HESI practice ?s II (AH III)

A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become addicted to paint fumes?" What is the best response for the nurse to provide? "Only hard drugs like cocaine and heroin can cause problems with addiction." "Tell me what you think may have caused him to start inhaling paint fumes." "Abuse of any of the inhalants can eventually lead to addiction." "Any time you use an illegal substance, you are abusing drugs."

"Abuse of any of the inhalants can eventually lead to addiction." Rationale Any inhalant can become addictive. Any substance that is used to alter perception can be addictive and is not limited to the common street drugs.

A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct? "An antibiotic ointment is placed in each newborn's eyes to prevent infection." "Conjunctivitis neonatorum is common in newborns." "This type of question should be discussed with your pediatrician." "Most infants have drainage from their eyes which usually resolves within 2 to 3 days of life."

"An antibiotic ointment is placed in each newborn's eyes to prevent infection." Rationale Antibiotic ointments, such as erythromycin ointment, are placed in the lower conjunctiva of each eye to prevent chlamydia and gonorrhea.

Yesterday a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional? "I really wish that my birthday wasn't so soon." "I don't talk about things like that anymore." "The doctor won't talk with me about this." "I think I should talk about this in group."

"I don't talk about things like that anymore." Rationale When the client states that she doesn't want to talk about things like that anymore, she is likely less delusional, because when a client begins to question the delusional belief or stops talking about it, the client is becoming less delusional.

A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response? "You need to stop thinking negative thoughts. They get in the way of your recovery." "You are no bother to me or to the staff. We want you to get well and not feel sad anymore." "I have known many clients with depression who have felt better after several weeks of treatment." "You are feeling very pessimistic, but that is part of your illness. It should go away as you recover."

"I have known many clients with depression who have felt better after several weeks of treatment." Rationale Stating the observation that others have recovered can give a client hope. Telling a person to stop negtive thinking is ineffective because the client must be taught cognitive strategies to stop negative thinking. Stating the person is "no bother" is arguing with the client's beliefs and attempting to tell him how to feel, both of which are not therapeutic responses. Bring up pessimistic feelings interprets the client's feelings and does not provide the same degree of hope.

A graduate nurse (GN) tells the RN preceptor, "I need to insert a nasogastric tube, and though I was checked off on this procedure in my nursing school's simulation lab, I have never inserted one on a real person." How should the preceptor respond? "I must see documentation of successful check-off by your school's instructor." "Performing the procedure on a simulator is different from performing it on a real person." "Let's review the procedure, then I will supervise you while you perform the procedure." "I will help you, but we need to inform the client that you are new at doing this."

"Let's review the procedure, then I will supervise you while you perform the procedure." Rationale Reviewing the procedure with the GN allows the preceptor to assess the GN's knowledge of the procedure, and supervising this first-time procedure is the safest option for the client. Documentation of a simulated experience does not negate the need to supervise the GN's first experience. The GN is already aware of the difference of performing the skill on a real person, which is why the issue was presented to the preceptor. Informing the client that the nurse is new at performing the procedure is not necessary, but reviewing the procedure and supervising the GN is necessary.

During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond? "Tell me about the drugs you use now." "Explain what you mean by many drugs." "Do you mean legal drugs or illegal ones?" "What kind of drugs are you talking about?"

"Tell me about the drugs you use now." Rationale Open-ended questioning allows the client provide specific information without probing. Asking the person to explain what drugs they are taking is critical of the client's descriptors and does not encourage further dialog. Asking about legal vs. illegal drugs or "kind of drugs" both are close-ended questions that require one word responses, and stop further exploration with the client.

The nurse calculates the mean arterial pressure (MAP) for a client whose blood pressure is 152/90. What is the MAP in mm Hg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

111 Rationale MAP is calculated by adding the systolic pressure to twice the diastolic pressure and dividing by 3. 152 + 180 = 332 3 = 110.66 = 111 mm Hg

A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another singleton at 35-weeks gestation. How should the nurse record her gravity and parity using the GTPAL system? 3-0-3-0-3. 3-1-1-1-3. 4-1-2-0-4. 4-2-1-0-3.

4-1-2-0-4. Rationale Using the GPTAL system is the correct record of gravity and parity. G reflects the total number of times the woman has been pregnant; she is pregnant for the 4th time. T indicates the number of pregnancies carried to term, not the number of deliveries at term; she has had only one pregnancy after 37-weeks gestation. P is the number of pregnancies that resulted in a preterm birth, not the number of infants born; she has had two pregnancies before 37-weeks gestation. A signifies elected abortions or miscarriages prior to the period of viability (20-weeks). L signifies the number of children born that are currently living.

A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid replacement at 20 ml/kg. How many ml should the nurse administer? (Enter numeric value only.)

400 Rationale Isotonic crystalloid solution (normal saline or lactated Ringer's solution) is usually the first choice for fluid replacement in children and is given in IV boluses of 10 to 20 ml/kg over 10 to 15 minutes and repeated as necessary. First convert the pounds to kg, then multiply by 20 ml. 44 pounds 2.2 pounds/kg = 20 kg 20 ml = 400 ml.

A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? (Enter numeric value only.)

90 Rationale The angle for needle insertion when performing intramuscular injections is 90 degrees.

The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit? An older client with end-stage cirrhosis who had a liver biopsy 4 hours ago. A client scheduled for a femoro-popliteal bypass surgery tomorrow. A middle-aged client with acute pancreatitis and lower left quadrant pain. A female client with angina and ectopy noted on the telemetry monitor.

A client scheduled for a femoro-popliteal bypass surgery tomorrow. Rationale The client with an elective surgical procedure can be rescheduled for a later date so is considered stable enough to be discharged. A client with a recent biopsy is not stable for discharge as the procedure can result in bleeding due to the high vascularity of the liver. A client with acute pancreatitis is unstable, in acute pain, and at risk for rupture of diverticula. A client with rhythm irregularities has a life-threatening condition because of the risk for ventricular tachycardia.

The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN? A client receiving Lactated Ringer's solution requests pain medication. A client with a history of falls needs assistance to the bathroom. A client's indwelling urinary catheter requires manual irrigation. A client with an epidural infusion reports lower extremity parasthesia.

A client with an epidural infusion reports lower extremity parasthesia. Rationale Assessment of possible adverse effects of an epidural infusion should be performed by the RN, who has the expertise to evaluate the significance of the assessment data. The other options are skills that can be delegated to the PN.

A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client? A negative pressure room. A semi-private room on a surgical unit. A postpartum room in the birthing center. A private room on a medical unit.

A private room on a medical unit. Rationale To protect others from contamination, the nurse should assign this client to a private room. Isolation room is not indicated(A) is an isolation room used for clients with TB. (B) should not be assigned because of the possibility of cross-contamination by the infected client. (C) should not be assigned because the OB unit is considered "clean."

When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention.

A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. Rationale A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs.

The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? An older man who is always happy and chooses to view only the good in every situation. A single mother who seeks the support of her two teenage daughters during difficult times. A successful businessman who is accustomed to handling highly-stressful situations. A teacher who seeks information about her disease and wants to continue teaching.

A teacher who seeks information about her disease and wants to continue teaching. Rationale Those who seek information about their disease while attempting to carry on with their lives as best they can are likely to handle the diagnosis of cancer best. Those who use repression to deal with traumatic events often have difficulty expressing their feelings. Depending on children for support, especially when the children are teenagers, may be disappointing. Someone who is used to handling high-stress situations is used to being in control, and control over a life-threatening diagnosis is not always possible.

A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client? A terminally ill and depressed client with cancer. A client who is planning to have an elective abortion. A suicidal client who has made a highly-lethal attempt. A client who refuses a blood transfusion due to religious beliefs.

A terminally ill and depressed client with cancer. Rationale A nurse who believes in the sanctity of life may find it difficult to relate to individuals who do not place the same high level of value on life. Clients with cancer, who have not made a conscious decision to end their lives, are most likely to be easily understood by this nurse.

Which client requires the most immediate intervention by the nurse? A client with low back pain who is experiencing tolerance to the effects of an analgesic. An adolescent with a history of drug addiction who is requesting a sedative. A client with a chronic renal disease who is demonstrating a therapeutic response to a diuretic. A young adult who is reporting an anaphylactic response to an antibiotic.

A young adult who is reporting an anaphylactic response to an antibiotic. Rationale An anaphylactic response is a severe allergic reaction that may result in airway constriction and shock, so the nurse should first respond to this potentially life-threatening situation.

