urine with sediment, specific gravity of 1.040. c. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. d. Hemoglobin of 10 g and hypophosphatemia.

C (In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia. BUN and creatinine levels are reflective of a non-renal cause, such as dehydration or liver pathology. Cloudy urine is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not hypophospehatemia.)

The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy? a. "I need to change the baby's position every four hours." b. "I should leave the baby under the light all of the time." c. "I will keep the baby's eyes covered when the baby is under the light." d. "I should dress the baby in light clothing when the baby is under the light."

C (Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the infant's eyes should be protected by closing the eyes and placing patches over them before placing the baby under the phototherapy light source. The baby's position should be changed about every two hours, not every 4, so that the light reaches all areas of the body to promote conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be removed from the light for feedings and diaper changes, but should receive phototherapy exposure for 18 hours a day. The baby should be naked or dressed in only a diaper to expose as much skin as possible to the light.)

The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" a. Morbidly obese. b. Markedly obese. c. Inadequate lifestyle changes in diet and exercise. d. Increased morbidity and mortality risks.

C (Obesity is a body weight that is 20% above desirable weight for a person's age, sex, height, body build, and calculated body mass index (BMI). Focusing on diet and exercise best identifies factors that contribute to the formulation of the nursing diagnosis. Markedly and morbid obesity are both medical classifications for a client's weight. Although the client is at an increased risk for several chronic illnesses, such as heart disease, diabetes mellitus, hypertension, coronary artery disease and hyperlipidemia, this is not a contributing cause or related factor that supports the nursing diagnosis.)

A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care? a. Two acute illnesses. b. Two chronic illnesses. c. One chronic and one acute illness. d. One acute and one infectious illness.

C (The plan of care should include goals that are specific for chronic and acute illnesses. Adult-onset diabetes is a life-long chronic disease, whereas influenza is an acute illness with a short term duration. The other choices do not include the correct duration categories for this situation.)

Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test? a. Collect the blood prior to the next 4-hour feeding to obtain a fasting specimen. b. Instruct the mother to bring the newborn back in one week to have this test completed. c. Assess the newborn's feeding patterns of formula or breast milk which has "come in." d. Obtain venipuncture specimens to prevent hemolysis when expressed from capillaries.

C (PKU screening is mandatory in most states and requires that the newborn has ingested adequate amounts (2 to 3 days) of milk proteins to detect metabolism errors, which result in abnormal phenylalanine (an amino acid) in the newborn's blood and predisposes the infant to mental retardation. A fast blood sample or venipuncture specimen are not necessary. Returning in a week may occur when infants are discharged at 24-hours of age or before adequate milk proteins have been ingested.)

An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? a. Stage 1. b. Stage 2. c. Stage 3. d. Stage 4.

C (Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 because it is a full-thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. Stage 1 is a non-blanchable pressure point over intact skin. Stage 2 is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. Stage 4 is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling.)

The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? a. A Hispanic client may have inward-turned eyelashes. b. An Asian client may have a horizontal palpebrale fissure. c. An African-American client may have slightly yellow sclerae. d. A Caucasian client may have a slightly protruding eyeball.

C (Recognizing normal variations that are common in different racial groups helps the nurse differentiate an early sign of pathology, such as yellow sclerae. A slightly yellow color of the sclera is a normal racial variation found in the African-American population. The other choices are findings not related to one racial group.)

A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room? a. Crash cart. b. Endotracheal tube. c. Rubber-tipped clamps. d. Partial rebreather oxygen mask.

C (Rubber-tipped clamps should be kept at the client's bedside for assessment of possible chest tube air leaks, with the prescription of the healthcare provider. A crash cart is used during a respiratory or cardiac arrest, and does not need to be brought to the client's room as a routine precaution. ET tubes are used to intubate a client and is not indicated for routine care of the client with a chest tube. Rebreather O2 mask is indicated by the client's oxygen saturation or arterial blood gases, and is not routinely placed in the room of a client with a chest tube.)

The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? a. Heart failure. b. Gastrointestinal hemorrhage. c. Spinal cord injury. d. Diabetes insipidus.

C (Spinal cord injuries place the client at high risk for the development of neurogenic distributive shock. The development to watch for in clients with heart failure is cardiogenic shock, in GI bleeding is hemorrhagic shock, and in diabetes insipidus is hypovolemic shock.)

Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit? a. Full rooming-in for the infant and mother. b. Restrict visitors who irritate the client. c. Supervised and guided visits with infant. d. Daily visits with her significant other.

C (Structured visits provide an opportunity for the mother and infant to bond and should be facilitated and encouraged according to the client's pace of progress. Rooming in is unrealistic and may not be safe for the baby or the client. Restricting visitors is an unrealistic expectation. Although daily visits may provide support, the significant other may not be able to be there every day based on other family responsibilities.)

A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? a. Thin, fragile skin, ecchymoses, and complaints of weakness. b. Headache, diaphoresis, and palpitations. c. Hypotension, rapid weak pulse, and rapid respiratory rate. d. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium.

C (The clinical manifestations of Addisonian crisis are often the manifestations of shock; the client is at risk for circulatory collapse and shock. thin frail skin indicates clinical manifestations of Cushing's syndrome, Headaches, sweating, and palpitations indicate a pheochromocytoma (tumor of adrenal medulla), and abrupt hyperpyrexia, tachycardia and delirium are indicative of a thyroid storm (thyrotoxic crisis).)

A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client? a. Rebreather mask. b. Venturi mask. c. Nasal cannula. d. Hand-held nebulizer.

C (The nasal cannula will provide oxygen without covering the client's face. The Venturi and rebreather masks are also masks and will not alleviate the problem of feeling "smothered." A hand-held nebulizer is used for medication administration rather than oxygen.)

The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? a. Adolescents who demonstrate labile behaviors are at risk for self-injury. b. Rebelliousness requires consequences to prevent socially deviant behavior. c. Early adolescence is a developmental stage of normal experimentation. d. The parents should consider hospitalization to prevent self injury.

C (The nurse should support the parents by explaining that early adolescence is a developmental change spurred by hormonal increases in pubescence and teenage experimentation with values, choices, and peer acceptance. The other choices are not applicable in the context of this adolescent's behavior.)

Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide? a. Initiate the lactation process. b. Prevent neonatal hypoglycemia. c. Stimulate contraction of the uterus. d. Facilitate maternal-infant bonding.

C (When the infant suckles at the breast, oxytocin is released by the posterior pituitary to stimulates the "letdown" reflex, which causes the release of colostrum, and contracts the uterus to prevent uterine hemorrhage. Initiating lactation or preventing low blood glucose levels in the newborn do not support the client's need in the immediate period after the emergency delivery. Although maternal-newborn bonding is facilitated by early breastfeeding, the priority is uterine contraction stimulation.)

The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select? a. Micro drop factor. b. Drop factor of 15 gtt/ml. c. An intact inline filter. d. A Buretrol attachment.

D (A buretrol attachment is used to restrict the total volume of IV fluids that a client receives. The tubing drop factors control the rate of administration, but not the total volume infused. An inline filter reduces the risk of infusion of particulates but does not control the volume infused.)

Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio? a. Evaluations by past nursing faculty and employers to document ongoing competence. b. Copies of any articles the nurse has read that relate to client care on the nursing unit. c. Letters of support from family members and friends who are healthcare professionals. d. A self-evaluation that identifies how the nurse has met professional objectives and goals.

D (A clinical portfolio should include pertinent information that assists in providing a comprehensive view of the employee's performance. A self-evaluation provides an important assessment of the nurse's strengths, weaknesses, and progress toward the achievement of professional goals. Past evaluations not pertinent nor useful evaluative data regarding current performance. While documentation of continuing education and any certifications achieved are important to include in a clinical portfolio, copies of articles read is not necessary. Letters of support are not a significant component of a clinical portfolio.)

A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide? a. Use a douche preparation no more than once a month. b. Increase daily intake of fiber and leafy green vegetables. c. Select nylon underwear that is loose-fitting, white, and comfortable. d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts.

D (A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated by tight-fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended because it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fiber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments, provide absorbancy and reduce moisture in the perineal area.)

A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide? a. The dead bone needs to be removed to provide a blood supply for new bone growth. b. The infection is caused by a mutated bacteria that is resistant to most antibiotics. c. If the infected dead bone is not removed, it will make a path to the skin and drain pus. d. The infection has walled off into an area of infected bone creating a barrier to antibiotics.

