Hesi Level 2 Practice Questions

A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer? A. Pneumococcal. B. Hepatitis B. C. Human papillomavirus. D. Measles-mumps-rubella.

Answer: Hepatitis B Multiple sexual contacts are associated with the risk for hepatitis B, so (B) has the highest priority for this client. The MMR vaccine (A), which contains attenuated live viruses that are teratogenic, is not recommended during pregnancy. The safety of the human papillomavirus (C) during pregnancy has not been determined and should not be given or completed during pregnancy. The pneumococcal vaccine (D) is not indicated at this time.

The healthcare provider prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet. Which rationale should be included in the nurse's explanation to this client? A. It does not dilate the stomach. B. It is quickly digested. C. It is slow to leave the stomach. D. It does not cause diarrhea.

Answer: It is slow to leave the stomach. This type of diet is slowly digested and is slow to leave the stomach (D). Because of its density from proteins an fats, and the reduction of fluids with the meal, the possibility of dumping syndrome is reduced. (A, B, and C) are incorrect rationales.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A. Glucose. B. Sodium. C. Antidiuretic hormone. D. Potassium.

Answer: Potassium Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (D) (hypokalemia)--hypertension is the most prominent and universal sign. (B) is normal or elevated, depending on the amount of water reabsorbed with the sodium. (A) is decreased with diabetes insipidus. (C) is not affected by primary aldosteronism.

The nurse is teaching a client about precautions for a new prescription for lovastatin (Mevacor). Which symptom should the nurse instruct the client to report to the healthcare provider immediately? A. Severe muscle pain. B. Visual disturbances. C. Terrible nightmares. D. Increased nocturia.

Answer: Severe muscle pain. A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching (C). (A) is a side effect, but not life threatening. (B) is not related to statin therapy. Blurred vision (D) is a transient side effect that does not need immediate medical treatment.

An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately? A. Elevated serum calcium level. B. Positive rapid plasma reagin (RPR). C. Increased serum creatinine level. D. Increased thyroid stimulating hormone (TSH).

Answer: Increased thyroid stimulating hormone (TSH). The healthcare provider should be notified of (D) immediately. An increased TSH suggests a low thyroxine level because the TSH is trying to stimulate thyroxine production, and hypothyroidism symptoms mimic those of depression. (A) often increases with aging. (B) is indicative of syphilis and should be reported, but does not have the priority of (C). (D) has implications for other illnesses, such as non-Hodgkin's lymphoma or hyperparathyroidism.

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 test measures intellectual ability and screens for possible learning difficulties later in school. 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 tool identifies achievement of development milestones in infants and young children.

Answer:This tool identifies achievement of development milestones in infants and young children. 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 (A). (B, C, or D) are not the focus of the ASQ.

A client receives a prescription for levothyroxine sodium (Synthroid) 0.05 mg by mouth once daily. The medication is available in scored tablets labeled 0.1 mg. How many tablets should the nurse administer?

Answer: 0.5 tablets Using the formula, Desired / Available x 1 tablet = 0.05/0.1 x 1 = 0.5

An infant weighs 7 lb at birth. How much should the nurse expect the infant to weigh at age 6-months? A. 12 lb. B. 17 lb. C. 14 lb. D. 21 lb

Answer: 14 lb. Infancy growth spurts double the birthweight by 4 to 6 months and triple it by one year. Twelve pounds (A) represents a lower-than-expected weight. A weight of 17 (C) or 21 (D) pounds is greater than expected.

Which pediatric client requires immediate intervention by the nurse? A. A 4-year-old with an easily palpable bladder and frequency. B. A 3-year-old with several episodes of nocturnal enuresis. C. A 5-year-old with diuresis following furosemide (Lasix) administration. D. A 2-year-old with a twenty-four hour urinary output of 500 ml.

Answer: A 4-year-old with an easily palpable bladder and frequency. Frequency and bladder distention (C) are indications of urinary retention, which requires immediate intervention by the nurse. (A) is the normal output for a child of this age. (B) describes bed-wetting, not uncommon in a child of this age, although if the problem persists in a child older than 5 years of age, further assessment and intervention is warranted. (D) is an expected response to the medication, which requires routine monitoring, but does not indicate a need for immediate intervention.

An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac (Toradol) 30 mg IV q6h. Which action should the nurse implement? A. Hold the ketorolac to prevent an antagonistic effect. B. Hold the morphine to prevent an additive drug interaction. C. Contact the healthcare provider to clarify the prescription. D. Administer both medications according to the prescription.

Answer: Administer both medications according to the prescription. Morphine and ketorolac (Toradol) can be administered concurrently (A), and may produce an additive analgesic effect, resulting in the ability to reduce the dose of morphine, as seen in this prescription. Toradol is an antiinflammatory analgesic, and does not have an antagonistic effect with morphine (B), like an agonist-antagonist medication would have. An additive analgesic effect is desirable (C), because it allows a reduced dose of morphine. This prescription does not require any clarification, and can be administered safely as written (D).

A client receiving albuterol (Proventil) tablets complains of nausea every evening with her 9:00 p.m. dose. What action can the nurse take to alleviate this side effect? A. Administer the dose with a snack. B. Change the time of the dose. C. Hold the 9 p.m. dose. D. Administer an antiemetic with the dose.

Answer: Administer the dose with a snack. Administering oral doses with food (C) helps minimize GI discomfort. (A) would be appropriate only if changing the time of the dose corresponds to meal times while at the same time maintaining an appropriate time interval between doses. (B) would disrupt the dosing schedule, and could result in a nontherapeutic serum level of the medication. (D) should not be attempted before other interventions, such as (C), have been proven ineffective in relieving the nausea.

The nurse plans to mix a medication with food to make it more palatable for a pediatric client. Which food should the nurse choose? A. Formula or milk. B. Syrup. C. Applesauce. D. Orange juice.

Answer: Applesauce In order to prevent the child from developing a negative association with an essential food, a nonessential food such as applesauce is best for mixing with medications (B). Syrup is not used to mix with medications because of its high sugar content (A). Medications may alter the flavor of the food and cause the child to avoid those foods in the future, so orange juice (C), which provides essential nutritional elements, and formula or milk (D), which are essential foods in a child's diet, should not be mixed with medications.

An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. What is the priority nursing intervention? A. Place the infant under a radiant warmer. B. Begin humidified oxygen via hood. C. Stimulate infant crying. D. Evaluate the blood pH.

Answer: Begin humidified oxygen via hood. An oxygen saturation of less than 90% (normal oxygen saturation is 96% to 98%) requires oxygen administration (B). (A) is not necessary. (C) may utilize additional oxygen and will not correct the problem. (D) is important because it may decrease energy use for respiratory effort, but it will not correct a low saturation level.

The nurse is instructing an adolescent with bulimia and a low potassium level about the risk for complications. Which medical problem should be the focus of the nurse's instruction to this client? A. Heightened neurologic reflexes. B. Gastrointestinal reflux. C. Anemia. D. Cardiac arrhythmias.

Answer: Cardiac arrhythmias. An adolescent with bulimia who purges by frequent self-induced vomiting, diuretic or laxative abuse can experience potassium depletion, which increases the risk for cardiac arrhythmias (B). (A) is more likely related to inadequate iron intake and absorption, not hypokalemia. (C) is related to frequent binging and gastric over-distention. Potassium depletion causes diminished reflexes, not (D)

A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? A. Isocarboxazid (Marplan). B. Chlordiazepoxide (Librium). C. Diphenhydramine (Benadryl). D. Perphenazine (Trilafon).

Answer: Chlordiazepoxide (Librium). Librium (B), an antianxiety drug, as well as other benzodiazepines, is used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. (A) is an antipsychotic agent. (C) is an antihistamine and antianxiety drug. (D) is an MAO inhibitor.

The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetrology of Fallot. Which symptom is this client most likely to exhibit? A. Clubbed fingers B. Machinery murmur. C. pedal pulses. D. Bradycardia

Answer: Clubbed fingers Tetrology of Fallot, a cyanotic heart defect, causes clubbing of fingers and toes (D) due to tissue hypoxia. Tachycardia, not (A), is a manifestation of congenital heart disease. (B) is a classic sign of ventricular septal defect. (C) is characteristic of coarctation of the aorta.

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? A. Response to separation from family. B. Concern for body integrity. C. Socialization with other children. D. Ability to communicate verbally.

Answer: Concern for body integrity The preschooler's major stressor is concern for his body integrity (C). He fears that his "insides will leak out." A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality (A). (B) is a concern for all children, but of most concern to the toddler. (D) is not a prime concern in this situation.

Which action by the nurse is most helpful in communicating with a preschool-aged child? A. Use a doll to play and communicate. B. Speak clearly and directly to the child. C. Play a board game with the child. D. Approach when a parent is not present.

Answer: Use a doll to play and communicate. Communicating through play with a doll (B) or other toy gives time for the child to feel comfortable with a stranger. (A) may frighten some children and is usually not as effective as (B). To provide security and comfort, preschool-aged children should be approached when a parent is present, not (C). (D) is too advanced for a preschooler.

What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. Vesicular breath sounds decrease B. Bronchodilators stimulate coughing C. Cough remains unproductive D. Wheezing becomes louder

Answer : Wheezing becomes louder. In an acute asthma attack, air flow may be so significantly restricted that wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing becomes louder (A) as air flow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough becomes more productive, not (B). Vesicular sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields (C) and is not an indicator of improvement during asthma treatment. Bronchodilators do not stimulate coughing (D).

The nurse is teaching the parents of a 5-year-old with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand? A. "Perform postural drainage before starting the aerosol therapy." B. "Ensure respiratory therapy is done daily during any respiratory infection." C. "Give respiratory treatments when the child is coughing a lot." D. "Administer aerosol therapy followed by postural drainage before meals."

Answer: "Administer aerosol therapy followed by postural drainage before meals." Postural drainage for a child with cystic fibrosis is most effective when performed after nebulization and before meals (C) or at least 1 hour after eating to prevent nausea and vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (A) treatments which open the airways. Pulmonary toileting or respiratory treatments should be given 3 to 4 times daily, not episodically (B and D).

The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? A. "Are you having any problems with your vision?" B. "When was the last time you took your synthroid?" C. "Have you lost any weight in the last month?" D. "Are you experiencing any type of nervousness?"

Answer: "Are you experiencing any type of nervousness?" Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism (B). Weight loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid (C). The client may have exophthalmus (bulging eyes) but hyperthyroidism does not cause vision problems (D).

A client taking furosemide (Lasix), reports difficulty sleeping. What question is important for the nurse to ask the client? A. "Have you lost weight recently?" B. "At what time do you take your medication?" C. "Are you eating foods rich in potassium?" D. "What dose of medication are you taking?"

Answer: "At what time do you take your medication?" The nurse needs to first determine at what time of day the client takes the Lasix (D). Because of the diuretic effect of Lasix, clients should take the medication in the morning to prevent nocturia. The actual dose of medication (A) is of less importance than the time taken. (B) is not related to the insomnia. (C) is valuable information about the effect of the diuretic, but is not likely to be related to insomnia.

The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates that they understand the teaching? A. "Having our children brush with fluoride toothpaste is not effective." B. "Excessive amounts of fluoride will make teeth turn brittle and yellow." C. "Use of fluoride in water is mostly effective during initial tooth formation." D. "Dental caries can be prevented through fluoridation of public water."

Answer: "Dental caries can be prevented through fluoridation of public water." Dental caries can be prevented through fluoridation of public water (D). Large amounts of fluoride (A) produces yellow and discolored teeth, not brittle teeth. (B) is effective for young teeth. Fluoride is effective throughout the life span, not just during initial tooth formation (C).

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? A. "I hear how miserable you are, but things will get better soon." B. "Let's talk about what is right with your life." C. "How can I help?" D. "Things probably aren't as bad as they seem right now."

Answer: "How can I help?" Offering self shows empathy and caring (C), and is the best of the choices provided. Combining the first part of (C) with (B) would be the best response, but this is not a fill-in-the-blank or an essay test! Choose the best of those choices provided and move on. (D) dismisses the client, things are bad as far as this client is concerned. (A) avoids the client's problems and promotes denial. "I hear how miserable you are" is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence--"but things will get better" which is offering false reassurance.

A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? A. "How can I help answer your questions?" B. "The healthcare provider should be here on Monday morning." C. "What concerns do you have at this time?" D. "Let me call and leave a message for your healthcare provider."

Answer: "Let me call and leave a message for your healthcare provider." It is best for the nurse to call the healthcare provider (D) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. The nurse can also implement offer to assist the client (A and C), but the highest priority intervention is contacting the healthcare provider.