A newborn is brought to the admissions nursery by the nurse and the father of the baby. The baby weighs 9 pounds 3 ounces and measures 21 inches head to toe. Which description is a correct assessment of this infant? Above average in weight but average in length. Above average in weight and length. Above average in weight but below average in length. Macrosomia with an average length.

Above average in weight but average in length. Rationale The baby is above the average weight of 7 pounds. The average newborn length ranges from 18 to 21 inches, so the baby is in the upper limit of average length.

A young adult female is brought to the emergency room by family members who report that she ingested a large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented? IV administration of Narcan. Syrup of ipecac per nasogastric tube. Acetylcysteine (Mucomyst) 140 mg/kg. Gastric lavage with normal saline.

Acetylcysteine (Mucomyst) 140 mg/kg. Rationale Mucomyst is the antidote for acute acetaminophen (Tylenol) poisoning and is the treatment of choice for an overdose.

When assessing a client's interior eye structures with an ophthalmoscope, which action should the nurse use? Use a red-free filter. Adjust the diopters. Direct a wide-beam light. Dilate the client's pupils.

Adjust the diopters. Rationale The diopter corresponds to the magnification power of the ophthalmoscope's lens, which is adjusted to bring the retina into focus when a client's error of refraction, such as myopia or hyperopia, causes a change in the eyeball shape. Using a red-free filter produces a green beam for examination of the optic disc for pallor and recognition of retinal hemorrhages. The direct wide-beam light is used to examine the anterior eye. The application of an ophthalmic mydriatic should be instilled prior to extended fundoscopic visualization.

The charge nurse, along with another RN and a practical nurse (PN) are caring for clients on a medical/surgical unit. Which nursing action should be assigned to the PN? Assist a client to look at the colostomy stoma for the first time. Access a central venous catheter via an implanted port. Develop a teaching plan for a client with rheumatoid arthritis. Administer a bolus tube feeding through a gastrostomy tube.

Administer a bolus tube feeding through a gastrostomy tube. Rationale Administration of a bolus tube feeding through a gastrostomy tube is a skill that can be safely performed by the PN. Looking at a stoma for the first time requires support from the RN, who has greater expertise in client teaching and emotional support than the PN. Accessing an implanted port is beyond the scope of practice of the PN. The PN can reinforce initial teaching presented by the RN, but should not be assigned to develop a teaching plan.

Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse? An adult who had a colon resection yesterday and has an IV. An older adult who has a fever of unknown origin. A woman who had an acute brain attack (stroke, CVA) 6 hours ago. A teenager with a femoral fracture who is in traction.

An adult who had a colon resection yesterday and has an IV. Rationale An OB nurse is usually experienced in caring for abdominal surgical wounds (cesarean sections) and IV infusions, so the adult who had a colon resection would be the best choice. The nurse should not knowingly be exposed to infectious organisms since OB is considered a "clean area," and the nurse will be returning to work on the OB unit. Ordinarily, OB nurses are not experienced in assessing and managing care for stroke victims or clients who are in traction.

During the initial home visit, the nurse performs a family assessment. Which component is most important for the nurse to consider? The legal definition of family in the United States. Members of the group that are direct descendents or bonded by marriage. An exploration of the group relationships, structure, functions, and roles. Cultural differences among members of the extended family.

An exploration of the group relationships, structure, functions, and roles. Rationale Part of understanding an individual is determining the family members' relationships, functions, and roles with one another in the group structure. Although the other options provide additional data about the family members' relationships, the functions of the members in the group provides clarification about decision making and responsibilities.

Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)? An older client with intestinal obstruction and septic shock. A near-drowning victim with a history of respiratory arrest. An adolescent with an autoimmune disease. An adult male with a myocardial infarction and pericarditis.

An older client with intestinal obstruction and septic shock. Rationale High risk clients vulnerable for MODS include older clients with decreased organ reserve, comorbidities, and massive inflammatory or immune dysfunction, such as septic shock, or clients who have experienced various ischemia-reperfusion events related to trauma or surgical complications. Although acute respiratory failure, respiratory arrest, or myocardial infarction may be precursors to MODS, additional complications usually precipitate the pathological cascade of hypermetabolism and excessive production of inflammatory and biochemical mediators that cause widespread organ damage. An adolescent with autoimmune disease is at risk for MODS only if complications such as massive infection, respiratory failure, or cardiac arrest occur.

When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? Place a sterile drape under the client's buttocks. Instruct the client to inhale and then exhale slowly. Discard the gloves and apply new sterile gloves. Apply a sterile lubricant to the end of the catheter.

Apply a sterile lubricant to the end of the catheter. Rationale After testing the balloon for patency, the nurse should next lubricate the end of the catheter. The sterile drape should already be positioned under the client's buttocks. The client is instructed in breathing just prior to insertion.

A nurse is caring for a male client with paranoid schizophrenia who believes that his antipsychotic medications are poison. Which intervention is best for the nurse to implement? Describe the need for consistently taking medications. Offer the medication in a concentrated form. Discard the medication and document the client's refusal. Approach the client with the medication 30 minutes later.

Approach the client with the medication 30 minutes later. Rationale Delusions of persecution and fear of being controlled by others are characteristic of those with paranoid schizophrenia, but these feelings fluctuate, and in 30 minutes the client may be willing to take the medications.

When culturing a wound, the nurse should obtain the sample from which part of the wound? The outer edges of the wound. All necrotic sections of the wound. Areas containing purulent or pooled exudates. Any particularly painful area of the wound.

Areas containing purulent or pooled exudates. Rationale To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions, then return the swab to the culturette tube, cap the tube, and crush the inner ampoule so that the medium for the organism growth coats the swab.

A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? Dismiss the staff nurse's report about the float nurse because it may be just gossip. Call the nursing supervisor and request a different employee be sent to the unit. Assign the float nurse to function as an unlicensed assistive personnel (UAP) for the day. Arrange for someone to be available to assess and assist the float nurse.

Arrange for someone to be available to assess and assist the float nurse. Rationale The float nurse is receiving education, but careful assessment of her/his skills and assistance, as needed, is still warranted, so assigning a mentor is the best choice. Though the staff member's report may indeed be gossip, failure to pay attention to the information about medication erorrs could constitute negligence on the part of the charge nurse.

Which action should the nurse implement when implementing a physical assessment of an older client? Avoid unnecessary touching while interacting with the client. Apply additional pressure to palpate the hepatic edge. Arrange the exam sequence to minimizes position changes. Speak loudly and slowly when telling the client how to assist.

Arrange the exam sequence to minimizes position changes. Rationale Adaptations of the physical examination sequence that limits the amount of position changes during the exam are often useful for an older adult who may have age-related problems, such as decreased mobility, limited energy, or perceptual changes.

An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first? Counsel the girl regarding hygiene. Ask if she is going to the bathroom frequently. Teach the girl the importance of practicing safe sex. Encourage the girl to see the school counselor.

Ask if she is going to the bathroom frequently. Rationale The nurse should ask questions directed toward symptoms of diabetes. Recurrent vaginal and urinary tract infections are often an early sign of diabetes.

The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement? Limit visitors to immediate family to decrease exposure to infection. Maintain "clean" technique in the change of wound dressing and IV site. Assess and document skin condition around the incision and IV site at each shift. Require the use of a face mask by staff when providing care requiring close contact.

Assess and document skin condition around the incision and IV site at each shift. Rationale Early identification of infection leads to prompt treatment and decreased nosocomial transmission to others, so the condition of any invasive lines or breaks in the skin should be assessed and documented during each shift.

The nurse is informed that a client is returning to the unit from the post-anesthesia care unit following abdominal surgery. Which task is best to delegate to the unlicensed assistive personnel (UAP)? Assess breathing pattern after transport is completed. Notify the family that the client is returning from surgery. Report to the charge nurse the appearance of the dressing. Assist the transport team with transferring the client to the bed.

Assist the transport team with transferring the client to the bed. Rationale The UAP can be assigned to assist with transferring the client from the gurney to the bed since repositioning following abdominal surgery is not a high-risk intervention and does not require nursing judgment. Assessing breath sounds requires judgment and should be performed by a licensed person. Notifying family should be done by the nurse who may provide additional information if requested. The nurse should directly observe the dressing and should not rely on the UAP's assessment of the dressing's appearance.

A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question? Morphine sulfate 5 mg IV on call to operating room. Atropine sulfate 0.4 mg IM on call to operating room. Betaxolol (Betoptic) one drop in each eye the morning of surgery. Benzodiazepine (Valium) 5 mg by mouth the morning of surgery.