D (A sequestrum (dead bone) is separated from the living bone and has no blood supply, so neither antibiotics nor white blood cells can reach the infected area. Dead bone removal or mutated bacteria does not address the encasement of the necrotic tissue. Although a sinus tract may occur, it does not address the purpose of the surgery.)

A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement? a. Place an isolation cart in the hallway. b. Fit the client with a respirator mask. c. Don a clean gown for client care. d. Assign the client to a negative air-flow room.

D (Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room. Although isolation gowns and isolation carts should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. The respirator mask should be implemented when the client leaves the isolation environment.)

A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? a. Apply warm compresses to reduce swelling. b. Wear sunglasses to protect eyes from sunlight. c. Take acetaminophen (Tylenol) for any eye discomfort. d. Avoid sharing towels and washcloths with siblings.

D (All of the information is important to include in the teaching plan, but it is most important to avoid spreading the bacterial infection. The child should avoid sharing towels and washcloths and should stay home from school for the first 24 hours after antibiotics are started, to prevent contamination of others. The other choices are important measures to reduce the child's discomfort, but inhibiting the spread of the infection is the priority intervention.)

After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response? a. Fasting serum glucose. b. Serum liver function test. c. Serum electrolyte levels. d. Erythrocyte sedimentation rate.

D (An elevated erythrocyte sedimentation rate (ESR) is indicative of active inflammation, so the nurse should determine if the ESR has normalized. Although corticosteroids influence glucose metabolism, an elevation in serum glucose may indicate a side-effect response to exogenous corticosteroids, not a desired effect. Liver function and serum electrolyte levels do not indicate a therapeutic response to the corticosteroid therapy.)

Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess? a. Ability to grasp objects. b. Ability to bear weight. c. Upper body muscle strength. d. Tolerance of exertion.

D (Awareness of the client's ability to tolerate exertion allows the nurse to plan how to prepare the client for the use of the lift. The other assessments are not needed when using a lift.)

The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take? a. Assess respiratory rate for one minute next. b. Give the medication dosage as scheduled. c. Wait 30 minutes and give half of the dosage of medication. d. Withhold the medication and contact the healthcare provider.

D (Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified. Assessing the respiratory rate is not indicated before administering Lanoxin. Administering the dose or only giving a partial dose places the infant at further risk for digoxin toxicity.)

The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond? a. Caring. b. Veracity. c. Advocacy. d. Confidentiality.

D (Confidentiality is the nurse's primary responsibility and is supported by HIPAA, which mandates that personal information is not disclosed and access to sensitive client information is limited. Caring involves the nurse's concern about how the client experiences the world. Veracity is the nurse's duty to tell the truth and not deceive others. Advocacy is support of the client's best interests.)

A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide? a. Midway between menstrual cycles. b. One week before your period. c. The first day of your period. d. Five to seven days after menses cease.

D (Due to the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is 5 to 7 days after menstruation stops because physiologic alterations in breast size and activity reach their minimal level after menses. One week before menses and midway between menses can vary from month to month and does not provide a consistent day of the month for the client to remember to do BSE. The first day of menses is commonly the day of the menstrual cycle that the breast are most affected by hormonal influence.)

The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? a. "Clients with an elevated blood pressure often exhibit a stiff neck and are diaphoretic." b. "As long as clients receive daily antihypertensive medications, no further interventions are needed." c. "Caregivers should only conduct blood pressure checks under a registered nurse's direct supervision." d. "Frequent blood pressure checks, including readings taken by automated machines, are recommended."

D (Frequent blood pressure checks are recommended for hypertensive clients to evaluate the effectiveness of treatment. Symptoms such as a stiff neck are not typical of essential hypertension, which is an asymptomatic disease. Treatment usually includes dietary modifications and exercise, which should not be discontinued when medications are added to the treatment plan. While the RN is ultimately responsible for the assessment of blood pressures, caregivers are not restricted from obtaining the blood pressure readings.)

The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? a. Thyroid cyst. b. Thyroid cancer. c. Hypothyroidism. d. Hyperthyroidism.

D (Hyperthyroidism is an enlargement of the thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with thyroid cancer, cyst, or hypothroidism.)

A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond? a. "I will ask the healthcare provider to modify the examination." b. "All clothing must be removed before the examination to provide full access to the area to be assessed." c. "What type of undergarments are you wearing?" d. "Tell me about your undergarments so we can discuss how you can have your examination comfortably."