A client asks the nurse if glipizide (Glucotrol) is an oral insulin. Which response should the nurse provide? A. "No, it is not an oral insulin and can be used only when some beta cell function is present." B. "Yes, it is an oral insulin and has the same actions and properties as intermediate insulin." C. "No, it is not an oral insulin, but it is effective for those who are resistant to injectable insulins." D. "Yes, it is an oral insulin and is distributed, metabolized, and excreted in the same manner as insulin."

Answer: "No, it is not an oral insulin and can be used only when some beta cell function is present." An effective oral form of insulin has not yet been developed (C) because when insulin is taken orally, it is destroyed by digestive enzymes. Glipizide (Glucotrol) is an oral hypoglycemic agent that enhances pancreatic production of insulin. (A, B, and D) do not provide accurate information.

A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents? A. "You can hold the baby with the oxygen blowing in the baby's face since the level is very close to room air." B. "Studies have shown that handling a sick newborn is not good for the baby and upsets the parents." C. "Since your baby has been doing well under oxygen for 24 hours, I can let you hold the baby without oxygen." D. "The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her."

Answer: "The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her." The baby is at 35% which is much more than room air (21%) and at this time the baby should not be moved from under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant (B). Holding sick babies benefits the infant and the parents (A). The first consideration now has to be the infant's oxygenation. The nurse should not take the baby out from under the hood without a prescription from the healthcare provider, as this could severely compromise the infant (C). A P02 of 35% cannot be readily achieved with "blow by" oxygen (D).

Which class of antiinfective drugs is contraindicated for use in children under 8 years of age? A. Quinolones. B. Tetracyclines. C. Penicillins. D. Aminoglycosides.

Answer: . Tetracyclines Tetracyclines (B) cause enamel hypoplasia and tooth discoloration in children under 8 years of age. (A, C, and D) are not contraindicated for use in children.

A 9-month-old infant receives a prescription for digoxin 40 mcg PO daily. Digoxin Oral Solution, USP 50 mcg (0.05 mg) per ml is available. How many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

Answer: 0.8 ml Using ratio and proportion, 40 mcg : X ml :: 50 mcg : 1 ml = 0.8 ml

The nurse plans to administer labetalol hydrochloride (Trandate) 0.3 grams PO to a client with hypertension. Trandate is available in 200 mg scored tablets. How many tablets should the nurse administer? (Enter numeric value only.)

Answer: 1.5 tablets First convert grams to milligrams using the known conversion: 1 gram = 1000 mg. 0.1 gram = 100 mg as 0.3 gram = 300 mg Next using the formula, Desired/Available x 1 tablet = 300 mg/200 mg x 1 = 1.5 tablets

A client who has congestive heart failure with paroxysmal atrial tachycardia is receiving digoxin (Lanoxin) 0.45 mg IV as the inital digitalizing dose. The pharmacy provides 0.25 mg/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Answer: 1.8 ml Using the formula D/H x Q 0.45 mg/0.25 mg x 1 mL = 1.8 mL.

An IV infusion of 0.9% normal saline 500 ml with ammonium chloride 0.2 mEq/ml is prescribed for a client who was admitted for an amphetamine overdose. How many mEq of ammonium chloride should the nurse use to prepare the solution? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Answer: 100 mEq 0.2 mEq x 500 ml = 100 mEq

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 13,000 units. B. 11,000 units. C. 17,000 units. D. 15,000 units

Answer: 11,000 units (A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units.

A child who is scheduled for a kidney transplant receives a prescription for basiliximab (Simulect) 20 mg IV 2 hours prior to surgery. The medication is available in a 20 mg vial that is reconstituted by adding 5 ml sterile water for injection, and administered in a 50 ml bag of normal saline over 30 minutes. The nurse should program the infusion pump to deliver how many ml/hour? (Enter the numeric value only.)

Answer: 110 ml/hr After reconstituting the medication vial, the nurse adds the 5 ml of medication to the 50 ml of sterile water to result in a 55 ml volume to infuse in 30 minutes. Using the formula, Volume/Time = 55 ml / 0.5 hours = 110 ml/hour

A client with hypernatremia is to receive an IV infusion of 1000 ml 5% dextrose in water to be infused over 6 hours. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer: 167 ml/hr Calculate using the ratio: 1000 ml : 6 hours :: X ml : 1 hour 1000/X :: 6/1 6X = 1000 X = 167 ml/hour

The healthcare provider prescribes an IV infusion of 0.9% sodium chloride with 40 mEq KCl/500 ml to infuse over 3 hours for a client with hypokalemia. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer: 167 ml/hr To determine ml/hour: 500 ml : 3 hours :: as X ml : 1 hour 500/X :: 3/1 500 = 3X X = 166.66 (rounds to)= 167 ml/hour

A client who is complaining of nausea and vomiting postoperatively receives a prescription for metoclopramide (Reglan) 10 mg IV. The medication is available in vials containing 5 mg/ml. How many ml should the nurse administer? (Enter numeric value only.)

Answer: 2 ml 10 mg : X ml = 5 mg : 1 ml 5X = 10 X = 2 ml

A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.)

Answer: 2 tablets Using the known equivalent, 1 gram = 1000 mg, the nurse should first convert the dose to the same unit of measurement, which is 1 gram = 1000 mg. Using the formula, Desired / Available x 1 tablets: 1000 mg / 500 mg x 1 = 2 tablets

The healthcare provider prescribes furosemide (Lasix) 25 mg IV. The drug is available in a solution of 40 mg/4ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Answer: 2.5 ml Using the formula D/H x Q: 25 mg/40 mg x 4 ml = 2.5 ml

0.9% normal saline with inamrinone (Inocor) 0.1 grams/100 ml is prescribed for client with heart failure. The medication is to be delivered at a rate of 400 mcg/minute. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer: 24 ml/hr First calculate the number of mcg/hour: 400 mcg x 60 minutes = 24000 mcg/hour Next calculate the number of ml/hour needed to administer 24,000 mcg/hour: 100,000 mcg: 100ml :: 24,000 mcg : X 100,000/24,000 :: 100/X 100,000X = 2,400,000 X = 24 ml/hour

A client with hypertension receives a prescription for carteolol (Cartel) 7.5mg PO daily. The drug is available in 2.5 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.)

Answer: 3 tablets Using D/H: 7.5mg / 2.5mg = 3 tablets

Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? A. 2 pounds weight gain. B. Hematuria. C. 3+ bacteria in urine. D. Steady, dull flank pain.

Answer: 3+ bacteria in urine. Urinary tract infections (UTI) for a client with PKD require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease, so bacteria in the urine (C) is the most significant finding at this time. (A) is an expected finding from the rupture of the cysts. (B) does not provide a time frame to determine if the weight gain is a significant fluid fluctuation, which is determined within a 24-hour time frame. Although kidney pain can also be abrupt, episodic, and colicky related to bleeding into the cysts, (D) is more likely an early symptom in PKD.

The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)? A. 18 to 24 months of age. B. 11 to 12 years of age. C. 13 to 18 years of age. D. 4 to 6 years of age.

Answer: 4 to 6 years of age. The second booster of the measles, mumps, rubella (MMR) vaccine is recommended by the CDC for routine immunization at 4 to 6 years of age (D), which is commonly required prior to entrance into elementary school. Those who have not previously received the second dose should complete the schedule by 11 to 12 years of age (A and B). The MMR may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and both doses are administered beginning at or after 12 months of age (C).

A child who weighs 32 pounds receives a prescription for amoxicillin with clavulanate (Augmentin) 194 mg PO every 8 hours. The recommended dose is 40 mg/kg/day, and the bottle contains 125 mg/5ml. How many mg should the child receive in a 24-hour period? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer: 582 The child's weight in kg (2.2 : 1 kg :: 32 pounds : X kg = 14.54 kg) is used to calculate the recommended dose (40 mg x 14.54 kg/day = 581.6 = 582 mg). The prescribed dose in 24 hours is 194 mg x 3 doses = 582 mg.

Which client should the nurse identify as the highest risk for the onset of stress-related problems? A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, "I think I'm in control of my destiny." B. A woman who is graduating from college, getting married in one month, and states, "I'm anticipating the changes these events will make in my life." C. A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." D. A client who is passed over for promotion, quits a job to start a new business, and states, "This is just one of a series of challenges I've faced in my life."

Answer: A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness (D) is at the highest risk for a stress-related health problem. (A, B, and C) describe persons who are coping with change using healthy strategies, such as perceiving change as challenging, expressing commitment to change, and believing they have control over their life paths.

A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? A. The dosage of the diuretic will be decreased. B. The dosage of the diuretic will be increased. C. A potassium supplement will be prescribed. D. The diuretic will be discontinued.

Answer: A potassium supplement will be prescribed This client's potassium level is too low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level (C). (A, B, and D) are not recommended actions for restoring a normal serum potassium level.

Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant? A. A thin stratum corneum that increases topical absorption. B. A greater body surface area that requires larger dosages. C. A lower sensitivity reactions to skin irritants. D. A smaller percentage of muscle mass.

Answer: A thin stratum corneum that increases topical absorption. infants have a thin outer skin layer (stratum corneum), so the nurse should monitor the infant for a prompt onset and response to the application of topical medication (B). (A, C, and D) are unrelated to topical medication administration.

Which client should the nurse identify as being at highest risk for complications during the use of an opioid analgesic? A. A client with a open compound fracture. B. An older client with Type 2 diabetes mellitus. C. A client with chronic rheumatoid arthritis. D. A young adult with inflammatory bowel disease.

Answer: A young adult with inflammatory bowel disease The principal indication for opioid use is acute pain, and a client with inflammatory bowel disease (D) is at risk for toxic megacolon or paralytic ileus related to slowed peristalsis, a side effect of morphine. Adverse effects of morphine do not pose as great a risk for (A, B, and C) as the client with bowel disease.

A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply.) A. Age. B. History of abuse. C. Pregnancy. D. Drug addiction. E. School dropout. F. Homelessness. G. Unmarried.

Answer: A, B, C, D, F Health risk factors for this client include (A, C, D, E and F). Each factor should be considered individually. The client, as an adolescent mother, is at high risk for nutritional deficits, anemia, gestational diabetes and hypertension, which also impact the fetus' risk for small for gestational age, fetal anomalies, and fetal demise. (B and G) may impact the client's social adaptation, but do not directly constitute health risk factors.

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) A. Decreased duodenal inhibition. B. An increased level of stress. C. An increased number of parietal cells D. Vagal stimulation. E. Hypersecretion of hydrochloric acid.

Answer: A,C,D,E Correct selections are (A, C, D, and E). Hypersecretion of gastric juices (D) and an increased number of parietal cells (E) that stimulate secretion are most often the causes of ulceration. Vagal stimulation (A) and decreased duodenal inhibition (C) also increase the secretion of caustic fluids. An increased stress level is not physiologic and is not a direct cause of ulceration (B).

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A. Accused of diversion. B. Accused of unprofessional conduct. C. Reported for stealing. D.Reported for a HIPAA violation.

Answer: Accused of diversion. Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome.

When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? A. Risk for infection related to urinary stasis. B. Deficient knowledge related to need for prevention of recurrence of calculi. C. Acute pain related to movement of the stone. D. Impaired urinary elimination related to obstructed flow of urine.

Answer: Acute pain related to movement of the stone. The nursing diagnosis of highest priority is acute pain (A), which if unresolved can represent pathology affecting renal function. Impaired urinary elimination (B), risk for infection (C), and knowledge deficit (D) are components of the plan of care with less immediacy than management of the etiology of the client's pain.

The primary nurse receives the 0700 shift report for 4 clients on a medical unit. When prioritizing care, which action should the nurse implement first? A. Flush the lumen of a client's triple lumen central venous catheter with saline. B. Review the potassium levels of a client who receives a daily loop diuretic. C. Administer insulin per sliding scale to a client with a capillary glucose of 285. D. Assess the lung sounds of a client with pneumonia who is ready to go home.

Answer: Administer insulin per sliding scale to a client with a capillary glucose of 285. The nurse should first administer the insulin per scaling scale (A) to the client with hyperglycemia to prevent further elevation of the serum glucose levels. (B and C) are of less immediacy and can be delayed until the higher priority interventions are completed. The client's potassium level should be checked before administering a loop diuretic (D), but this can be done after administering the sliding scale insulin.