Atropine sulfate 0.4 mg IM on call to operating room. Rationale Many ophthalmic agents used to reduce intraocular pressure (IOP) in glaucoma cause miosis, which increases the outflow of aqueous humor. Atropine is an anticholinergic agent that causes mydriasis, which can increase IOP and counteracts the action of β-blocking agents, so Atropine prescription should be brought to the attention of the healthcare provider.

Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first? Assess the client's current oxygen saturation level. Auscultate the client's breath sounds bilaterally. Prepare to administer a dose of naloxone (Narcan) IV. Attempt to arouse the client to stimulate respirations.

Attempt to arouse the client to stimulate respirations. Rationale The nurse should first attempt to stimulate respirations by arousing the client. This measure is noninvasive and may produce an immediate increase in respiratory rate. If this action is unsuccessful, the nurse should then implement the other options listed.

The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the mother's lap, chewing on a toy. Which action should the nurse implement first? Elicit reflexes. Auscultate heart and lungs. Examine eyes, ears, and mouth. Take an axillary temperature.

Auscultate heart and lungs. Rationale The sequence for physical examination in a quiet child begins with auscultation of heart and lungs to enable the nurse to hear the breath and heart sounds clearly.

Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse implement? Avoid any intramuscular medications to prevent localized bleeding. Have vitamin K available in the event the client begins to bleed. Notify the healthcare provider if the partial thromboplastin time is greater than 50 seconds. Start instruction for self-administered SC heparin injections for long-term home therapy.

Avoid any intramuscular medications to prevent localized bleeding. Rationale Bleeding precautions for a client receiving anticoagulant treatment include minimizing IV punctures and avoiding IM injections. Heparin inactivates prothrombin and prevents the formation of thromboplastin, which is monitored by the serum PTT results (normal range between 60 and 70 seconds) during heparin therapy.

An older adult client begins wearing binaural hearing aids due to presbycusis. Which instruction should the nurse provide to assist the client in adapting to the new hearing aids? Begin wearing the aids in quiet environments to experiment with adjustments. Wear the hearing aids for an hour a day at first, gradually increasing the time. Keep the volume on low until the conditions with noises are audible. Use one hearing aid until comfortable, then add the second aid.

Begin wearing the aids in quiet environments to experiment with adjustments. Rationale Initially, the use of hearing aids should be restricted to quiet situations in the home. As adjustments occur, the client should gradually be exposed to conditions with background noise and the outdoors. Time restriction is not necessary.

The new parents express concern that they did not have the opportunity to hold and bond with their infant immediately after birth because the mother received anesthesia during an emergency cesarean delivery. What information should the nurse provide? The baby is healthy and they should not worry about the delay between birth and their first visit. Early contact is essential for optimum parent-infant relationships. The time immediately after birth is the critical period for human attachment. Bonding is a process that occurs over time and begins with the first parent-newborn contact.

Bonding is a process that occurs over time and begins with the first parent-newborn contact. Rationale Bonding is a gradual emotional process and begins when the parents first make contact with the infant. It does not have to begin in the first minutes after birth. Telling the parents not to worry since their child is healthy dismisses their concerns. The time immediately after birth is not a critical period for human attachment, but telling the parents otherwise is not indicated and may increase their anxiety.

What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply.) Select all that apply White patches. Cherry angiomas. Border irregularity. Lesion with asymmetry. Lesion with color variations. Lesion of 3 to 5 mm diameter.

Border irregularity. Lesion with asymmetry. Lesion with color variations. Rationale ABCDE is the acronym used by the American Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin cancer: A for asymmetry of the lesion; B for irregular border; C for color, usually dark; D for diameter equal to or greater than 6 mm; and E for elevation. A lesion with any of the characteristics of ABCDE should be evaluated by a healthcare provider. Lesions that lack the color variable, are raised, dome-shaped, or benign clusters of blood vessels that do not require treatment. Lesions of 3 to 5 mm diameter are small and may be monitored instead of treated.

A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's first action? Hyperextend the client's neck. Call for emergency assistance. Document the finding as a normal expectation. Reassure the client that the voice change is temporary.

Call for emergency assistance. Rationale Stridor upon exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema postoperatively. In life-threatening complications, such as respiratory obstruction or bleeding, a call for emergency assistance should be made first in the event intubation is required. Extending the clients neck is contraindicated. Although documentation is necessary, a stridor or voice change are indicators of early airway compromise.

The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding perianal care is effective? Soaks in a sitz bath for 40 minutes after each diarrhea stool. Takes prescribed antidiarrheal medication after each diarrhea stool. Applies witch hazel compresses to provide relief from anal irritation. Cleans perianal area with mild soap and water after each diarrhea stool.

Cleans perianal area with mild soap and water after each diarrhea stool. Rationale To remove bacteria, provide comfort, stimulate circulation, and prevent skin breakdown, the client is demonstrating effective perianal care when the perianal area is cleansed after each bowel movement with mild soap and warm water, and then dried thoroughly.

The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? Page the unit manager to address the situation. Close the demographic screen on the computer. Instruct the UAP to end the phone call immediately. Send a UAP into the client's room to relieve the nurse.

Close the demographic screen on the computer. Rationale The priority is for the charge nurse to close the computer screen, so the health information stored in computerized systems is secured because it is considered to be Protected Health Information (PHI) under HIPAA (Health Insurance Portability and Accountability Act).

After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers that the oxygen tank that was attached to the oxygen supply was empty during the transport. What action should the flight nurse take? Replace the empty tank without reporting the situation to any members of the agency. Complete an adverse occurrence report and submit it to the nurse-manager. Send an anonymous letter explaining the situation to the family of the client. Advise the flight crew of the situation, then suggest that no further discussion be held.

Complete an adverse occurrence report and submit it to the nurse-manager. Rationale A medication error occurred, so an adverse occurrence report should be completed and submitted to the nurse-manager for evaluation of the situation, so that measures can be implemented to prevent a repeat of the occurrence.

The nurse asks an older female client with cognitive impairment who has been hospitalized for three days how her previous evening was. The client replies, "I had the best time. My husband took me out to dinner and then to a concert. The music was wonderful." Which term should the nurse document to best describe the client's response? Delusions. Confabulation. Concretization. Circumstantiality.

Confabulation. Rationale Confabulation describes the client's story that is made-up to fill in the gaps of memory when one is unable to remember something that might have happened.

Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa? Improve the client's body perception. Consume at least 50% of all meals. Exercise no more than one hour daily. 5% decrease in serum potassium levels.

Consume at least 50% of all meals. Rationale An outcome statement should be measurable and provide observable behaviors that indicate the client's problem is resolving. Self-starvation is the major problem associated with anorexia nervosa, so stating the person should consuming 50% of diet should be included in this client's plan of care. "Improve bosy perception" is vague and not measurable. Adolescents with anorexia nervosa often obsessively exercise to lose additional weight, so defining exercise time limits may be excessive. Clients with anorexia have an increased risk for hypokalemia, so decreasing serum potassium levels is an inappropriate goal for this client.

During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention should the nurse implement? Prepare a written schedule to remind the client when to take each dose of aspirin. Observe the client place each dose in the correct boxes of her pill container. Contact the client's healthcare provider to report the assessment findings. Ask a family member to ensure that the client takes the medication as prescribed.

Contact the client's healthcare provider to report the assessment findings. Rationale Tinnitus and confusion are both signs of aspirin toxicity, which is consistent with the high dose of aspirin that the client is taking. The healthcare provider should be notified of the symptoms to determine further treatment. The other choices will likely increase the client's symptoms of toxicity.

A healthcare provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? Write the correct prescription as a verbal order received from the healthcare provider. Correct the misspelled medication in the written prescription and initial the change. Consult with the pharmacist to determine the best medication for the client. Contact the healthcare provider to clarify the prescription intended for the client.

Contact the healthcare provider to clarify the prescription intended for the client. Rationale Since the nurse received contradictory information, the provider should be contacted to clarify the intended prescription othewise it may result in a medication error. The nurse does not have the authority to alter prescriptions. The pharmacist cannot determine the best medication for a client.

While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client makes little direct eye contact, is deferential to healthcare personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? Continue the interview process and record the findings. Refer the client to a psychiatric outpatient clinic. Determine if there is a family history of emotional disorders. Encourage the woman to attend citizenship classes.