D (It is important that a nurse have respect for the unique qualities that cultural diversity brings to individuals. Asking about undergarments and how they can accommodate the examination reflects cultural competence by the nurse and displays respect for the woman's religious practices. The examination may not be able to be modified. Insisting clothing be removed or asking what she is wearing are both dictatorial and do not show respect for different cultures or religions.)

A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet-to-dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement? a. Perform the wound care and have the PN provide the client's morning care. b. Advise the PN to review the procedure in the procedure manual and then complete the wound care. c. Note the PN's learning need to perform a wound packing and contact nursing education to schedule a time for instruction. d. Demonstrate the wound care procedure to the PN while the PN assists.

D (It is within the PN's scope of practice to perform sterile wound care. The best learning of skills is through demonstration and return demonstration, which promotes safe practice while allowing the PN the best opportunity to learn. the charge nurse performing the wound packing does not allow the PN to gain the experience needed to perform her role. The procedure should be reviewed by the PN but proceeding to doing the packing does not provide the best learning opportunity for the PN, or ensure safe practice. While having nursing education to instruct the PN would provide a safe method for learning the wet-to-dry procedure, it doesn't address the problem immediately and is a more costly way for the PN to learn.)

A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next? a. Did the client receive a prescription for methadone or clonidine? b. Is the client using a fentanyl patch after stopping the opiate analgesic? c. Has the client taken any over-the-counter agents for these symptoms? d. When did the symptoms begin after the last dose of opiate analgesic?

D (Moderate to severe opiate withdrawal manifests with moderate to severe vomiting, diarrhea, muscle cramps, and elevated blood pressures greater than 110 systolic or 70 diastolic. The onset of withdrawal for opiate analgesics typically coincides with the time of the next habitual drug dose at 4-6 hours and may last as long as 7 to 14 days, so determining the time of the last dose pinpoints the relationship of opiate dependency and withdrawal symptoms. Methodone or fentanyl patches are treatment options prescribed for withdrawal once further information is collected. OTC medications may be helpful information, but questioning about last dose of opioids is more focused and helps to differentiate the symptoms from a viral syndrome.)

The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? a. Unequal pupils. b. Loss of central reflexes. c. Inability to open the eyes. d. Change in level of consciousness.

D (Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness, as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. The other assessment data choices are late signs of altered cerebral function.)

A young adult female arrives at the emergency department with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings? a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of the face. b. Client reports her boyfriend hit her in the eye and on the head. Bruises and lacerations present on face. c. Client presents with a right black eye and a cut on the left side of her head that is bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe place to stay. d. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive.

D (Proper documentation of abuse as reported by the victim is crucial, and the nurse should document specific and objective data that gives an accurate depiction of the events without documentation of judgmental inferences. All the other choices lack specificity and important details related to the event.)

Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? a. "I will be your primary resource person, and will gather the information you need to get through this situation." b. "Based on past coping, I believe you will be able to deal with future problems successfully." c. "I have a plan of action that I think will help you. Would you like to see if it will work for you?" d. "You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?"

D (Stating the obvious and asking if they would like to talk acknowledges the stress and encourages the client to discuss options to deal with the problems. Recognizing early signs/symptoms of heightened stress can help to avert a crisis. Talking about past experiences with coping may be offering false reassurance. The other choices deny the client the opportunity to take control of the problem and use problem solving techniques to resolve the situation.)

A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn't want any more contact with the hospital. How should the nurse respond? a. "Because you are leaving against medical advice, you may not have your chart." b. "The information in your chart is confidential and cannot leave this facility legally." c. "This hospital does not need to keep it if you are leaving and not returning here." d. "The chart is the property of the hospital but I will see that a copy is made for you."

D (The chart is the property of the facility, but the client has a legal right to the information in it, even if he is leaving AMA, so a copy of the record should be provided. The client does not lose his legal rights to his medical record if he leaves AMA. The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy. The hospital must maintain records of the care provided and should not release the original record.)

The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? a. "Addicts who use illegal drugs are trying to escape reality." b. "Addiction causes people to steal and lie." c. "Those who are unhappy with themselves are more likely to become addicts." d. "Wanting the drug is all that matters to an addict."