Based on the blood culture and sensitivity results, the healthcare provider prescribes an IV aminoglycoside antibiotic and discontinues the current prescription for another broad spectrum antibiotic. The medication administration record indicates that the client received the broad spectrum antibiotic two hours ago. Which action should the nurse implement? A. Obtain peak and trough serum levels so the aminoglycoside antibiotic can be initiated. B. Schedule the initial dose of the aminoglycoside antibiotic for the following day. C. Withhold antibiotic administration until the healthcare provider clarifies the prescriptions. D. Administer the initial dose of the aminoglycoside antibiotic as soon as possible.

Answer: Administer the initial dose of the aminoglycoside antibiotic as soon as possible. The blood culture and sensitivity results identify the specific antibiotic that is most effective in treating the client's infection, so the aminoglycoside antibiotic should be administered as soon as possible (B). Obtaining peak and trough levels (A) before starting administration of the aminoglycoside provides no useful data. The prescription does not need clarification (C) from the healthcare provider. The aminoglycoside antibiotic is the correct antibiotic to treat the infection and should be started as soon as possible, rather than waiting until the next day (D).

A client with heart failure is prescribed digoxin (Lanoxin) 0.125 mg PO. The client's apical heart rate is 70 beats per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per minute. Which action should the nurse implement next? A. Administer the medication. B. Reassess the apical heart rate. C. Review the vital sign flowsheet. D. Inform the healthcare provider.

Answer: Administer the medication Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered (A) since the client is not demonstrating any signs of toxicity. (B and D) are not necessary because the apical pulse is above 60 beats per minute. Review of the client's past vital signs (C) provides data for evaluation of the client's clinical progress, but based on the client's present clinical findings, the medication should be administered next.

A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition? A. Acrophobia. B. Claustrophobia. C. Post-traumatic stress disorder. D. Agoraphobia

Answer: Agoraphobia Agoraphobia (C) is the fear of crowds or being in an open place. (B) is the fear of being in closed places. (A) is the fear of high places. Remember, a phobia is an unrealistic fear which is associated with severe anxiety. (D) consists of the development of anxiety symptoms following a life event that is particularly serious and stressful (war, witnessing a child killed, etc.) and is experienced with terror, fear, and helplessness--a phobia is different.

A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today? A. The routine immunizations and schedule another appointment to administer the influenza vaccine. B. The influenza vaccine and schedule another appointment to administer the immunizations. C. All the immunizations with the influenza vaccine given at a separate site from any other injection. The influenza vaccine and the polio vaccine and schedule another appointment to administer the remaining immunizations.

Answer: All the immunizations with the influenza vaccine given at a separate site from any other injection. At 6-months of age, the routine immunizations include Hepatitis B, DTaP, Hib (Haemophilus influenza type b) , PCV (Pneumococcal), IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site from any other injection (B). Scheduling a return visit (A, B, or C) increases the risk that the mother will not bring the child back for the immunizations.

A client is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the client is taken into a treatment room and asks to stay with the client. What action should the nurse implement? A. Advise the spouse that if unsuccessful, the resuscitation scene should not be the last memory of a loved one. B. Insist that the spouse wait outside the room while resuscitation is being performed. C. Allow the spouse to be present and ensure that a member of the team explains the care given and answers questions D. Explain to the spouse that there will be no time for explanations during the resuscitation efforts.

Answer: Allow the spouse to be present and ensure that a member of the team explains the care given and answers questions. Research supports the positive benefits of family presence during invasive procedures and cardiopulmonary resuscitation to clients, family, and staff. Facilitating family presence allows family to view themselves of active participants and completes the last step of the secondary survey in the care of an emergency client (B). (A) does not facilitate family presence. Someone should be assigned to the family to explain the care being delivered and to answer questions, not (C). (D) does not offer the spouse support and is not recommended.

Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? A. Teach the client relaxation and thought stopping techniques. B. Administer a prescribed PRN antianxiety medication. C. Assist the client to identify stimuli that precipitates the ritualistic activity. D. Allow time for the ritualistic behavior, then redirect the client to other activities.

Answer: Allow time for the ritualistic behavior, then redirect the client to other activities. Initially, the nurse should allow time for the ritual (C) to prevent anxiety. (A) may help reduce the client's anxiety, but will not prevent ritualistic behavior resulting from the client's ineffective coping ability. (B) is a long-term goal of individual therapy, but is not directly related to controlling the behavior at this time. (D) lists techniques that can be used to assist the client in learning new ways of interrupting obsessive thoughts and resulting ritualistic behavior as treatment progresses.

Which rationale best supports an older client's risk of complications related to a dysrhythmia? A. Cardiac symptoms, such as confusion, are more difficult to recognize in an older client. B. An older client is intolerant of decreased cardiac output which may cause dizziness and falls. C. An older clients is more likely to eat high-fat diets which predisposes to heart disease. D. An older client usually lives alone and cannot summon help when symptoms appear.

Answer: An older client is intolerant of decreased cardiac output which may cause dizziness and falls. In an older client, cardiac output is decreased and a loss of contractility and elasticity reduces systemic and cerebral blood flow, so dysrhythmias, such as bradycardia or tachycardia is poorly tolerated, and increases the client's risk for syncope, falls, transient ischemic attacks, and possibly dementia. (B and C) are generalized statements that are not applicable to most individuals in the older population. Although many older persons do live alone, inability to summon help (A) cannot be assumed.

During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next? A. No action required, as this is an expected finding for a school-aged child. B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately. C. Send a note home advising the parents to have the child evaluated by a healthcare provider as soon as possible. D. Call the parents and have them take the child home from school for the rest of the day.

Answer: Ask the child if he/she has had a cold, runny nose, or any ear pain lately. More information is needed to interpret these findings (B). The tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of history and related signs and symptoms is indicated for accurate interpretation of the findings. (A, C, and D) are inappropriate actions based on the data obtained from the otoscope examination.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? A. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. B. Ask the client if this decision has been discussed with his healthcare provider. C. Document the client's request in the medical record. D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Answer: Ask the client if this decision has been discussed with his healthcare provider. Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action.

The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with congestive heart failure. Which intervention should the nurse implement prior to administering the digoxin? A. Monitor the serum glucose level. B. Assess the serum potassium level. C. Observe respiratory rate and depth. D. Obtain the client's blood pressure.

Answer: Assess the serum potassium level Hypokalemia (decreased serum potassium) will precipitate digitalis toxicity in persons receiving digoxin (B). (A and C) will not affect the administration of digoxin. (D) should be monitored if he/she is a diabetic and is perhaps receiving insulin.

All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child? A. Assessing fontanels. B. Weighing diapers. C. Observing mucous membranes for moisture. D. Checking skin turgor.

Answer: Assessing fontanels. All of these interventions evaluate fluid status in infants. But, how old is this child? Posterior fontanel closes at 2 months and anterior fontanel closes by 18 months of age (B)! Remember normal growth and development!

The nurse notes a client's postoperative leg is cool with a capillary refill greater than 4 seconds and calls the healthcare provider. After 30 minutes of not receiving a return call from the healthcare provider, which action should the nurse take first? A. Continue to monitor and call if there is a change. B. Attempt to recall the same healthcare provider. C. Describe the problem to the answering service. D. Notify the hospital's "on call" nursing supervisor.

Answer: Attempt to recall the same healthcare provider. The healthcare provider may have inadvertently not received the first call, so (A) is the best action to take first. According to the TeamSTEPPS, two attempts should be made to notify the provider before proceeding through the chain of command (B). (C) should be implemented, but these assessment findings require immediate medical action. Although (D) is an option, the client's urgent condition needs treatment.

A client with pneumonia receives a prescription for tetracycline (Sumycin). What precaution should the nurse include in this client's teaching? A. Avoid diary products for 2 hours after taking the medication. B. Avoid over-the-counter medications containing alcohol. C. Do not use teeth whitening agents during the treatment regimen. D. Take the medication with a glass of orange juice

Answer: Avoid diary products for 2 hours after taking the medication. Dairy products should be ingested at least 2 hours after taking Sumycin (C) because calcium binds with tetracycline and decreases its absorption. Sumycin can be taken with orange juice (A) because it does not affect absorption of the medication. Sumycin does not cause a disulfiram-like reaction, so (B) is not indicated. Although Sumycin causes enamel hypoplasia and permanent yellow, gray, or brown staining of the teeth during the ages of tooth development (children younger than 8 years of age), it does not affect adult enamel, so (D) is not indicated.

A 4-year-old is brought to the emergency room for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergency room experience? A. Avoid using jargon, such as a "shot" when giving care B. Give the child some time after explaining procedures. C. Remind the preschooler how big children should act. D. Avoid the use of bandages to keep wounds open to air.

Answer: Avoid using jargon, such as a "shot" when giving care. Using positive terms and avoiding words that have frightening connotations (D) assist the preschool-age child in coping with an emergency room experience. Bandages (A) are important to preschool-aged children because this age group often believe bandages stop their insides from leaking out. Children need to feel comfortable expressing their fears and feelings and should not be shamed into cooperation by referencing expected "big" children behaviors (B). Preschool-age children should be told about procedures immediately before they are performed (C), which minimizes the time a child fantasies about the treatment, which causes increased anxiety.

The parents of a child with hemophilia A ask the nurse about their probability of having another child with hemophilia A. Which information is the basis for the nurse's response? (Select all that apply.) A. Men with hemophilia have sons who also manifest the disease. B. The disease occurs in daughters of men with hemophilia. C. Autosomal dominance occurs with this disorder. D. Sons of female carriers have a 50% chance of inheriting hemophilia. E. Hemophilia is an X-linked recessive disorder.

Answer: B,E Correct choices are (B and E). Hemophilia is an inherited disease that manifests in male children whose mother is a carrier. With each pregnancy there is a 50% chance that a male child will inherit the defective gene and manifest hemophilia A (B), which is an X-linked recessive disorder (E). (A) is descriptive of a rare type of hemophilia, known as von Willebrand's disease. Hemophilia is inherited by male offspring of female carriers (C). Daughters (D) do not manifest the disease, but have a 50% chance of being a carrier.

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)? A. Teach insulin self-administration for a client with Type 1 diabetes. B. Update the nutrition needs in the plan of care. C. Evaluate goal attainment for a client with a below-the-knee prosthesis. D. Bathe an unconscious client with decubitus ulcers.

Answer: Bathe an unconscious client with decubitus ulcers. Delegation requires determining which staff member is capable of performing what tasks. Basic hygiene (B) is within the role of the UAP. Coordination and planning of care (A), teaching (C), and evaluating desired goal attainment or client outcomes (D) are responsibilities outside the scope of practice for the UAP, and within that of the nurse.

A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time? A. Begin one-on-one supervision immediately. B. Keep the room dimly lit and turn on the radio. C. Push fluids and provide calorie-rich nutritional supplements. D. Check on the client every 15 minutes.

Answer: Begin one-on-one supervision immediately. One-on-one supervision (B) ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Checking every 15 minutes (A) does not provide sufficient assessment of the client's safety. Additional auditory stimulation and a dimly lit room (C) can create illusions that contribute to the client's altered sensory distress and should be avoided. Fluid replacement and nutritional supplements (D) should be initiated when the client is more stable because the risk for overhydration can occur as blood alcohol levels fall and fluids are retained.

Which change in data indicates to the nurse that the desired effect of the angiotensin II receptor antagonist valsartan (Diovan) has been achieved? A. Pulse rate reduced from 150 to 90 beats/minute. B. Dependent edema reduced from +3 to +1. C. Serum HDL increased from 35 to 55 mg/dl. D. Blood pressure reduced from 160/90 to 130/80.

Answer: Blood pressure reduced from 160/90 to 130/80 Diovan is an angiotensin receptor blocker, prescribed for the treatment of hypertension. The desired effect is a decrease in blood pressure (D). (A, B, and C) do not describe effects of Diovan.

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? A. Notify the client's surgeon immediately. B. Ask the client what he means by "heart trouble." C. Notify surgery that the ECG is over two years old. D. Call for an ECG to be performed immediately.

Answer: Call for an ECG to be performed immediately Clients over the age of 40 and/or with a history of cardiovascular disease, should receive ECG evaluation prior to surgery, generally 24 hours to two weeks before. (D) should be implemented to ensure that the client's current cardiovascular status is stable. Additional data might be valuable (B), but since time is limited, the priority is to obtain the needed ECG. Documentation of vital signs is important, but does not replace the need for the ECG (C). The surgeon only needs to be notified if the ECG cannot be completed, or if there is a significant problem (A).

At a support meeting of parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information? A. Feelings of depression frequently lead to drug abuse and addiction. B. Careful monitoring should be provided during withdrawal from the drugs. C. Addiction is a chronic, incurable disease. D. Tolerance to the effects of drugs causes feelings of depression.