Continue the interview process and record the findings Rationale The nurse should accept these behaviors as culturally determined and continue with the interview. These behaviors are common in the Chinese culture where people are members of strong, cohesive groups that focus on the group rather than the individual.

While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first? Unexplained weight gain. Current hair care practices. Family history of alopecia. Absence of axillary hair.

Current hair care practices. Rationale Dry and brittle hair may be a result of hair treatments such as hair dyes, rinses, permanents, straighteners, or frequent blow-drying. Although an unexplained weight gain could be related to hypothyroidism, which causes hair to become dry and brittle, assessing current hair care practices should be determined first because of the prevalent use of cosmetic products. Next, a family history of alopecia and absence of axillary hair should be assessed to identify other problems contributing to hair abnormalities, such as nutritional deficiencies, endocrine dysfunction, or genetic predisposition.

The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement? Prepare for intubation. Defibrillate at 200 joules. Insert intravenous catheter. Obtain arterial blood gases.

Defibrillate at 200 joules. Rationale After confirming ventricular fibrillation, rapid defibrillation is critical in re-establishing cardiac output and preserving vital organ function. After CPR is initiated and defibrillation attempted, airway intubation and intravenous access are indicated for successful resuscitation. Arterial blood gases are obtained during or after resuscitation to determine medical management for metabolic acidosis which occurs secondary to anaerobic glycolysis during VF or cardiac arrest.

Which responsibility best describes the role of a nurse as manager? Development of long range career goals. Maintenance of harmony within the agency. Assignment of nursing personnel and resources. Delivery of client care while meeting agency goals.

Delivery of client care while meeting agency goals. Rationale The nurse manager is accountable for organizing direct and indirect client care functions that necessitate delegation and assignment to competent unit staff, personnel management, quality improvement of client care, and system coordination to achieve agency goals. The other options are all components of professional nursing practice.

A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first? Flush the catheter to maintain patency of the CVC access. Describe the placement and rationale for care of the catheter. Reassure the client that the TPN administration is temporary. Provide passive range of motion to the right arm and neck.

Describe the placement and rationale for care of the catheter. Rationale A client's anxiety or fear about a treatment or procedure is commonly the result of a lack of knowledge, so providing information, such as drawings or pictures, and explanations about the catheter, may help the client understand the catheter's function and decrease his anxiety regarding its presence.

To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication? Review the client's fasting blood glucose levels for a hyperglycemic trend. Determine if the client has ever had a hypersensitivity reaction to penicillins. Restrict the use of dairy products in the client's diet for the next 3 weeks. Take the client's vital signs prior to the first dose and once daily for 14 days.

Determine if the client has ever had a hypersensitivity reaction to penicillins. Rationale Most individuals who have an allergy to penicillins are at risk of hypersensitivity to cephalosporins. To prevent a potential hypersensitivity reaction that could cause a life-threatening episode of anaphylactic shock, the nurse must determine if the client has a known penicillin allergy before giving the client a cephalexin (Ceclor) dose.

The nurse is preparing a teaching plan for the parents of a 3-year-old who is newly diagnosed with Duchenne muscular dystrophy (DMD). Which implementation should the nurse include in the initial teaching plan? Refer to a nutritionist for dietary management. Encourage the parents to join a grief support group. Teach the parents to suction the child's oropharynx. Develop an active range of motion (ROM) exercise schedule.

Develop an active range of motion (ROM) exercise schedule. Rationale DMD is a genetic degenerative muscular disease that results in muscle wasting, immobility, and eventual death. The initial plan of care should include active exercises to maintain muscle strength, which can prolong independence. Although obesity is a common complication of DMD that contributes to early loss of ambulation, nutritional counseling is not as essential as ROM exercises. Teaching suctioning and grief counseling are both premature at this stage in the child's illness.

A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? Use disposable plates and utensils. Stay in a room with the door closed. Dispose of soiled dressings in plastic bags that are securely closed. Others who are in the same room with the client should wear a mask.

Dispose of soiled dressings in plastic bags that are securely closed. Rationale Contact precautions require the use of a barrier that prevents contact with wound secretions on soiled dressings, which are best disposed of in tightly closed plastic bags. Disposable dishes is not necessary with contact precautions. Isolating themself to one room or wearing masks should be implemented for airborne, droplet precautions, or protective environments.

A 6-year-old boy says he does not like the food at the hospital. A review of the child's intake reveals that he has eaten very little for the past 2 days. The nurse formulates a nursing problem of, "Imbalanced nutrition, less than body requirements." What action should the nurse implement? Select nutritious foods on the menu for the child. Provide the child with any snack foods between meals. Encourage family members to bring foods from home. Arrange the child's meal tray with generous portions of food.

Encourage family members to bring foods from home. Rationale Encouraging the parents to bring familiar foods from home that the child likes should increase the child's likelihood to eat. Although selecting nutritious food from the menu gives a 6-year-old control in the selection of foods that are preferred, an adult should provide direction to ensure nutritious variation, instead of any snack or "junk" food that can curb the appetite. Children should be served smaller portions to prevent feeling overwhelmed by large portions that may be refused.

A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? Encourage the student to associate with non-smokers only while attempting to stop smoking. Tell the student that he is still young and should continue to try various smoking cessation methods. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. Provide the student with the latest research data describing the long-term effects of tobacco use.

Encourage the student to associate with non-smokers only while attempting to stop smoking. Rationale It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers.

A client has a precipitous delivery attended only by the nurse. What nursing intervention has the highest priority? Ensure an adequate airway in the newborn. Massage the uterine fundus until it is firm. Clamp and cut the umbilical cord. Assess for signs of placental detachment.

Ensure an adequate airway in the newborn. Rationale Ensuring an adequate airway in the newborn is the first intervention that should be implemented. Suctioning of secretions should be performed immediately. Airway of newborn is priority.

Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting? Promote hygiene by ensuring that children's faces and hair are kept clean. Ensure that all enrolled children have been immunized for Hepatitis A. Put a strip bandage on bleeding injuries to prevent contamination of others. Teach children the correct handwashing technique to use after toileting.

Ensure that all enrolled children have been immunized for Hepatitis A. Rationale The CDC recommended immunization schedule for children includes the hepatitis A vaccine (HAV), so follow-up of enrolled children's immunization status with HAV or human-immune gamma globulin should be implemented. Preschoolers should be taught the importance of hygiene practices, such as keeping themselves clean or correct handwashing technique, but hepatitis A is transmitted via the fecal-oral route and immunization provides the best universal protection. Hepatitis A is not transmitted through blood contact.

What is the underlying pathophysiologic process between free radicals and destruction of a cell membrane? Inadequate mitochondrial ATP. Enzyme release from lysosomes. Defective chromosomes for protein. Defective integral membrane proteins.

Enzyme release from lysosomes. Rationale Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals bind to polyunsaturated fatty acids found in the lysosome membrane, the lysosome, nicknamed "suicide bags", leaks its protein catalytic enzymes intracellularly and the cell is destroyed.Inadequate ATP production and defective protein synthesis lead to cell death either as the result of defective chromosomes or production of defective integral proteins.

A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care? Determination of the compatibility of the intravenous fluids and prescribed antibiotics. Provision of nursing staff education about safe administration of IV antibiotics. Maintenance of data related to the number of IV infiltration occurrences in the hospital. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes.

Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. Rationale The nurse may collaborate with the case manager to evaluate the need for continued IV antibiotics. The role of the case manager is to ensure desired client outcomes in a cost-effective manner. Looking at compatibilities is within the nurse's scope of practice. Staff education about IV antibiotics is a role of the nurse, or a nurse-educator. Data related to IV infiltration is a role of the quality improvement team

A client who has been taking a diuretic and ACE inhibitor for hypertension has a blood pressure of 160/90. Today a new drug, carvedilol (Coreg), is prescribed, and the client expresses concern about receiving so many different medications. What action should the nurse implement? Explain the rationale for the administration of all three medications to the client. Withhold the newly prescribed medication until contacting the healthcare provider. Administer the newly prescribed medication and withhold the other two medications. Document the client's BP and refusal to take the newly prescribed medication.

Explain the rationale for the administration of all three medications to the client. Rationale Treatment of hypertension may require a combination of several different medications, so the nurse should explain the rationale for the use of three different types of medications, thus addressing the client's expressed concern. Since the client's BP is elevated, there is no indication that any of the prescribed medications should be withheld. The client has expressed concern, not refusal to comply with treatment.