D (The hallmark characteristic of addiction is impaired control: all that matters is obtaining the drug of choice. Trying to escape reality may or may not be true, but is not the primary characteristic of addiction. Stealing/lying to get the drug is a manifestation of impaired control. Addiction is not caused by being unhappy with one's self, but such unhappiness is usually a result of addiction.)

The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement? a. Direct the questions to the spouse whenever possible. b. Repeat each question and tell the client to speak up. c. Ask another nurse to complete the interview. d. Ask the spouse to step out for a few minutes.

D (The nurse should ask the spouse to step out of the room, which maintains the client's privacy and allows the client to respond, without confronting the spouse. Directing the questions to the spouse reinforces the spouse's responses. Asking the client to speak up may not eliminate the spouse's responses on behalf of the client. Having another nurse complete the interview does not foster the nurse-client relationship.)

The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 ml of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome? a. Demonstrates adequate fluid intake and output. b. Voids at least 1000 ml between 7am and 3 pm. c. Verbalizes abdominal comfort without pressure. d. Drinks 240 ml of fluid five times during the shift.

D (The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 ml of fluid five or six times during the shift indicates a fluid intake of 1200 to 1440 ml, which meets the objective of at least 1000 ml during the designated period. The term "adequate," which is not quantified. Voiding 1000 ml between 0700 and 1500 is not the objective, which establishes an intake of at least 1000 ml. Abdominal comfort is not an evaluation of the specific fluid intake.)

A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement? a. Remove the client from the table and have him sit alone. b. Send the client back to his room and do not allow him to eat. c. Report the behavior to the on-call psychologist immediately. d. Confront the client about the consequences of the behavior.

D (The nurse should provide a reality check by helping the client realize that there are consequences to his behavior. Removing the client from the room or table does not help the client realize that his behavior is manipulative and harmful to himself as well as others. This behavior needs to be documented, but does not need to be reported immediately.)

To assess a client's pupillary response to accommodation, a nurse should perform which activity? a. Cover one eye for one minute and note the pupil reaction when the cover is removed. b. Shine a light into the client's eye and watch the pupil response in the opposite eye. c. Touch the cornea with a piece of sterile cotton and observe for a change in pupil size. d. Ask the client to look at a distant object and then at an object held 10 cm from the nose.

D (To check the accommodation response, the client should gaze and fixate on an object 2 to 3 feet away, then bring the object closer until the client is fixated on the object at 6 to 8 inches (10 cm) and identify pupillary constriction as the client focuses on the near object. Covering the eye and shining a light in one eye to watch the other pupil evaluates pupillary reactivity to light (PERL). Touching the cornea with sterile cotton evaluates pupil and blink reflexes (Cranial Nerve III).)

A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement? a. Put petroleum jelly on the lips and around the nasogastric tube. b. Allow the client to drink water and record on the I and O record. c. Offer the client ice chips and instruct client to spit out the water. d. Apply a water soluble lubricant to the lips, oral mucosa and nares.

D (To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist. A petroleum-based product should not be used because it is flammable. Oral intake of any kind should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance.)

A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture? a. Asymmetry of the face and eye movements. b. Abnormal position and movement of the arm. c. Hematemesis and abdominal distention. d. Rhinorrhoea or otorrhoea with Halo sign

D Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose. Asymmetry of the face is consistent with orbital fractures. Abnormal position of arms occurs with wrenching traumas of the shoulder or arm fractures. Vomiting blood occurs with blunt abdominal injuries.

The nurse dons gown, mask with eyeshield, and gloves before entering a client's room that has airborne precautions. Upon leaving the client's room, in which sequence should the nurse remove the personal protective equipment (PPE)? (Place the first action on top and last action on the bottom.) a. Wash hands. b. Remove mask. c. Remove gown. d. Remove gloves.

D, C, B, A Remove gloves. Remove gown. Remove mask. Wash hands. (Correct order is Gloves, Gown, Mask, Wash. The nurse should first remove the contaminated gloves by grasping the cuff and pulling the glove inside out over the hands. Then, untie the gown waist and neck strings, remove the gown without the hands touching the outside of the gown, and fold inside out to discard. Because the client is on airborne precautions, the nurse should then remove the mask . Handwashing should be done after all the PPE is removed. Handwashing may be recommended at other times as well, however in this sequence, it should always be done at the end--before leaving the room and after leaving the room.)