Answer: Careful monitoring should be provided during withdrawal from the drugs. The priority is to teach the parents that their son will need monitoring and support during withdrawal (B) to ensure that he does not attempt suicide. Although (A and C) are true, they are not as relevant to the parent's expressed concern. There is no information to support (D).

The parents of a toddler brought to the clinic for a well-child visit tell the nurse that their child becomes upset if even the smallest things change in the environment. What information should the nurse provide the parents? A. A child is insecure because trust is not fostered and developed during infancy. B. A toddler should be exposed to different routines to promote adapting to new experiences. C. Children of this age are comfortable with ritualism and display global thinking. D. Should be frequently moved in the environment to teach the child to acclimate to change.

Answer: Children of this age are comfortable with ritualism and display global thinking. A 2-year-old is ritualistic and wants consistency and routine, so changes in the toddler's environment or schedule is upsetting. Another mark of the toddler's sensitivity to change is global thinking (change in one small part, such as a minor shift in room arrangement or changes in the whole environment), and the 2-year-old's equanimity disintegrates (C). There is not enough information to make the assumption the child did not develop trust (A). Frequent changes (B and D) in the schedule or the environment can lead to insecurity on the part of the toddler.

A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What action should the nurse take? A. Suggest that the client also select orange juice, to promote absorption. B. Commend the client for selecting a high biologic value protein. C. Encourage the client to attend classes on dietary management of CKD. B. Remind the client that protein in the diet should be avoided.

Answer: Commend the client for selecting a high biologic value protein. Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary.

The charge nurse assigns the care of a client with diabetes who has hyperglycemia to a practical nurse (PN). In supervising the PN, what is the charge nurse's most important action? A. Confer with the PN about any manifestations the client is exhibiting. B. Decide which sliding scale insulin dose should be administered. C. Obtain the blood sugar results via skin puncture and glucometer. D. Notify the healthcare provider of the daily serum glucose results.

Answer: Confer with the PN about any manifestations the client is exhibiting. The nurse's expertise is needed to perform a critical assessment, such as assessing the client for signs of hyperglycemia and to supervise the ongoing monitoring of the client by the PN (D). (A, B, and C) are tasks which the PN can perform.

An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom? A. Pharyngitis and sputum production. B. Leukocytosis and febrile. C. Confusion and tachycardia. D. Polycythemia and crackles.

Answer: Confusion and tachycardia. The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate (D). (A, B, and C) are often absent in the elderly with bacterial pneumonia.

A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A. Consistently follow a set mealtime routine. B. Invite other children home to share meals. C. Reward the child with a nap after eating. D. Accept that he will eat when he is hungry.

Answer: Consistently follow a set mealtime routine. A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child's fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms.

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A. Add oral methadone to the protocol. B. Discontinue ibuprofen. C. Continue gabapentin. D. Add aspirin to the protocol.

Answer: Continue gabapentin. Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given €Å"around the clock€� rather than by the client's PRN requests.

During report, the charge nurse informs a nurse that she must work on another unit. The nurse begins to sigh deeply and tosses about her belongings as she is preparing to leave, making it known that she is very unhappy about having to "float." What is the best immediate action for the charge nurse to take? A. In the presence of other staff members, inform the nurse that her behavior is inappropriate. B. Ask the nurse to call the supervisor to see if she can be reassigned. C. Continue with report, and talk to the nurse about the incident at a later time. D. Stop report and remind the nurse that all staff must "float" at some time.

Answer: Continue with report, and talk to the nurse about the incident at a later time. (A) is the best immediate action. At a later time (after the nurse has "cooled off") the charge nurse should discuss with the nurse in private her inappropriate conduct. (B) only reinforces inappropriate behavior and dismisses the problem to the supervisor. (C and D) would incite conflict in that both actions would likely encourage justification and argumentative behavior, and reprimanding the nurse in front of colleagues is poor management (D). The first priority is to provide care for clients--hopefully, traveling to the unit will provide a "cooling off" time for the nurse.

During the well-child assessment of an 18-month-old male toddler, the nurse determines the child does not walk while holding on to furniture but prefers to crawl, rarely speaks, has a flat affect, and is small for his age. Which nursing diagnosis should the nurse formulate? A. Delayed growth and development. B. Alteration in health maintenance. C. Alteration in parenting. D. Alteration in nutrition.

Answer: Delayed growth and development. This child does not demonstrate gross motor or psychosocial skills typical of an 18-month-old toddler, which best supports delayed growth and development (C). Additional information about the child's growth parameters is needed to support (A, B, or D).

A seven-month old infant is admitted with nonorganic failure to thrive (NFTT). To aid the child's growth and development, which intervention is most important for the nurse to implement? A. Provide instructions about formula preparation and feeding schedules. B. Demonstrate feeding strategies and infant cues that indicate hunger and satiation. C. Encourage the parents to participate in a planned program of play with the infant. D. Refer the parents for psychological counseling to identify parental detachment.

Answer: Demonstrate feeding strategies and infant cues that indicate hunger and satiation. NFTT most often occurs due to inadequate parent knowledge or a disturbance in maternal-child attachment, but the first goal for infants with NFTT is to provide nutrition to promote "catch-up" growth. The nurse should demonstrate positive feeding strategies that reduce parent and infant frustration, such as recognizing the infant's cues indicated by vigorous sucking and satiation (C). (A) encourages normal growth and development, but is not likely to teach the parents how to respond to the infant's nutritional needs. Although family dysfunction may contribute to NFTT and (B) may eventually be indicated, additional assessment is needed before such a referral is made. (D) provides a structured schedule, but positive infant feeding strategies should be implemented first.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? A. Describe diet changes that can improve the management of her diabetes. B. Evaluate the client's ability to do glucose monitoring. C. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. D. Demonstrate self-administration of insulin.

Answer: Describe diet changes that can improve the management of her diabetes. Diet modifications (A) are effective in managing Type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client. (B, C, and D) are interventions that should also be implemented, but do not have the priority of (A).

What action should the nurse implement to provide analgesic titration for a client in pain? A. Teach the client to increase the time range between doses of pain medication. B. Monitor the effects of continuous intravenous infusion of narcotic analgesics. C. Determine the optimal analgesic dosage required that causes the least side effects. D. Plan with the client how to use a specific total dose of analgesic over a 24-hour period.

Answer: Determine the optimal analgesic dosage required that causes the least side effects. No given dosage of an analgesic provides the same level of pain relief for every patient, and so titration upward or downward is determined based on the client's response, so that the optimal dosage achieves adequate pain relief with minimal side effects (D) for the client. Titration does not necessarily mean continuous intravenous infusion (B), but considers dose adjustments to achieve a therapeutic analgesic response. An individual's response to the medication dosage is the assessment for titration, not a specific total dose over 24 hours (C). Although (A) may be a component of pain management, particularly during rehabilitation or remission, the titration dose should be implemented as long as analgesia is needed.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? A. Assessment of the client's vital signs. B. Determine the time the client last voided. C. Document the finding as the only action. D. Insert a rectal tube for the passage of flatus.

Answer: Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided (C) should be determined next. Documentation (B) should be made, but the client's distended bladder requires additional intervention. (A and D) are not priority actions based on the client's abdominal findings.

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Determine who is legally empowered to make decisions. C. Notify the hospital ethics committee of the client situation. D. Refer the client and family members for hospice care.

Answer: Determine who is legally empowered to make decisions. When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution.

The charge nurse working in a long-term care facility is informed by the LPN that a client's son is unhappy with the care his mother is receiving. What action should the nurse take first? A. Discuss with the LPN the son's concerns about his mother's care. B. Ask the family member to come to the nurses' station to discuss the concerns. C. Provide the son with a complaint form and ask him to describe the situation. D. Notify the administrator of the long-term care facility about the son's discontent.

Answer: Discuss with the LPN the son's concerns about his mother's care. The nurse should first obtain information about the nature of the complaint and ask the LPN to describe what he/she knows of the situation. (C) should be the nurse's first action. (A, B, and D) may all need to be implemented after (C).

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? A. Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache." B. Do not give if the child has chickenpox, the flu, or any other viral illness. C. If the child's tongue darkens, discontinue the Pepto Bismol immediately. D. Avoid the use of Pepto Bismol until the child is at least 16 years old.

Answer: Do not give if the child has chickenpox, the flu, or any other viral illness. Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium.

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A. Decrease in the infusion rate of the current IV and report to the healthcare provider. B. Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV. C. Notify healthcare provider and request to change the IV infusion to hypertonic D10W. D. Document in the medical record that these normal findings are expected outcomes.

Answer: Document in the medical record that these normal findings are expected outcomes. The results are all within normal range (C). No changes are needed (A, B, and D).

A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain? A. Family history of suicide. B. Drugs taken in last 7 days. C. Frequency of anxiety attacks. D. Usual coping mechanisms.

Answer: Drugs taken in last 7 days. Use of prescribed, over-the-counter, and illicit drugs (A) is the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations. (B, C, and D) are worthwhile assessment findings, but they do not have the priority of (A).

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Encourage additional oral intake of juices and water. B. Provide additional coffee on the client's breakfast tray. C. Exchange the client's grape juice for cranberry juice. D. Bring the client additional fruit at mid-morning.

Answer: Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).

The nurse is assessing a client who is experiencing anaphylaxis from an insect sting. Which prescription should the nurse prepare to administer this client? A. Epinephrine. B. Dopamine. C. Diphenhydramine. D. Ephedrine.

Answer: Epinephrine Epinephrine (C) is an adrenergic agent that stimulate beta receptors to increase cardiac automaticity in cardiac arrest and relax bronchospasms in anaphylaxis. Dopamine (A) is a vasopressor used to treat clients with shock. Ephedrine (B) causes peripheral vasoconstriction and is used in the treatment of nasal congestion. Diphenhydramine (D) is an antihistamine decongestant used in the treatment of mild allergic reactions and motion sickness.

A 48-year-old client is experiencing a severe anaphylactic reaction to an injection of contrast media. What pharmacologic agent is of greatest use in this situation? A. Epinephrine (Adrenalin). B. Nitroprusside (Nipride). C. Dopamine (Intropin). D. Loratadine (Claritin).

Answer: Epinephrine (Adrenalin). Epinephrine (D) is the drug of choice in treating hypotension and circulatory failure associated with anaphylaxis because it is a potent vasoconstrictor. An anaphylactic reaction is an acute systemic hypersensitivity reaction that occurs within minutes of antigen exposure (such as with contrast material containing iodine) that can result in peripheral vascular collapse. (A) may eventually be necessary if the client does not respond to initial treatment of hypotension with epinephrine. Antihistamines, including (B), are useful adjunctive therapies. (C) is contraindicated.

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? A. Evaluate the effectiveness of narcotic analgesics. B. Limit the client's intake of oral fluids and food. C. Teach the client about prevention of crises. D. Encourage the client to ambulate as tolerated.

Answer: Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated (B) frequently to determine if the client's pain is adequately controlled. (A, C, and D) are not indicated at this time.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A. Excessive CNS stimulation will be reduced. B. Co-dependent behaviors will be decreased. C. Client's level of consciousness will increase. D. Client will not demonstrate cross-addiction.

Answer: Excessive CNS stimulation will be reduced. Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (A). (B, C, and D) are all appropriate outcome statements for the client described, but do not have the priority of (A).

A client with hyperlipidemia receives a prescription for niacin (Niaspan). Which client teaching is most important for the nurse to provide? A. Symptoms of hyperglycemia. B. Expected duration of flushing. C. Diets that minimize GI irritation. D. Comfort measures for pruritis.

Answer: Expected duration of flushing Flushing of the face and neck, lasting up to an hour, is a frequent reason for discontinuing niacin. Inclusion of this effect in client teaching (A) may promote compliance in taking the medication. While (B, C, and D) are all worthwhile instructions to help clients minimize or cope with normal side effects associated with niacin (Niaspan), flushing is intense and causes the most concern for the client.

A Spanish-speaking 5-year-old child starts kindergarten in an English-speaking school. The child cries most of the time, appears helpless and unable to function in the new situation. After assessing the child, how should the school nurse document the situation? A. Experiencing culture shock. B. Refuses to participate in school activities. C. Lacks the maturity needed in school. D. Going through minority group discrimination.

Answer: Experiencing culture shock. An inability to function may apply to persons of all ages undergoing transitions, such as moving to a new country and adjusting to a subculture within a larger culture that is unfamiliar. Culture shock (A) describes feelings of discomfort and disorientation when adapting to new cultural settings. Language barriers inhibit effective communication, so a child who is unable to communicate in the spoken language in the school environment may lack the skills necessary to participate, and is not refusing to participate (C). The child may be adequately mature (B), accepted by peers (D) within the environment, but continues to not join in because of the impact of culture shock.