Which assessment is most important for the nurse to implement when performing a comprehensive assessment for an older adult? Chronic illnesses. Functional abilities. Immunologic function. Physical signs of aging.

Functional abilities. Rationale The focus of a geriatric assessment is to determine the older client's functional abilities, so appropriate interventions can be planned and implemented to maintain and enhance independence.

Which type of delivery of nursing care is organized around tasks? Team nursing. Primary nursing. Case management. Functional nursing.

Functional nursing. Rationale Functional nursing is a care delivery model that provides client care by assignment for functions or tasks. Team nursing is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Primary nursing is a model of delivery of care where one nurse is accountable for 24-hour care for specific clients from hospital admission through discharge. Case management is the delivery of care that uses a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs that promotes quality cost-effective outcomes

When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement? Lower the extremity below the level of the client's heart. Gather the supplies needed to discontinue the IV fluid. Obtain an intravenous infusion pump to regulate the rate of infusion. Convert the IV to a saline lock until the healthcare provider is notified.

Gather the supplies needed to discontinue the IV fluid. Rationale An IV infusion stops when pressure is placed on the skin above the tip of the catheter, but will continue to flow into the subcutaneous tissue if there is infiltration, which requires removal of the IV. The other options will not resolve the infiltration.

An adult male with a history of heart failure tells the nurse that his lower extremities and feet swell when he sits at his computer all day. Which response is best for the nurse to provide? Limit the amount of table salt that you add to your meals. Take a daily vitamin with minerals to correct imbalances. Get up and walk around frequently during the day. Elevate your feet every night to reduce swelling.

Get up and walk around frequently during the day. Rationale Edema and swelling in the lower extremities results from gravitational pooling of blood and are common after extended periods of standing or sitting. Walking is a common recommendation to stimulate circulation, venous return, and to reduce swelling. Although limiting salt intake is a common heart-healthy life-style modification, the client's sedentary hours predispose to venous stasis and distal swelling. Recommending a daily vitamin with minerals is not a common remedy for the client's complaint. Elevating the feet at night may be helpful, but the best information is to consider the cause and get up and move around.

Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide? Give the toddler nutritious snacks. Offer rewards for eating at mealtimes. Avoid snacks so the child is hungry at mealtimes. Explain to the child in a firm manner what is expected.

Give the toddler nutritious snacks. Rationale At approximately 18 months of age, most toddlers manifest lower nutritional need and decreased appetite, a phenomenon known as "physiologic anorexia" which is often manifested as a picky, fussy eater with strong taste preferences, and erratic eating patterns. Toddlers are learning to differentiate self and social boundaries and may be disruptive while sitting at the table, so offering nutritious finger foods is a good way to ensure proper nutrition during this stage.

A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload? Increase in size. Decrease in length. Increase in number. Decrease in excitability.

Increase in size. Rationale Hypertension and incompetent or stenotic heart valves cause an increase in the workload of the heart by increasing afterload which requires an increase in the force of contraction to pump blood out of the heart. Myocardial hypertrophy results because the cells increase in surface area or size by increasing the amount of contractile proteins, but the quantity of fibers remain constant. As myocardial hypertrophy progresses, the heart becomes ineffective as a pump because the ventricular wall cannot develop enough tension to cause effective contraction, which causes myocardial irritability due to hypoxia.

The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow? Check the pilot balloon to ensure that it is firm. Verify the healthcare provider's prescription for the required cuff pressure. Use a manometer to maintain cuff pressure between 25 and 30 mmHg. Inject air until no air is auscultated over the larynx during a deep breath.

Inject air until no air is auscultated over the larynx during a deep breath. Rationale To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a stethoscope placed over the larynx (over the cuff) during inhalation. At the point when sounds of air movement cease, inflation is stopped, indicating that the cuff is sealed against the tracheal wall.

A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? History of alcohol intake. Time of last meal. Frequency of vomiting. Intensity of pain.

Intensity of pain. Rationale The hallmark sign of pancreatitis is severe abdominal pain due to autodigestion of the pancreas by the enzymes amylase and lipase.

A client who delivered a 9 pound 2 ounce infant 3 hours ago is experiencing uterine atony. Which action should the nurse implement first? Massage the fundus. Catheterize the bladder. Establish venous access. Prep for surgical intervention.

Massage the fundus. Rationale The initial management for uterine atony is fundal massage to prevent postpartum hemorrhage.

The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? Hand washing prior to preparation of the injection. Method used to aspirate medication from a vial. Selection and rotation of injection sites. Proper disposal of injection equipment.

Method used to aspirate medication from a vial. Rationale To maintain sterility of the procedure, the most important factor to include in the teaching plan is how to manipulate the syringe parts so that the medication maintains sterility during the preparation and administration. The other options are teaching topics, but are not components of maintaining sterile technique while administering an injection.

A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first? Prednisone (Deltasone) 10 mg PO. Albuterol (Proventil) 0.5% solution per nebulizer. Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. Oxygen 2 to 6 liters per minute using a nasal cannula.

Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. Rationale Comfort and pain management using an effective analgesic-sedative such as morphine, is the most important standard of care therapy in hospice home care to ensure comfort and enhance the quality of life for a client with a life expectancy of less than six months, as in this case. Adjunct therapy that promotes a sense of well-being, including prednisone, and provides adequate oxygenation work to supplement morphine in easing a client's discomfort, associated shortness of breath, and anxiety during a terminal illness.

Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure 135/90, temperature 97.6 F, pulse rate of 98 beats/minute, and respiratory rate 22 breaths/minute. The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching. What action should the nurse take? Notify the healthcare provider of the client's status. Assess vital signs q15 minutes until stable. Place the client in a vest-type restraining jacket. Encourage the client to take a warm bath to help relax.

Notify the healthcare provider of the client's status. Rationale The healthcare provider should be notified so that medications can be prescribed to prevent seizures. Grand mal seizures sometimes occur during barbiturate withdrawal, and pronounced muscle twitching can herald seizure activity

A young adult female comes to the health clinic to confirm a positive home pregnancy test. After determining the client's last menstrual period (LMP) as February 14, what expected date of birth (EDB) should the nurse calculate? January 7. October 17. November 21. December 11.

November 21. Rationale N gele'srule for calculation of EDB is determined by adding 7 days to the first day of the LMP and then subtracting 3 months.

The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first? Counsel the UAP about the inaccurate blood pressure readings. Observe the UAP performing blood pressure measurements. Make staff members aware of the possible errors in blood pressure readings. Ask the education department to provide additional training for the UAP.

Observe the UAP performing blood pressure measurements. Rationale The charge nurse should first observe the UAP's performance to determine if the UAP is performing the task appropriately. If the UAP needs education, the charge nurse can provide instruction real time.

The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot who has a prescription for partial weight-bearing. Which intervention should the nurse to implement before the client is discharged? Review the client's most recent serum calcium level. Verify that the crutches fit snugly under the axilla. Observe the client while demonstrating crutch walking. Determine if the client lives alone or with others.

Observe the client while demonstrating crutch walking. Rationale To evaluate a client's ability to crutch walk, the nurse should observe the client perform the skill. It is not necessary to check the client's serum calcium level. Crutches should be two to three inches from the axilla to prevent brachial plexus damage. Living alone should not be a problem because the client can use the three point gait with the crutches to perform self-care.

A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? Obstruction at the urinary bladder neck. Ureteral calculi obstruction. Ureteropelvic junction stricture. Partial post-renal obstruction due to ureteral stricture.

Obstruction at the urinary bladder neck. Rationale Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed.

A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? Ask the parents to participate in encouraging the child's fluid intake. Tell the child he can go outside after he drinks a full glass of water. Offer the child a popsicle and allow him to pick the flavor he prefers. Make a game of seeing who can finish a glass of water first--the nurse or the child.

Offer the child a popsicle and allow him to pick the flavor he prefers. Rationale Fluids in popsicle form are an excellent choice for a child, and small children react best when they are provided with possible choices, such as choosing a flavor. Manipulation should be avoided and the nurse must be careful not to make promises that may not be possible.

Which action should the nurse take first when performing tracheostomy care? Cleanse around the stoma. Suction the tracheostomy. Oxygenate with 100% oxygen. Secure the new neck strap.

Oxygenate with 100% oxygen. Rationale Hyperinflation with 100% oxygen helps minimize hypoxia and atelectasis during the suctioning procedure, so the nurse should take this action first, before any of the other options.

Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder? Describes success in dismissing persistent thoughts that used be bothersome. Reports that the obsessions and compulsions experienced are silly. Avoids obsessive verbalizations while interacting with family and staff. Participates in one social or recreational activity each morning and afternoon.

Participates in one social or recreational activity each morning and afternoon. Rationale Participation in social/recreational activities is an expected outcome of treatment for a client with impaired social interaction because it indicates that the client is no longer totally immersed in obsessive thoughts and compulsive rituals.

Which type of management style is a case management model for nursing care delivery? Patient focused and primary nursing. Clinically oriented and business oriented. Centralized and decentralized systems models. Clinical pathways and patient classifications.

Patient focused and primary nursing. Rationale A client classification or acuity system is used in many acute care hospitals to estimate the intensity of nursing care required to meet patient needs. Case management is patient focused and provides primary nursing. Clinically- and business-oriented is a business model of organizational decision making. Centralized and decentralized systems models are management strategies or models of organizational decision making, such as shared governance which is a decentralized model. Clinical pathways are interdisciplinary plans of care that outline the optimal sequencing and timing of interventions for clients with a particular diagnosis, procedure, or symptoms.

About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat? A chocolate bar. A soft drink. Peanut butter crackers. A piece of buble gum.

Peanut butter crackers. Rationale Peanut butter crackers provide a complex carbohydrate, plus protein and fat. This child is exhibiting signs and symptoms of mild to moderate hypoglycemia and needs to eat about 15 grams of carbohydrates to increase the blood sugar level. Complex carbohydrates are broken down more slowly and are slower acting than simple sugars, so they prevent the blood glucose level from peaking and then dropping precipitously.

Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis? Jaundice. Vomiting. Peripheral edema. Left upper quadrant pain.

Peripheral edema. Rationale Four types of cirrhosis include alcoholic, post-necrotic, biliary, and cardiac cirrhosis, which are associated with severe right-sided heart failure (HF), so peripheral edema is most consistent with right-sided HF. Although jaundice and vomiting can occur in all types of cirrhosis, the most defining characteristic of cardiac cirrhosis is related to HF. Hepatic engorgement can occur in a client with HF or cirrhosis and cause right upper quadrant pain, not left sided quadrant pain.

A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? Place the client in mechanical restraints until calm. Administer a PRN dose of haloperidol (Haldol) IM. Use a calm, soothing voice to diffuse the situation. Encourage the client to focus on his feelings of anger.

Place the client in mechanical restraints until calm. Rationale This client is demonstrating behaviors that may be a danger to himself or others, and in such an emergency situation, restraints may be applied by an authorized staff member. This client is experiencing distorted sensory perceptions, so he is unlikely to respond to or have the ability to verbalize his feelings.

A multigravida at 41-weeks gestation is receiving an oxytocin (Pitocin) infusion for induction of labor. The nurse notes the fetal heart rate (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction. What action should the nurse implement at this time? Discontinue the oxytocin (Pitocin) infusion. Notify the healthcare provider. Administer 10 L of oxygen via face mask. Place the client on her left side.

Place the client on her left side. Rationale A sharp drop in the FHR from the baseline that returns quickly to the FHR baseline is a variable deceleration. Variable deceleration occurs when the umbilical cord is being compressed, so the nurse should change the client's position to determine if this resolves the cord compression.

A mother calls the emergency department because her 9-year-old son has just fallen on his face and one of his front teeth has fallen out. Which instructions should the nurse provide to preserve the tooth's viability? Clean the tooth with toothpaste. Place the tooth in milk or water. Put the tooth back in the child's mouth. Gently place the tooth in a plastic bag.

Place the tooth in milk or water. Rationale To preserve the tooth's viability when reinserted by the healthcare provider, the tooth should be kept moist by placing it in saline, water, or milk. Cleaning or scrubbing the tooth can damage it and interfere with replacement of the tooth. A healthcare professional should treat and reinsert the tooth because the parent's efforts may pose additional trauma. Placing the tooth in a plastic bag may keep it clean, but moisture of the tooth is essential.

A client at 13-weeks gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information? Level of fetal lung maturity. Presence of genetic disorders. Quantification of alpha-fetoprotein levels. Determination of gestational age.

Presence of genetic disorders. Rationale Amniocentesis is done at 14 to 16 weeks gestation to determine chromosomal, genetic, and metabolic disorders. Amniocentesis in the third trimester assesses fetal lung maturity by evaluating the lecithin/sphingomyelin (L/S) ratio and the presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify alpha-fetoprotein levels after abnormal maternal serum alpha-fetoprotein levels (done at 15 to 18 weeks ) are found.

The nurse is assigned a client with numerous treatments and decides it is not possible to complete all the needed treatments in the time scheduled for this shift. Which process should the nurse use? Delegate tasks to competent team members. Prioritize tasks with the most crucial needs first. Report the incomplete treatments to next shift nurse. Start with the easiest treatment first.

Prioritize tasks with the most crucial needs first. Rationale Planning care for a client with numerous treatments should be prioritized with the most crucial client needs first to the least. Delegating to others or reporting displace the nurse's responsibility to provide care. Starting with easiest is an inefficient utilization of time in meeting critical client needs.

The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction in the ventricles? T wave of 0.16 second. PR interval of 0.18 second. QT interval of 0.34 second. QRS interval of 0.14 second.

QRS interval of 0.14 second. Rationale The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS indicates an electrical anomaly in the ventricles. The T wave is normally 0.16 seconds. The PR interval range is 0.12 to 0.20 second. The QT interval should be 0.31 to 0.38 second.

The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented? (Place the first action on top and last action on the bottom.) 1. Measure the client's vital signs. 2. Review medications client is taking. 3. Notify the healthcare provider. 4. Complete an incident report.

Rationale Cardizem is a calcium channel blocker that decreases blood pressure, and slows SA or AV node conduction, which can cause bradycardia or cardiac arrhythmias, so the client's vital signs should be measured first to determine the client's reaction to the medication error. The client's current medications should be reviewed before notifying the healthcare provider, and then the incident report completed.

A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.) 1. Airway and breathing. 2. Pain management. 3. Sleep and rest. 4. Definitive therapy.

Rationale First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway and breathing are the first priority, followed by pain management, Maslow's hierarchy of basic needs for rest and sleep, and then definitive drug therapies.

The nurse is planning to withdraw 10 ml of urine from the port on the tubing of a client's indwelling catheter to obtain a urine specimen. In which order should the nurse implement these actions? (Arrange from first on top to last on the bottom.) 1. Clamp the drainage tubing. 2. Label the urine specimen. 3. Place in a biohazard bag. 4. Document the procedure.

Rationale The drainage tubing should be clamped before obtaining the specimen. After withdrawing the urine specimen, the specimen is labeled, and then the container is placed in a biohazard bag for transport to the laboratory. Documentation should be completed after the specimen is labeled and transported to the laboratory.

The nurse is preparing to perform oral care for an unconscious client.In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.) 1. Raise bed to a comfortable working height. 2. Lower the side rail between the nurse and the client. 3. Position the client in a flat side-lying position. 4. Place an emesis basin under the client's chin.

Rationale To ensure client and nurse safety when performing oral care for an unconscious client, first raise the bed to a comfortable working level, then lower the side rail between the nurse and the client, position the client in a flat side-lying position, and place a towel and an emesis basin under the client's chin.

The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first? Document the change in pulse rate on the graphics sheet. Review the client's medical history for cardiac problems. Reassess the rate and characteristics of the client's pulse. Ask the UAP to recheck the client's pulse in thirty minutes.

Reassess the rate and characteristics of the client's pulse. Rationale A change in heart rate or rhythm reflects a change in physiologic homeostasis that may be potentially life threatening, so it is most important to immediately reassess the client's pulse rate and characteristics. After reassessing the client, the nurse should document the findings, review the client's medical record for related history, and determine further needed intervention, such as rechecking the client's vital signs.

When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? Record these findings in the client's record. Observe closely for possible dehiscence. Notify the healthcare provider that the client's wound is producing a sanguineous drainage. Increase the IV fluid rate and encourage the client to eat more ice chips.

Record these findings in the client's record. Rationale These are normal findings for one-day postoperative and indicate that the wound is healing by primary intention. Dehiscence is separation of a surgical incision, and there is no indication that this is a possibility at this time.

A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement? Refer for further diagnostic evaluation. Determine exposure of others to the tuberculosis. Begin anti-tubercular drug therapy. Quarantine or isolate to control communicability.