The therapeutic effect of insulin in treating Type 1 diabetes mellitus is based on which physiologic action? A. Stimulates function of beta cells in the pancreas. B. Increases intracellular receptor site sensitivity. C. Facilitates transport of glucose into the cells D. Delays carbohydrate digestion and absorption.

Answer: Facilitates transport of glucose into the cells. Glucose moves across the cell membrane by using an active transport mechanism. Insulin acts as the carrier of glucose and is the only hormone that decreases blood glucose levels by facilitating transport of glucose into the cells (A). (B and C) describe actions of oral hypoglycemic agents, such as metformin (Glucophage), a biguanide oral antidiabetic drug. (D) describes the action of alpha-glucosidase inhibitors, such as acarbose (Precose) and miglitol (Glyset)

Which task should the nurse delegate to an Unlicensed Assistive personnel (UAP)? A. Feed a client with minimal dysphagia. B. Determine a client's response to pain. C. Observe a client's central venous catheter site. D. Accompany the healthcare provider during client visits.

Answer: Feed a client with minimal dysphagia. Delegation of client care is delineated by state boards of nursing practice and include specific guidelines regarding which tasks are within the scope of practice for each level of care provider and include the components of delegation to the UAP. Feeding a client (D) is a basic client care measure that is within the scope of practice for a UAP. (A, B, and C) require assessment and analysis which require the expertise of a licensed nurse.

The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider? A. Low-grade fever, diaphoresis, hypertension, and tachycardia. B. Global confusion and inability to recognize family members. C. Agitation, vomiting, and visual and auditory hallucinations. D. Restlessness, anxiety, and difficulty sleeping.

Answer: Global confusion and inability to recognize family members. Delirium tremens (DT) or alcohol withdrawal delirium usually peaks 2 to 3 days (48 to 72 hours) after cessation or reduction of intake (although it can occur later) and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal, manifested as global confusion and an inability to recognize family members (B), is life-threatening and requires emergency medical intervention. The early signs of withdrawal (A) develop within a few hours after cessation or reduction of alcohol (ethanol) intake; the signs peak after 24 to 48 hours (C and D) and then rapidly and dramatically disappear, unless the withdrawal progresses to alcohol withdrawal delirium.

The nurse is assessing a 2-year-old. What behavior indicates that the child's language development is within normal limits? A. Half of child's speech is understandable. B. Is able to name four colors. C. Is capable of making a three word sentence. D. Can count five blocks.

Answer: Half of child's speech is understandable. Between approximately 15 and 24 months of age, a child's speech is only half understandable (D). (A and B) usually occur between 3 and 5 years of age. (C) is usually accomplished by 18 months of age.

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? A. Have a bulb syringe readily available to remove secretions. B. Give small, frequent feedings of fluids. C. Accurately chart observations regarding breath sounds. D. Encourage older siblings to visit.

Answer: Have a bulb syringe readily available to remove secretions A patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration and prevent tiring, but an open airway has a higher priority! (B) is important for evaluation of therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs usually have a higher priority than psychosocial needs (D) and an open airway is the highest physiological need!

The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? A. Avoid consuming alcohol and caffeinated beverages. B. Wear a condom when having sexual intercourse. C. Have intercourse or masturbate at least twice a week. D. Empty the bladder completely with each voiding.

Answer: Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation (D) decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated fluids. (A, B, and C) do not reduce the risk of spreading the infection internally.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. B. He comments on the community service announcements about preventing complications associated with diabetes. C. He is provided with the most current information about the dangers of untreated diabetes. D. He visits his diabetic brother who just had surgery to amputate an infected foot.

Answer: He visits his diabetic brother who just had surgery to amputate an infected foot. The loss of a limb by a family member (D) will be the strongest event or "cue to action" and is most likely to increase the perceived seriousness of the disease. (A, B, and C) may influence his behavior but do not have the personal impact of (D).

A medication that is classified as a beta-1 agonist is most commonly prescribed for a client with which condition? A. Glaucoma. B. Hypertension. C. Heart failure. D. Asthma.

Answer: Heart failure. Beta-1 agonists improve cardiac output by increasing the heart rate and blood pressure and are indicated in heart failure (C), shock, atrioventricular block dysrhythmias, and cardiac arrest. Glaucoma (A) is managed using adrenergic agents and beta-adrenergic blocking agents. Beta-1 blocking agents are used in the management of hypertension (B). Medications that stimulate beta-2 receptors in the bronchi are effective for bronchoconstriction in respiratory disorders, such as asthma (D).

Which action should the nurse implement during the termination phase of the nurse-client relationship? A. Confront changes not completed. B. Explore the client's past in depth. C. Help summarize accomplishments. D. Identify new problem areas.

Answer: Help summarize accomplishments. By noting the client's accomplishments (D), the client's progress and self-confidence can be summarized. The working phase focuses on identifying new problem areas (A) and confronting necessary changes (B). The orientation phase includes an in-depth assessment of the client, including past history (C).

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? A. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen. B. Help the client to determine ways to increase his fluid intake. C. Obtain an appointment for the client to see an ear, nose, and throat specialist. D. Schedule an appointment with an allergist to determine if the client is allergic to the cat.

Answer: Help the client to determine ways to increase his fluid intake. The nurse should suggest creative methods to increase the intake of fluids (A), such as having disposable fruit juices readily available. Clients with COPD should have at least three liters of fluids a day. These clients often reduce fluid intake because of shortness of breath. (B) is not indicated. These symptoms are not indicative of an allergy (C). Many elderly depend on their pets for socialization and self-esteem. Humidified oxygen will not relieve these symptoms and increased oxygen levels will stifle the COPD client's trigger to breathe (D).

The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? A. Thinning hair and dry scalp. B. Increase in muscle tone but decreased muscle strength. C. Increase in abdominal fat deposits. D. Increase in appetite and taste-bud acuity.

Answer: Increase in abdominal fat deposits. An increase in the abdominal girth (D) may be indicative of the onset of metabolic syndrome, which places the client at risk for cardiac disease and requires further assessment. During middle adulthood, common findings include thinning hair, dry skin and scalp (A), changes in taste bud acuity (B), and muscle size and strength (C), which are consistent with normal system functioning during aging.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? A. Increased abdominal pain with rebound tenderness. B. Complaint of feeling weak with watery diarrheal stools. C. Large amounts of expelled flatus with mucus. D. Tympanic abdomen and hyperactive bowel sounds.

Answer: Increased abdominal pain with rebound tenderness. Positive rebound tenderness (C) may be an indication of peritonitis or perforation and needs follow-up immediately. Clients typically experience a large amount of flatus (A) and may have mucus from bowel irritation from the procedure. A tympanic abdomen on percussion and hyperactive bowel sounds are typical post procedure findings (B). Weakness and watery stools are a result from the preparation and are common symptoms experienced after a colonoscopy (D).

An 8-year-old boy who is recently diagnosed with diabestes mellitus is admitted to the intensive care unit with diabetic ketoacidosis (DKA). Which nursing action has the highest priority? A. Initiate an intravenous infusion. B. Obtain fingerstick glucose. C. Place on cardiac monitor. D. Collect specimen for serum electrolytes.

Answer: Initiate an intravenous infusion The priority for a child with DKA, an emergency life-threatening situation, is to obtain venous access for administration of fluids, electrolytes, and insulin (B). The child should be placed on a cardiac monitor and have serum electrolytes and glucose levels obtained but not before initiating venous access (A, C, and D).

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Offer to contact a member of the local ostomy support group to help him with his concerns. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Encourage the client to handle the stoma equipment to gain confidence with the procedure. D. Reassure the client that he will become accustomed to the stoma appearance in time.

Answer: Instruct the client that the stoma will become smaller when the initial swelling diminishes. Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D).

The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? A. Poor concentration skills suggests limited intelligence. B. The inability to think abstractly indicates limited intelligence. C, Acute psychiatric illnesses impair intelligence. D. Intelligence is influenced by social and cultural beliefs.

Answer: Intelligence is influenced by social and cultural beliefs. Social and cultural beliefs (D) have significant impact on intelligence. Chronic psychiatric illness may impair intelligence (C), especially if it remains untreated. Limited concentration does not suggest limited intelligence (A). Difficulties with abstractions are suggestive of psychotic thinking (B), not limited intelligence.

When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness? A. Logical mathematics and linguistic abilities. B. Bodily kinesthetic and spatial abilities. C. Linguistic and musical abilities. D. Interpersonal and intrapersonal skills.

Answer: Interpersonal and intrapersonal skills. Interpersonal and intrapersonal intelligence form one's personal intelligence or "emotional quotient," so the nurse should focus inquiries on social skills (B). (A and D) assesses cognitive and mental status. (C) determines neurophysical interpretation of one's body within the environment, but does not assess emotional intelligence.

The practical nurse (PN) is working with the registered nurse (RN) to provide care for several clients. Which task should the RN, rather than the PN, perform? A. Apply a neck brace prior to ambulating a client the first day after a cervical laminectomy. B. Assist a healthcare provider performing a joint fluid aspiration of a client's knee. C. Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia. D. Remove the staples from a client's incision one week after hip arthroplasty.

Answer: Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia. Care of a stage IV pressure ulcer (C) is a complex, sterile procedure that requires assessment of the wound, and evaluation of the effectiveness of the treatment plan, and should be performed by the RN. (A, B, and D) are procedures that require the skill and expertise of a licensed nurse, but are within the scope of practice for a PN (C).

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH), which is manifested by which symptoms? A. Polydipsia, polyuria. B. Hypernatremia, tachypnea. C. Dependent edema, fever. D. Loss of thirst, weight gain

Answer: Loss of thirst, weight gain SIADH occurs when the posterior pituitary gland releases too much ADH, causing water retention, a urine output of less than 20 ml/hour, and dilutional hyponatremia. Other indications of SIADH are loss of thirst, weight gain (A), irritability, muscle weakness, and decreased level of consciousness. (B) is not associated with SIADH. (C) is a finding associated with diabetes insipidus (a water metabolism problem caused by an ADH deficiency), not SIADH. The increase in plasma volume causes an increase in the glomerular filtration rate that inhibits the release of rennin and aldosterone, which results in an increased sodium loss in urine, leading to greater hyponatremia, not (D).

A client who was prescribed atorvastatin (Lipitor) one month ago calls the triage nurse at the clinic complaining of muscle pain and weakness in his legs. Which statement reflects the correct drug-specific teaching the nurse should provide to this client? A. Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect. B. Be sure to consume a low-cholesterol diet while taking the drug to enhance the effectiveness of the drug. C. Increase consumption of potassium-rich foods since low potassium levels can cause muscle spasms. D. Have serum electrolytes checked at the next scheduled appointment to assess hyponatremia, a cause of cramping..

Answer: Make an appointment to see the healthcare provider, because muscle pain may be an indication of a serious side effect. Myopathy, suggested by the leg pain and weakness, is a serious, and potentially life-threatening, complication of Lipitor, and should be evaluated immediately by the healthcare provider (C). Although electrolyte imbalances such as (A or B) can cause muscle spasms in some cases, this is not the likely cause of leg pain in the client receiving Lipitor, and evaluation by the healthcare provider should not be delayed for any reason. A low-cholesterol diet is recommended for those taking Lipitor since the drug is used to lower total cholesterol (D), but diet is not related to the leg pain symptom.`

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Confusion. B. Stomatitis. C. Dyspnea. D. Nocturia.

Answer: Nocturia As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal failure.

A 4-month-old breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret this finding? A. Inadequate milk supply in mother. B. Milk allergy. C. Normal growth curve of a breast-fed infant. D. Failure to thrive.

Answer: Normal growth curve of a breast-fed infant. When plotting weights and heights on a standard growth chart used for both breast-fed and formula-fed infants, the breast-fed infant grows more rapidly during the first 2 months of life, and then growth slows from 3 to 12 months. A breast-fed infant is leaner and has less body fat than a formula-fed infant. Normal patterns of infants who are breast fed (D) differ from those who are formula fed. (A) is an incorrect interpretation of the data. This finding is not consistent with failure to thrive (B) or an inadequate milk supply (C)

The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan? A. The xray procedure may last for several hours. B. Enemas are given to empty the bowel after the procedure. C. Nothing by mouth is allowed for 6 to 8 hours before the study. D. A nasogastric tube (NGT) is inserted to instill the barium.

Answer: Nothing by mouth is allowed for 6 to 8 hours before the study. The client should be NPO for at least 6 hours before the UGI (D). (A) is not typical for this procedure. A NGT is not needed to instill the barium (B) unless the client is unable to swallow. A laxative, not enemas (C), is given after the procedure to help expel the barium.

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Report the client's acuity level to the nursing supervisor. B. Request hospice care for the client. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent.

Answer: Notify family members of the client's condition. The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D).

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Prepare the family for the client's impending death. B. Notify the healthcare provider of the family's request. C. Reaffirm the client's desire for no resuscitative efforts. D. Transfer the client to a hospice inpatient facility.

Answer: Notify the healthcare provider of the family's request. The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented.

A client with osteoarthritis receives a new prescription for celecoxib (Celebrex) orally for symptom management. The nurse notes the client is allergic to sulfa. Which action is most important for the nurse to implement prior to administering the first dose? A. Review the client's hemoglobin results. B. Record the client's vital signs. C. Notify the healthcare provider. D. Inquire about the reaction to sulfa.

Answer: Notify the healthcare provider. Celebrex contains a sulfur molecule, which can lead to an allergic reaction in individuals who are sensitive to sulfonamides, so the healthcare provider should be notified of the client's allergies (B). Although (A, C, and D) are important assessments, it is most important to notify the healthcare provider for an alternate prescription.

A client with Paget's disease is started on calcitonin (Calcimar) 500 mcg subcutaneously daily. During the initial treatment, what is the priority nursing action? A. Assess the injection site for inflammation. B. Observe the client for signs of hypersensitivity. C. Evaluate the client's level of pain. D. Monitor the client's alkaline phosphatase levels.

Answer: Observe the client for signs of hypersensitivity. The nurse's highest priority is to observe for signs of hypersensitivity, such as skin rash, hives, or anaphylaxis (D). Calcitonin is given to a client with Paget's disease to lower serum calcium levels. However, hypersensitivity can cause life-threatening anaphylaxis. Calcitonin may cause local site inflammation, so (A) is important, but does not have the priority of (D). A reduction in (B and C) are indicators that the calcitonin is having the desired effect.

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? A. Give an insulin dose using parameters of a sliding scale. B. Withhold insulin while the client is NPO. C. Administer an oral anti-diabetic agent. D. Obtain a prescription for an adjusted dose of insulin.

Answer: Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin (A). (B, C, and D) are not indicated.

Which menu selection by a child with celiac disease indicates to the nurse that the child understands necessary dietary considerations? A. Graham crackers and fruit juice. B. Oatmeal-raisin cookies and milk. C. Peanut butter and banana sandwich. D. Oven-baked potato chips and cola.

Answer: Oven-baked potato chips and cola. Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any products containing these ingredients to avoid symptoms such as diarrhea. (A) is the selection which avoids all of these ingredients. (B, C, and D) contain gluten in one form or another.

The nurse receives a lab report stating a child with asthma has a theophylline level of 15 mcg/dl. What action will the nurse take? A. Pass the information on in the report. B. Hold the next dose of theophylline. C. Notify the healthcare provider because the value is high. D. Repeat the lab study because the value is too high.

Answer: Pass the information on in the report. The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report (A). (B, C, and D) would be inappropriate actions in view of the laboratory finding.

A healthcare provider prescribes cefadroxil (Duricef) for a client with a postoperative infection. It is most important for the nurse to assess for what additional drug allergy before administering this prescription? A. Penicillins. B. Aminoglycosides. C. Sulfonamides. D. Erythromycins.

Answer: Penicillins. Cross-allergies exist between penicillins (A) and cephalosporins, such as cefadroxil (Duricef), so checking for penicillin allergy is a wise precaution before administering this drug.

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? A. Lethargy and fatigue. B. Polyuria and polydipsia. C. Facial bone structure changes. D. Increased facial hair.

Answer: Polyuria and polydipsia. Signs and symptoms of diabetes or hyperglycemia (A) need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance. (B) is associated with any number of heath alterations, but is not associated with the growth hormone therapy. (C and D) are normal changes that occur with 12-year-old males.

The nurse is assessing a child's skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended and tented for a few seconds, then slowly falls back on the abdomen. How should the nurse document this finding? A. Assessment inconclusive. B. Poor skin turgor. C. Adequate hydration. D. Normal skin elasticity

Answer: Poor skin turgor Tissue turgor refers to the amount of elasticity in the skin and is one of the best estimates of adequate hydration and nutrition. Elastic tissue immediately resumes its normal position without residual marks or creases. In a child with poor turgor (B), the skin remains tented or suspended for a few seconds before returning to a normal position. (A, C and D) are inaccurate.

The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had three loose stools since surgery yesterday. Which nursing diagnosis has the highest priority? A. Pain related to postoperative condition. B. Potential for fluid volume deficit. C. Alteration in bowel elimination. D. Anxiety of parents related to newborn's condition.

Answer: Potential for fluid volume deficit. All stated nursing diagnoses are appropriate for a postoperative colostomy client. However, fluid balance is the priority concern (A) for any newborn infant. Though three loose stools in 24-hours is not significant, depending on the amount of fluid lost with each stool, potential for fluid volume deficit is always a concern for a postoperative infant. Newborns are extremely vulnerable to fluid imbalances due to immature body systems and a larger percentage of their body weight consisting of fluid. (B, C, and D) do not have the priority of (A).

A 3-year-old boy is brought to the emergency room because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 beats/minute, respiratory rate 20 breaths/minute, and blood pressure 70/30. Which nursing intervention has the highest priority? A. Insert an orogastric tube for gastric lavage. B. Prepare a set-up for an endotracheal intubation. C.Draw blood for stat chemistries and blood gases. D. Insert a Foley catheter to monitor renal functioning.

Answer: Prepare a set-up for an endotracheal intubation. Diazepam causes respiratory depression, so preparation for intubation (B) to protect the airway is the priority intervention at this time. (A) may be necessary, but the child is lethargic and confused, with a lowered respiratory rate, so (B) takes priority. (C and D) are interventions that should be implemented, but they are both secondary to ensuring an open airway.

Which action should the nurse implement first for a client experiencing alcohol withdrawal? A. Apply vest or extremity restraints. B. Provide a diet high in protein and calories. C. Give an alpha-adrenergic blocker. D. Prepare the environment to prevent self-injury.

Answer: Prepare the environment to prevent self-injury. Self-destructive or violent behavior provides a potentially immediate and life-threatening risk to the client and others, so a safe environment should be provided (D) by removing any potential objects that could inflict self-injury. Secondary prevention strategies (frequent orientation to surroundings, restraints to prevent self-injury (A), and the administration of antianxiety agents or alpha-adrenergic blockers (B) for hallucinations, delusions, confusion, and agitation) should then be implemented. Once the client is stabilized, nutritional issues (C) should be addressed.

An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? A. Reduce peripheral tissue hypoxia and nailbed clubbing. B. Prevent the return of oxygenated blood to the lungs. C. Increase the flow of unoxygenated blood to the lungs. D. Stop the flow of unoxygenated blood into systemic circulation.

Answer: Prevent the return of oxygenated blood to the lungs. Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.

The nurse administers a booster dose of DTaP (diphtheria, tetanus, and pertussis) vaccine to an infant. Which level of prevention is the nurse implementing? A. Primary prevention. B. Secondary prevention. C. Primary nursing. D. Tertiary prevention.

Answer: Primary prevention. Primary prevention (A) involves activities that focus on reducing the potential for illness before it occurs, such as immunizations. Tertiary prevention (B) minimizes the consequences of a disorder or illness through aggressive management or rehabilitation. Secondary prevention (C) includes early diagnosis and implementing interventions aimed at a cure or reducing the progress of a disease. Primary nursing (D) describes a method of nursing management and nursing care assignments, not a healthcare strategy.

In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? A. Drawing up the correct insulin dose. B. Process of glucose testing. C. Administering insulin injections. D. Food planning and selection.

Answer: Process of glucose testing. Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer (C) and to read the number (it is especially helpful if the nurse presents this activity as a game). (A, B, and D) require more advanced cognitive and psychomotor skills and have greater potential for errors.

During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? A. Productive cough with grayish-white sputum. B. An increased chest diameter. C. Clubbing of the fingers. D. Racing pulse with exertion.

Answer: Productive cough with grayish-white sputum. Chronic bronchitis, one of the diseases comprising the diagnosis of COPD, is characterized by a productive cough with grayish-white sputum (A), which usually occurs in the morning and is often ignored by smokers. (D) is not related to chronic bronchitis; however, it is indicative of other problems such as ventricular tachycardia and should be explored. (B and C) are symptoms of emphysema and are not consistent with the other symptoms. (B) is usually referred to as a "barrel chest."

The nurse is triaging a child with a fever brought to the emergency department by the parents. Which finding requires the nurse's immediate intervention? A. Frequent nonproductive cough. B. Prolonged exhalations. C. Oxygen saturation is 95% by pulse oximeter. D. Thick yellow rhinorrhea.

Answer: Prolonged exhalations. Prolonged exhalation (A) indicates breathing difficulty, and intervention for this should be taken immediately. Nasal discharge (B) and a productive cough (C) are not findings that indicate the child is in immediate distress. An oxygen saturation of 95% is a normal finding (D).

What is the expected outcome of esomeprazole (Nexium) when prescribed for a client with gastroesophageal reflux disease (GERD)? A. Improved esophageal peristalsis. B. Increased gastric emptying. C. Neutralization of gastric secretions. D. Promotion of rapid tissue healing.

Answer: Promotion of rapid tissue healing Proton pump inhibitors, such as esomeprazole (Nexium), act to inhibit gastric acid secretion and promote rapid healing of esophageal tissue (A). (B and C) are actions of prokinetic drugs, and (D) is the action of over-the-counter antacids.

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? A. Propanolol (Inderal). B. Furosemide (Lasix). C. Dobutamine (Dobutrex). D. Captopril (Capoten).

Answer: Propanolol (Inderal). Inderal (A) is a beta adrenergic blocking agent, which causes decreased heart rate and decreased contractility. Neither (D), an ACE inhibitor, nor (B), a loop diuretic, causes bradycardia. (C) is a sympathomimetic, direct acting cardiac stimulant, which would increase the heart rate.

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? A. Provide cheese and bread to eat. B. Collect a glycosylated hemoglobin specimen. C. Obtain a specimen for serum glucose level. D. Administer insulin per sliding scale.

Answer: Provide cheese and bread to eat. Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal or a snack to prevent hypoglycemia from recurring (C). Blood glucose has just been checked and a serum level is not indicated at this time (A). The blood glucose does not indicate a need for insulin (B) which may further exacerbate a hypoglycemic response. A glycosylated hemoglobin (hemoglobin A1C) level is not indicated at this time (D).

A 14-year-old is brought to the emergency room after a biking accident. How should the nurse interact with the adolescent? A. Provide clear explanations while encouraging questions. B. Limit the number of choices to be made by the adolescent. C. Have the parents remain with the adolescent at all times. D. Furnish rewards for cooperation during procedures.

Answer: Provide clear explanations while encouraging questions. Adolescents are capable of abstract thinking and understand explanations, so the opportunity to ask questions (C) should be provided. Giving rewards (A), such as stickers for cooperation with treatments or procedures are best used with a younger child. An adolescent's modesty should be respected, so the presence of the parents (B) at the bedside should be a choice made by the adolescent. An adolescent's ability to think abstractly engages problem solving, so the 14-year-old should be allowed to make decisions about care, not (D).

When caring for a child who has pertussis that is in the paroxysmal stage, which intervention should the nurse implement to support the child's nutritional needs? A. Maintain a liquid diet. B.Provide small, frequent meals. C. Offer the child a regular diet. D. Increase protein intake.

Answer: Provide small, frequent meals. The paroxysmal stage of pertussis is characterized by coughing with vomiting. Frequent small meals (A) are vomited less often than larger meals. (B, C, and D) are not useful interventions at this stage of the child's pertussis.

The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What intervention should the nurse implement? A. Question the healthcare provider's prescription. B. Instruct the client to swallow the tablet whole. C. Administer 30 minutes before eating. D. Evaluate the effectiveness 1 hour after administration.

Answer: Question the healthcare provider's prescription. Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse (D). (A, B, and C) are not recommended nursing actions for the administration of aluminum and magnesium hydroxide (Maalox).

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A. Raising the head of the bed on blocks. B. Avoiding large meals. C. Decreasing caffeine intake. D. Losing weight.

Answer: Raising the head of the bed on blocks. Raising the head of the bed on blocks (D) (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most effective recommendation for a client experiencing severe gastroesophageal reflux during sleep. (A, B and C) may be effective recommendations but raising the head of the bed is more effective for relief during sleep.

A client is taking sulfisoxazole (Gantrisin) for a urinary tract infection (UTI) and complains of nausea and gastric upset since starting the medication. Which additional adverse reaction should the nurse instruct the client to report? A. Diarrhea. B. Muscle cramping. C. Rash. D. Hematuria.

Answer: Rash Side effects of sulfisoxazole (Gantrisin), a sulfonamide antibiotic, include possible allergic response, manifested by skin rash (A) and itching, which can progress to Stevens-Johnson syndrome - erythema multiforme, a severe hypersensitivity reaction. Other gastrointestinal disturbances, such as diarrhea (B), crystalluria and photosensitivity are other side effects that commonly occur with "sulfa" agents but do not need the discontinuation of the prescription. Hematuria (C) is associated with a UTI. Muscle cramping (D) is mostly likely related to an electrolyte disturbance.

A client is receiving ampicillin sodium (Omnipen) for a sinus infection. The nurse should instruct the client to notify the healthcare provider immediately if which symptom occurs? A. Rash. B. Headache. C. Dizziness. D. Nausea.

Answer: Rash Rash (A) is the most common adverse effect of all penicillins, indicating an allergy to the medication which could result in anaphylactic shock, a medical emergency. (B, C, and D) are common side effects of penicillins that should subside after the body adjusts to the medication. These would not require immediate medical care unless the symptoms persist beyond the first few days or become extremely severe.

A client with heart failure is prescribed spironolactone (Aldactone). Which information is most important for the nurse to provide to the client about diet modifications? A. Refrain for eating foods high in potassium. B. Do not add salt to foods during preparation. C. Increase intake of milk and milk products. D. Restrict fluid intake to 1000 ml per day.

Answer: Refrain for eating foods high in potassium. Spironolactone (Aldactone), an aldosterone antagonist, is a potassium-sparing diuretic, so a diet high in potassium should be avoided (B), including potassium salt substitutes, which can lead to hyperkalemia. Although (A) is a common diet modification in heart failure, the risk of hyperkalemia is more important with Aldactone. Restriction of fluids (C) or increasing milk and milk products (D) are not indicated with this prescription.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A.Refuse to perform the task that is beyond the nurse's experience. B. Review the steps in the procedure manual. C. Ask another nurse to assist while implementing the procedure. D. Follow the agency's policy and procedure.

Answer: Refuse to perform the task that is beyond the nurse's experience. According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C).

A client receives a new prescription for an angiotensin-converting enzyme (ACE) inhibitor. What client history contraindicates its use? A. Asthma. B. Heart failure. C. Coronary artery disease. D. Renal artery stenosis.

Answer: Renal artery stenosis Angiotensin-converting enzyme (ACE) inhibitors can cause severe renal insufficiency in clients with bilateral renal artery stenosis (C) or stenosis in the artery to a single remaining kidney. ACE inhibitors should not be used during the second and third trimesters of pregnancy and should be used with caution in clients who are taking potassium-sparing diuretics or who have hyperkalemia. The use of ACE inhibitors is not contraindicated for clients with asthma (A). ACE inhibitors are indicated for clients with heart failure (B). Ramipril, an ACE inhibitor, is approved for use in high risk clients for future cardiac events, including those with a history of coronary artery disease (D).

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? A. Increase the IV flow rate for 15 minutes. B. Irrigate the indwelling urinary catheter. C. Report the findings to the surgeon. D. Apply manual pressure to the bladder.

Answer: Report the findings to the surgeon An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. Although other actions (B, C, and D) may be indicated, the assessment findings should be reported to the healthcare provider.

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Reassure the client that the vital signs are normal. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Remain calm with the client and record abnormal results in the chart.

Answer: Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority.

A nurse receives an emphatic complaint from a client in a semi-private room that the night shift nurse did not come into the room the entire night. What action should the nurse implement first? A. Verify occurrence with client's roommate while he's ambulating in the hall. B. Telephone the night shift nurse as soon as possible to ask about the situation. C. Discuss the situation with staff to determine if this client has a history of complaining. D. Review the night shift nurse's documentation with the charge nurse.

Answer: Review the night shift nurse's documentation with the charge nurse. The client's concern needs to be assessed immediately. This can best be accomplished by reviewing the documentation with administration, i.e., the charge nurse, to determine the client's needs and the night nurse's response. The night shift nurse may need to be contacted at some point (A) but reviewing the documentation should occur first. The nurse should not discuss the situation with (C or D).

What is the most effective time management strategy for a nurse who needs to review 10 client records in 2 weeks? A. Delegate other nursing responsibilities to the team members. B. Designate 15 minutes a day to respond to each time-waster. C. Schedule specific times on a written calendar to review 2 charts per day. D. Review all records 2 days before the due date to focus on the deadline.

Answer: Schedule specific times on a written calendar to review 2 charts per day. Creating a disciplined approach by scheduling time periods for each issue is the most effective time-management strategy (C). Although (A and B) are options, the priority responsibility is to accomplish the goal within the designated time frame without imposing on others. (D) can create more stress that may hinder accomplishing the goal.

Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? A. Context. B. Counter transference. C. Therapeutic self-disclosure. D. Self-analysis.

Answer: Self-analysis Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs, so (B) is a primary tool used by the nurse to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. Although (A, C, and D) may occur in a nurse-client relationship, they may not contribute to establishing a therapeutic relationship.

A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis? A. Aplastic. B. Vaso-occlusive. C. Hyperhemolytic. D. Sequestration.

Answer: Sequestration. The findings support a sequestration crisis (B), where blood pools in the spleen, and is characterized by abdominal pain and anemia. (A and C) crises produce anemia but no abdominal pain or splenic enlargement. (D) crisis may produce abdominal pain, but no splenic enlargement or exacerbation of anemia.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Prealbumin. B. Transferrin. C. Serum albumin. D. Urine urea nitrogen.

Answer: Serum albumin Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C).

A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? A. Urine specific gravity. B. Serum creatinine. C. Blood Urea Nitrogen (BUN). D. Sedimentation rate.

Answer: Serum creatinine Creatinine (A) is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration. (B) is also an indicator of renal activity, but it can be affected by non-renal factors such as hypovolemia and increased protein intake. (C) is a nonspecific test for acute or chronic inflammatory processes. (D) is useful in assessing hydration status, but not as useful in assessing glomerular function.

A client is receiving methylprednisolone (Solu-Medrol) 40 mg IV daily. The nurse anticipates an increase in which laboratory value as the result of this medication? A. Serum potassium. B. Red blood cells. C. Serum glucose. D. Serum calcium.

Answer: Serum glucose Solu-Medrol is a corticosteroid with glucocorticoid and mineralocorticoid actions. These effects can lead to hyperglycemia (A), which is reflected as an increase in the serum glucose value. The client taking Solu-Medrol is at risk for hypocalcemia (B) and hypokalemia (D), which result in a decrease, not an increase, in the serum calcium and serum potassium levels. This medication does not adversely affect the RBC count (C).

The nurse calculates a 4 ml dose of prescribed digoxin a 9-month-old infant. What action should the nurse implement? A. Check heart rate and administer dose by letting the infant suck it through a nipple. B. Check heart rate and administer dose by placing it to the back and side of mouth. C. Suspect dosage error and do not give dose. D. Mix dose with juice to disguise its taste.

Answer: Suspect dosage error and do not give dose. Digoxin narrow margin of safety for an infant should not exceed 1 ml (50 mcg) in one dose. The nurse's calculation indicates a dosage error and should not be given (B). Digoxin is given without mixing with any other fluids or foods (A) because the infant may refuse to consume the total amount which results in an inaccurate drug dose. Although (C and D) are interventions for administration of oral digoxin to an infant, the dose is an error and should not be administered.

Which ego-defense mechanisms are exhibited by a phobic client who refuses to leave home? A. Fantasy. B. Denial. C. Intellectualization. D. Symbolization.

Answer: Symbolization Symbolization (D) allows external objects to carry the internal emotional feeling through some act such as refusing to leave a "safe" harbor. (A) is the unconscious failure to acknowledge an event, thought or feeling. (C) is pretending, usually of a more desirable situation. (B) is using reason to avoid emotional conflicts.

A 43-year-old female client is receiving thyroid replacement hormone following a thyroidectomy. What adverse effects associated with thyroid hormone toxicity should the nurse instruct the client to report promptly to the healthcare provider? A. Tachycardia and chest pain. B. Weight gain and increased appetite. C. Dry skin and intolerance to cold. D. Tinnitus and dizziness.

Answer: Tachycardia and chest pain. Thyroid replacement hormone increases the metabolic rate of all tissues, so common signs and symptoms of toxicity include tachycardia and chest pain (B). (A, C, and D) do not indicate a thyroid hormone toxicity.

A client is being treated for osteoporosis with alendronate (Fosamax), and the nurse has completed discharge teaching regarding medication administration. Which morning schedule would indicate to the nurse that the client teaching has been effective? A. Take medication with breakfast, then take a 30 minute morning walk. B. Take medication, rest in bed for 30 minutes, eat breakfast, go for morning walk. C. Take medication, go for a 30 minute morning walk, then eat breakfast. D. Go for a 30 minute morning walk, eat breakfast, then take medication.

Answer: Take medication, go for a 30 minute morning walk, then eat breakfast. Alendronate (Fosamax) is best absorbed when taken thirty minutes before eating in the morning. The client should also be advised to remain in an upright position for at least thirty minutes after taking the medication to reduce the risk of esophageal reflux and irritation. (A) is the best schedule to meet these needs. (B, C, and D) do not meet these criteria.

Which task is best for a nurse to delegate to an unlicensed assistive personnel (UAP)? A. Assess a client's skin to see if there is any skin breakdown. B. Take the 4th set of vital signs on a client receiving a blood transfusion. C. Teach a client how to use an incentive spirometer. D. Monitor a postoperative client and notify a nurse if the client needs anything.

Answer: Take the 4th set of vital signs on a client receiving a blood transfusion. Taking vital signs (B) on a client receiving blood is only data collection, which is within the practice role of a UAP. The registered nurse (RN) must interpret the findings. (A) is too vague. (C) is teaching, which is always the responsibility of the RN. (D) asks for an assessment, which is within the scope of practice for an RN, not the UAP.

A client with chronic pancreatitis receives a new prescription for pancrelipase (Pancrease). Which instruction is most important for the nurse to include in this client's teaching? A. Take the medication when consuming food. B. Stay away from products containing alcohol. C. Ingest 8 oz of grapefruit juice with the medication. D. Avoid prolonged exposure to direct sunlight.

Answer: Take the medication when consuming food. With the loss of exocrine function for a client with chronic pancreatitis, replacement of pancreatic enzymes using pancrelipase (Pancrease) becomes necessary. Diarrhea and steatorrhea (fatty stools) indicate insufficient pancreatic enzymes are present to digest dietary fats and other of nutrients, so pancrelipase, a fat-digesting enzyme, should be consumed with any type of food (D). (A, B, and C) are not related to the administration of Pancrease.

A mother expresses concern to the nurse about the behavior of her 15-year-old adolescent who is frequently finding fault and criticizing her. What information should the nurse provide? A. Teens create psychological distance from parents in order to separate from them. B. The family value system may need to be changed to meet the teen's changing needs. C. Parents should relinquish their relationship with their teen to the teen's peers. D. Conflicts in the parent-teen relationship are to be expected during adolescence.

Answer: Teens create psychological distance from parents in order to separate from them. Although a mutually respectful parent-adolescent relationship is important, an adolescent may use critical and fault-finding behavior as a mechanism to separate from the parent (B). Changing the family's value system to meet the teen's needs (A) does not provide consistency for an adolescent who is examining oneself. (C) does not provide guidance or boundary setting that is needed to foster judgment during adolescence. Although (D) may occur as an adolescent struggles for independence, healthy family dynamics foster the parent-teen relationship even though it may not seem as important to the teen as it was in earlier years.

A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention should the nurse take at this time? A. Arrange for emergency admission to a detoxification unit. B. Tell the client that therapy cannot take place while she is intoxicated. C. Talk to the spouse about strategies to limit the client's drinking. D. Have the client admitted to the inpatient psychiatric unit.

Answer: Tell the client that therapy cannot take place while she is intoxicated. Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur (D) because the client's judgment is altered. (A and C) are not necessary at this time. (B) is ineffective.

Which statement best describes durable power of attorney for health care? A. The healthcare decisions made by another person designated by the client are not legally binding. B. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.

Answer: The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time.

A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because my husband told me I will be deported if my depression is not cured." What information should the nurse report to the healthcare provider? A. The client is not competent to sign permission for treatment. B. All the elements of informed consent were met. C. The client's consent may have been coerced. D. The woman may not fully understand the risks and benefits.

Answer: The client's consent may have been coerced. Informed consent requires that the choice is freely given. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced (A) based on family pressure. (B, C, and D) are not accurate.

The healthcare provider discontinues prednisone, a glucocorticoid, for a client with chronic obstructive pulmonary disease. What instructions should the nurse give the client about the regimen to follow? A. The dose must be tapered over the course of 7 to 10 days. B. Another glucocorticoid should be used to prevent cross-tolerance. C. Life-long treatment is common for chronic disease. D, The drug should be stopped immediately if no longer needed.

Answer: The dose must be tapered over the course of 7 to 10 days. To minimize the impact of adrenal insufficiency, withdrawal of exogenous glucocorticoids should be done by gradually decreasing the dosage over several days (C). Prolonged treatment with a glucocorticoid is not indicated for life (A) and can cause life-threatening adrenal insufficiency if abruptly terminated (B). Tapering the dosage should be done rather than substituting another glucocorticoid (D).

A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? A. We don't really know what or when CHDs occur. B. The heart develops in the third to fifth weeks after conception. C. They usually occur in the first trimester of pregnancy. D. It depends on what the causative factors are for a CHD.

Answer: The heart develops in the third to fifth weeks after conception. The cardiovascular system is the first organ system to develop and function in the embryo. The blood vessel and blood formation begin in the third week, and the heart is developmentally complete in the fifth week (D). Regardless of the etiological factor, the heart is vulnerable during its period of development -- the third to fifth weeks. (A, B, and C) are inaccurate.

A single-parent mother brings her 3-year-old daughter to the emergency department after the child fell off a playground swing at school and hit her head. Which finding should prompt the nurse to advocate for continued hospital observation of the child instead of discharging the child to care at home? A. The mother states they do not have the money to pay for transportation home. B. The child had a 10 second loss of consciousness immediately after the fall. C. The mother is slurring her words and is not attentive to discharge instructions. D. The child indicates that she is tired and wants to take a nap.

Answer: The mother is slurring her words and is not attentive to discharge instructions Having a responsible adult to make on-going observations is the most important criteria for discharging anyone to their home after a head injury. The child (who needs observation) should not go home with an impaired adult (C). Alternative arrangements can be made regarding the follow-up care (A). The events of the head injury do not necessarily indicate the need for hospitalized observation (B). It is normal to be drowsy after a concussion (D); immediate intervention is needed if the child cannot be aroused from sleep.

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. The nurse assigned to care for the client who was at lunch at the time of the fall. B. The nurse who transferred the client to the chair when the fall occurred. C. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. D. The charge nurse who completed rounds 30 minutes before the fall occurred.

Answer: The nurse who transferred the client to the chair when the fall occurred. The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D).

The nurse is reviewing the use of the patient-controlled analgesia (PCA) pump with a client in the immediate postoperative period. The client will receive morphine 1 mg IV per hour basal rate with 1 mg IV every 15 minutes per PCA to total 5 mg IV maximally per hour. What assessment has the highest priority before initiating the PCA pump? A. The expiration date on the morphine syringe in the pump. B. The type of anesthesia used during the surgical procedure. C. The client's subjective and objective signs of pain. D. The rate and depth of the client's respirations.

Answer: The rate and depth of the client's respirations. A life-threatening side effect of intravenous administration of morphine sulfate, an opiate narcotic, is respiratory depression (B). The PCA pump should be stopped and the healthcare provider notified if the client's respiratory rate falls below 12 breaths per minute, and the nurse should anticipate adjustments in the client's dosage before the PCA pump is restarted. (A, C, and D) provide helpful information, but are not as high a priority as the assessment described in (B).

After abdominal surgery, a male client is prescribed low molecular weight heparin (LMWH). During administration of the medication, the client asks the nurse why he is receiving this medication. Which is the best response for the nurse to provide? A. This medication enhances antibiotics to prevent infection. B. This medication dissolves any clots that develop in the legs. C. This medication is a blood thinner given to prevent blood clot formation. D. This abdominal injection assists in the healing of the abdominal wound.

Answer: This medication is a blood thinner given to prevent blood clot formation Unfractionated heparin or low molecular weight heparin (LMWH) is an anticoagulant that inhibits thrombin-mediated conversion of fibrinogen to fibrin and is given prophylactically to prevent postoperative venous thrombosis (A) or to treat pulmonary embolism or deep vein thrombosis following knee and abdominal surgeries. Heparin does not dissolve clots but prevents clot extension or further clot formation (C). The anticoagulant heparin does not prevent infection (B) or influence operative wound healing (D).

A registered nurse (RN) is caring for several clients on a progressive care "step-down" unit. After assessing the clients, which clerical task should the nurse assign to a unlicensed assistive personnel (UAP)? A. Record the presence of blood-tinged urine and the hourly Foley output on the flow sheet. B. Document the type and amount of drainage on a new surgical dressing in the progress note. C. Transcribe the vital signs from a unit worksheet to the individual graphic page in the client charts. D. Chart pulse oximeter readings and type of breath sounds auscultated in the medical record.

Answer: Transcribe the vital signs from a unit worksheet to the individual graphic page in the client charts. Recording the vital signs on the graphic record (D) does not entail assessment or evaluation of the findings, so the UAP may perform this function. RNs may not delegate assessment or documentation responsibilities to UAPs. RNs must complete assessment activities and record findings in the medical record. The RN is responsible for including the evaluation of the vital signs in the nursing assessment. (A, B, and C) include activities that are within the scope of practice for the RN, but cannot be delegated to the UAP.

The registered nurse (RN) and unlicensed assistive personnel (UAP) are working together to provide care for a bedfast client needing total care, medications, and Foley catheter irrigation. How should the RN assign the client's care? A. UAP: Personal care, catheter irrigation, I&O. RN: Medications. B. UAP: Catheter irrigation, I&O. RN: Medications. Both provide personal care. C. UAP: Personal care, I&O. RN: Catheter irrigation, medications. D. UAP: Personal care. RN: Medications, catheter irrigation, I&O.

Answer: UAP: Personal care, I&O. RN: Catheter irrigation, medications. The RN is responsible for medication administration and sterile procedures such as catheter irrigation. The UAP is qualified to provide personal care and measure I&O. Based on these management concepts (D) provides the best assignment of the client's care.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. After instruction, the nurse will ensure the client understands foot care rationale. B. The nurse will provide client instruction for daily foot care. C. Upon discharge, the client will list three ways to protect the feet from injury. D.The client will demonstrate proper trimming toenail technique.

Answer: Upon discharge, the client will list three ways to protect the feet from injury. An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. (C) is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or more of these elements.

The nurse-manager observes that a staff nurse consistently fails to complete assigned care for clients who are obese. When counseling this employee, what issue is the priority concern? A. Reduction of client complaints. B. Dissatisfaction of co-workers. C. Poor time management skills. D. Violation of ethical principles.

Answer: Violation of ethical principles. The priority concern is the lack of fair and equal treatment of obese clients assigned to this staff nurse for care. This reflects a violation of the ethical principle of justice (A). Counseling the nurse about (B) is important because using time effectively allows the nurse to ensure that all clients receive fair and equal treatment, but this is of less concern than (A). (C and D) may also be important concerns, but they are secondary to ensuring justice.

The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "Yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother? A. Paddle him gently as soon as the behavior is initiated. B. Walk away from him and ignore the behavior. C. Quietly remind him that others are watching him. D. Immediately put him in "time-out."

Answer: Walk away from him and ignore the behavior. The best approach for a toddler is to ignore the attention-seeking behavior (D). The parent should be somewhat nearby, within view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs. (A, B, and C) would all provide attention for the inappropriate behavior.

When conducting a hygiene class for adolescent girls, it is important for the nurse to include which instruction about preventing toxic shock syndrome? A. Douche every month following menstruation. B. Wash your hands before inserting a tampon. C. Use super absorbent tampons. D. Wear cotton underwear.

Answer: Wash your hands before inserting a tampon The single most effective means of preventing infection is handwashing (A). (B and D) are contraindicated. (C) is not related to prevention of toxic shock syndrome.

The nurse is caring for a client who had an excision of a malignant pituitary tumor. Which findings should the nurse document that indicate the client is developing syndrome of inappropriate antidiuretic hormone (SIADH)? A. Increased urinary output and thirst. B. Hypernatremia and periorbial edema. C. Weight gain with low serum sodium. D. Muscle spasticity and hypertension.

Answer: Weight gain with low serum sodium. SIADH most frequently occurs when cancer cells manufacture and release ADH, which is manifested by water retention causing weight gain and hyponatremia (C). Other manifestations include oliguria, weakness, not (A, B, and D), anorexia, nausea, vomiting, personality changes, seizures, decrease in reflexes, and coma.

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that A. only an RN should be assigned to monitor this child's temperature. B. a tympanic measurement of temperature will provide the most accurate reading. C. the licensed practical nurse should be instructed to obtain rectal temperatures on this child. D. the healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.

Answer: a tympanic measurement of temperature will provide the most accurate reading. (B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management--sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary

A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because A. they occur in healthy young adults who have recently been debilitated by an upper respiratory infection. B. gram-negative organisms are more resistant to antibiotic therapy. C. they occur in the lower lobe alveoli which are more sensitive to infection. D. gram-negative pneumonias usually affect infants and small children.

Answer: gram-negative organisms are more resistant to antibiotic therapy. The gram-negative organisms are resistant to drug therapy (B) which makes recovery very difficult. Gram-negative pneumonias affect all lobes of the lung (C). The mean age for contracting this type of pneumonia is 50 years (A and D), and it usually strikes debilitated persons such as alcoholics, diabetics, and those with chronic lung diseases.

An antacid (Maalox) is prescribed for a client with peptic ulcer disease. The nurse knows that the purpose of this medication is to A. maintain a gastric pH of 3.5 or above. B. decrease gastric motor activity. C. produce an adherent barrier over the ulcer. D. decrease production of gastric secretions.

Answer: maintain a gastric pH of 3.5 or above The objective of antacids is to neutralize gastric acids and keep pH of 3.5 or above (C) which is necessary for pepsinogen inactivity. (A) is the purpose of H2 receptor antagonists (cimetidine, ranitidine). (B) is the purpose of sucralfate (Carafate). (D) is the purpose of anticholinergic drugs which are often used in conjunction with antacids to allow the antacid to remain in the stomach longer.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's A. blood pressure is 104/68. B. serum digoxin level is 1.5. C. serum potassium level is 3. D. apical pulse is 68/min.

Answer: serum potassium level is 3. Hypokalemia (C) 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); (B) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. Which question is a priority for the nurse to ask this client or her family on admission? "Does the client A. have her own teeth or dentures?" B. take aspirin and if so, how much?" C. take nitroglycerin?" D. take digitalis?"

Answer: take digitalis?" Elderly persons are particularly susceptible to digitalis intoxication (D) which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Although it is important to obtain a complete medication history (B and C), the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. (A) is irrelevant.

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's A. blood pressure, both standing and sitting. B. temperature. C. pulse rate, both apically and radially. D. skin color and turgor.

Answer: temperature It is very important to check the client's temperature (B). Infection is the most common factor precipitating respiratory distress. Clients with COPD who are on maintenance doses of corticosteroids are particularly predisposed to infection. (A and C) are important data for baseline and ongoing assessment, but they are not as important as temperature measurement for this client who is taking steroids. Assessment of skin color and turgor is less important (D).

The father of an 8-year-old tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father? A. The father should decrease his expectations to give the son a chance to succeed. B. The child has an introverted personality and should be encouraged to play isolated games. C. The child should be given opportunities to achieve a sense of competency in an area he chooses. D. The father should encouraged the son to participate in team sports instead of less physical activities.

Answer:The child should be given opportunities to achieve a sense of competency in an area he chooses. According to Erickson, the developmental stage "Industry versus inferiority" builds feelings of confidence, competence, and industry if there is achievement in an area of interest. If a child believes that he or she cannot measure up to society's expectations, the child loses confidence and may not find pleasure in the activity. Children should be encouraged to do the things they enjoy and succeed in (D). The father does not need to decrease his expectations (A), but should be encouraged to shift the expectation to an activity the child takes pleasure in. (B) does not encourage autonomy. (C) can cause a feeling of inadequacy.