Refer for further diagnostic evaluation. Rationale The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis infection (LTBI), which this client is in a high-risk category for exposure in a homeless environment. Although productive prolonged cough, fever, and night sweats are common early symptoms, persons suspected of LTBI should not begin treatment until active TB disease has been excluded. Further diagnostic evaluation should be implemented. A dormant form that neither causes disease nor is communicable.

What instrument should the nurse use to determine the presence of deep tendon reflexes? Goniometer. Wood's lamp. Reflex hammer. Transilluminator.

Reflex hammer. Rationale Deep tendon reflexes are assessed using a reflex hammer. A goniometer is used to assess the degree of joint flexion and extension. A Wood's lamp determines the presence of fungi. Transilluminator is a light source that helps detect the presence of fluid in the sinus cavities.

The nurse is assessing a client with multiple trauma from a motorcycle crash who is being ventilated due to multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse monitor as an indicator of MODS progression? Cardiac function. Renal function. Hepatic function. Coagulation system.

Renal function. Rationale MODS includes the immediate consequences of posttraumatic pulmonary failure, thermal injuries, acute tubular necrosis, or invasive infections. Acute renal failure is a common manifestation of MODS, so the client's renal function should be monitored closely because the kidneys are highly vulnerable to reperfusion injury. Although cardiovascular function becomes vasopressor-dependent, dysfunction and failure of the heart, liver, and coagulation system are late and ominous signs of MODS characterized by the onset of heart failure, hepatic failure, and disseminated intravascular coagulation (DIC).

Which biological practices are federally regulated for healthcare workers? (Select all that apply.) Select all that apply Standard precautions. N-95 tuberculosis standard. Blood-borne pathogen standard. Biological product exposure limit (BPEL). Resource Conservation and Recovery Act (RCRA). As Low as Reasonably Allowable standard (ALARA).

Resource Conservation and Recovery Act (RCRA). Rationale Basic standards for healthcare workers, as delineated by Occupational Safety and Health Administration (OSHA), include standard precautions, droplet precautions using N-95 respiratory particulate masks when caring for a client who is positive for tuberculosis, and required annual updates for healthcare workers about blood-borne pathogen transmission, methods of minimizing exposure, and employee rights. Other options [BPEL and ALARA ] are not federally regulated.

A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding? Deep tendon reflexes 1+. Blood pressure of 140/90. Respirations of 10. Urinary output of 130 ml in 4 hours.

Respirations of 10. Rationale With respirations less than 12, the client is at risk for developing respiratory arrest and the magnesium sulfate should be discontinued. Other cardinal signs of magnesium toxicity include urinary output <100 ml/4 hours (or 25 ml/hour) (D) and absent reflexes. Reflexes of 1+ are hypoactive but present. A client with preeclampsia can seize with blood pressures lower than 140/90. Magnesium sulfate is not an antihypertensive.

The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? Use an electronic sphygmomanometer to take the BP every 30 minutes. Retake the blood pressure in the same arm, deflating the cuff slowly. Ask another nurse to recheck the blood pressure to compare results. Obtain another blood pressure cuff and retake the blood pressure.

Retake the blood pressure in the same arm, deflating the cuff slowly. Rationale The nurse should first retake the blood pressure in the right arm, deflating the cuff more slowly because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. There is no indication that the BP needs to be taken frequently. If the blood pressure remains low, further assessment is needed, which may include asking other staff to recheck the BP. If deflating the cuff slowly does not resolve the discrepancy, the nurse may then need to implement getting another BP cuff and retaking the BP.

A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased lochia flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of 102.2 F, chills, pelvic pain, and uterine tenderness. What action should the nurse take? Review the complete blood count. Tell client to discard pumped milk. Initiate a 24-hour urine collection. Arrange for the baby to room-in.

Review the complete blood count. Rationale This client is exhibiting symptoms of endometritis, and an elevated white blood count suggests infection. The breast milk is not contaminated, so a breast pump should be provided to maintain lactation. Collection of a 24-hour urine specimen is not indicated for a client with endometritis. Infant safety is jeopardized by a client exhibiting these symptoms, so rooming-in should be discouraged.

A child with nephrotic syndrome is receiving prednisone (Deltasone). Which priority nursing diagnosis should the nurse include in the plan of care? Nausea. Risk for Infection. Risk for Bleeding. Disturbed Body Image.

Risk for Infection. Rationale Risk for Infection related to altered immune mechanisms caused by disease and effects of steroids is the priority. The other nursing diagnoses are not priority for a child with nephrotic syndrome who is receiving prednisone.

Which action should the nurse implement when using the confrontation technique during a vision exam? Use an ophthalmoscope to watch the client's pupil constrict when a strong light is shown on it. Stand behind the client and direct the client to tell the nurse when an object enters the peripheral field of vision. Show the client a series of four cards with printing of varying sizes and ask which card the client sees most clearly. Sit facing the client and while look directly at the client's face, move an object inward from the periphery.

Sit facing the client and while look directly at the client's face, move an object inward from the periphery. Rationale Confrontation technique during a vision exam is used to determine peripheral vision, sodirectly facing the client and moving an object inward allows the client to state when the object enters the nasal, temporal, superior, and inferior fields of vision. Using an ophthalmoscope determines pupillary reactivity. Standing behind the client and asking them to identify when an object enters peripheral fields does not allow the examiner to determine if the client's eyes stay centered when testing the peripheral fields. Having client look at cards with different size of printing evaluates the client's visual acuity.

The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider? Sinus bradycardia at 50 beats per minute. Flaccid paralysis below the level of the injury. Systolic blood pressure 80 mm Hg after 2 fluid boluses. SpO2 is 88% with shallow, slow respirations.

SpO2 is 88% with shallow, slow respirations. Rationale Bradypnea, ineffective gas exchange, and low SpO2 (D) should be reported to the healthcare provider because a client with a C7 spinal cord injury is likely to deteriorate due to post-injury spinal cord edema that may extend to cervical innervation of the diaphragm. Bradycardia and hypotension occur after spinal cord injury above T6 due to autonomic nervous system dysfunction. Flaccid paralysis is consistent with spinal shock which occurs after injury and resolves in varying degrees and time frames. Although fluid resuscitation may be prescribed to ensure tissue perfusion, hypotension may persist with peripheral vasodilation that results from loss of sympathetic function.

After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next? Collect blood for hemoglobin and hematocrit. Start the first transfusion of blood. Insert an indwelling urinary catheter. Encourage alternate rest periods with activity.

Start the first transfusion of blood. Rationale The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation (normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be started. Rechecking labs should be obtained after the client is transfused to evaluate its effectiveness. Placing a catheter is not indicated at this time. Rest periods should be included in the plan of care, but is not as essential as giving the transfusion at this time.

A client with chronic kidney disease (CKD) and severe anemia refuses blood transfusions. The healthcare provider prescribes epoetin alfa. Which action should the nurse explain to the client about the medication's therapeutic response? Accelerates neutrophil production, maturation, and activation. Activates the immune system with development of T and B cells and natural killer cells. Stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes. Increases production and maturation of granulocytes and macrophages.

Stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes. Rationale Epoetin alfa is a biological response modifier that is used to stimulate the formation of red blood cells. Accelerating neutrophil production describes agents, such as filgrastim, used to decrease the risk for infection in clients with chemotherapy-induced neutropenia.Immunomodulators, a subtype of biologic response modifiers, such as interferon, provide a specified action in the immune system used in chemotherapeutic protocols. Increased production of granulocytes nd macrophages specifies the therapeutic response of agents, such as sargramostim, which also inhibits neutrophil migration and is primarily used to accelerate myeloid recovery during bone marrow transplantation.

A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part of preoperative teaching, what information should the nurse provide? The transverse loop ostomy is permanent. Easily removable appliances allow independence in self-care. Daily irrigation is started after the J pouch heals. Stool is eventually expelled through the rectum.

Stool is eventually expelled through the rectum. Rationale An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so that passage of stool through the rectum is the eventual result. To promote healing of the anastomosed parts of the colon, a temporary loop ostomy is created, not a permanent one. Although appliances that are easy to use are advantageous, the ostomy is reversed after healing takes place. Stool drains into the reservoir, so daily irrigation is not usually indicated.

An elderly client is admitted with suspected bacterial pneumonia and lethargy. Ten minutes after the nurse initiates low-flow oxygen per nasal cannula and a peripheral IV with a secondary infusion of ticarcillin (Ticar), the client becomes disoriented, restless, and tachypneic. Which nursing action has the highest priority? Call for the emergency resuscitation team and retrieve the unit's crash cart. Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute. Observe the client's trunk and back for any hives and ask about the onset of urticaria. Notify the healthcare provider and prepare to administer IV diphenhydramine (Benadryl).

Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute. Rationale The client's symptoms depict the onset of an anaphylactic reaction to ticarcillin, an extended-spectrum penicillin, so the priority nursing actions include halting the client's exposure to the medication and supporting breathing efforts. The other choices are important interventions that should occur immediately after stopping the IV antibiotic.

A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first? Notify the healthcare provider. Stop the irrigation flow. Document the finding and continue to observe. Irrigate the catheter with a large piston syringe.

Stop the irrigation flow. Rationale The urinary output should be at least the volume of irrigation input plus the client's actual urine. A significant decrease in output indicates obstruction in the drainage system, and the irrigation flow should be stopped to prevent severe bladder distention. The next action is to check the external system for kinks or obstruction. If no output occurs, the catheter is irrigated with 30 to 50 ml of normal saline using a large piston syringe. If the obstruction is not resolved, then the healthcare provider should be implemented.

A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he eats and drinks a snack before going to bed, and that he checks his blood glucose before eating in the morning. This client requires further teaching on which subject? Storing nitroglycerin. Fluid intake. Blood glucose monitoring. Diabetic diet.

Storing nitroglycerin. Rationale Nitroglycerin must be kept in the original dark-tinted, glass, screw-top bottle so that contact with air can be avoided, and keeping it in a pants pocket exposes it to body heat, which can reduce its effectiveness. The client should keep the medication in a jacket pocket, which would reduce direct body contact with the bottle. He should also check the expiration date on the bottle (it is good for 3 months and tingling in the mouth indicates that the drug is fresh). Some people experience a headache when taking nitroglycerin, due to the vasodilatation effect.

While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take? Notify respiratory therapy immediately for a PRN bronchodilator treatment. Obtain a prescription to increase the tidal volume setting on the ventilator. Stop mechanical ventilation and re-assess the client's lung sounds bilaterally. Suction the client's endotracheal tube and auscultate following suctioning.

Suction the client's endotracheal tube and auscultate following suctioning. Rationale Suctioning the ET tube clears secretions and will usually eliminate the coarse snorous sounds. Respiratory therapy usually provides treatments when airways are edematous, not for secretions. Changing the tidal volume will not clear the airways. Clients on a ventilator will have sounds of the ventilator working, however the ventilator should not be stopped for auscultation of breath sounds.

Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? African-American women who are 30 to 35 years of age. Survivors of violence that occurred at least 5 years ago. Active armed forces reserve unit returning from Europe. Full-time students who are attending public colleges.

Survivors of violence that occurred at least 5 years ago. Rationale Vulnerable populations are those groups who have an increased risk of developing adverse health outcomes. Survivors of violence, even though the violence occurred more than 5 years ago, have an increased risk for adverse health outcomes. The other options just describe demographic groups.

A client is transferred to the postoperative unit after 2 hours in the postanesthesia care unit (PACU). What is the priority nursing action? Determine the client's pain. Take the client's vital signs. Calculate the IV infusion rate. Check the postop prescriptions.

Take the client's vital signs. Rationale After the client is transferred from the PACU stretcher to the hospital bed and the PACU nurse reports the client's condition, the client's vital signs should be obtained first, so a change in the client's status can be determined. Vital sign changes are a primary indicator of cardiopulmonary complications and bleeding in the first hours postoperatively.

What is the most effective way to implement a teaching plan? Teach the information that the client wants to learn first. Streamline the teaching plan to include only essential information. Present to the client all the information necessary to meet the objectives. Provide the client with written material to review before teaching sessions.

Teach the information that the client wants to learn first. Rationale Teaching is most effective when it responds to the learner's needs, and learning begins when a person identifies a need for knowing or acquiring an ability to do something.

A healthcare provider (HCP) asks the nurse to give a medication to a client, and the nurse tells the HCP that the client is allergic to the medication. The HCP says, "Give the medication or I will report this to your supervisor." What response should the nurse provide? Walk away and ignore the threatening statement. Give the prescribed medication and document the situation. Tell the HCP that both of you should talk to the supervisor now. Respond that this client is not assigned to the nurse.

Tell the HCP that both of you should talk to the supervisor now. Rationale Conflict resolution between staff and HCP is best resolved with a mediator who can address facts, not emotional reactions. Walking away or stating it is not their client ignores the conflict, which may escalate. Giving the medication is unsafe practice.

The nurse is assessing an older adult client's living arrangements and care. Which situation should the nurse identify as contributing the most to the client's vulnerability for elder abuse? The caregiver's stress level is overwhelming. Programs for older adults are not being utilized. Several generations in the family are providing care. The client does not appreciate the care provided by the family.

The caregiver's stress level is overwhelming. Rationale The intensity and complexity of caregiving places a caregiver at risk for high levels of stress which contribute to being overwhelmed (A), invoking feelings of inadequacy, powerlessness, depression, or anger, and may be displaced to the older client.

A client at 26-weeks gestation comes to the labor and delivery unit and complains, "Something is not right". Which finding should the nurse assess further? Estriol is absent from the maternal saliva. The cervix is effacing and dilated to 2 cm. Fetal fibronectin is absent in vaginal secretions. Irregular mild uterine contractions occurring daily.

The cervix is effacing and dilated to 2 cm. Rationale Cervical changes, such as shortened endocervical length, effacement, and dilation accompanied by regular contractions indicate labor at any gestation period, so the client should be monitored for pre-term labor. Estriol is a form of estrogen found in plasma at 9-weeks gestation, and increased levels of salivary estriol have been shown to occur before preterm birth. The presence of fetal fibronectin in vaginal secretions, between 24 and 36 weeks of gestation has a 20% to 40% positive predictive value for preterm labor. Irregular mild contractions that do not cause cervical change indicate Braxton Hicks contractions or false labor.

A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated, if the need arises. How should the nurse respond? Nurses use their best judgment based on the client's condition. The healthcare team must honor the written wishes of the client. Notify the healthcare provider of the family's wishes, so a decision can be made. Every effort must be made to honor the family's wishes about their loved one.

The healthcare team must honor the written wishes of the client. Rationale The client is the ultimate decision-maker regarding treatment or refusal of treatment. The client's ethical right to autonomy and legal right to give informed consent for treatment are recognized in both legally created special directives and living wills. Although family members are very important in the care and support of the client, the nurse, and healthcare provider must respect the legal document that the client created to direct the course of treatment.

Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)? Type 1 DM and a serum hemoglobin-A1c of 3.5%. Type 1 DM and retinopathy and mild vision loss. Type 2 DM and hypertension controlled by metoprolol. Type 2 DM and a history of morbid obesity for 5 years.

Type 1 DM and retinopathy and mild vision loss. Rationale Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension which damage the microvasculature of the eyes and kidneys, so a client with Type 1 DM and retinopathy is most likely to develop nephropathy and CKD. The client with hemoglobin A1C of 3.5% is demonstrating compliance with therapy (H-A1c target level is no greater than 7%), which indicates tight glucose control and reduces the risk for microvascular complications. The client with controlled hypertension is less likely to develop CKD, although metoprolol, a beta adrenergic receptor antagonist, can mask the signs of hypoglycemia. A client with Type 2 DM is more likely at risk for complications associated with chronic obesity.

A male client who is two days postoperative for a bowel resection moves as little as possible and does not use the incentive spirometer unless specifically reminded. The client reports his pain level at an 8 on a 10-point scale, but refuses a PRN dose of an opioid analgesic and tells the nurse that he can "tough it out." What response is best for the nurse to provide? Side effects are not a concern because they usually decrease over time. Very few clients become addicted to opioids when using them for pain control. There are multiple options of medications that can be offered if one drug does not relieve the pain. Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from surgery.

Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from surgery. Rationale Unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate, cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal motility and transit, and increased catabolism

Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion of packed red blood cells? Skin turgor. Weight. Oxygen saturation. Vital signs.

Vital signs. Rationale Baseline vital signs are essential to obtain prior to administering a blood transfusion, so that vital signs measured during the transfusion administration can be compared to the baseline to assess for the onset of a transfusion reaction. The other assessments provide less significant data immediately prior to the administration of the transfusion.

Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.) Select all that apply Economics. Workforce. Technology. Interventions. Socio-economic status. Legislation/regulation.

economics technology Rationale Economics affects the health of the company and its workforce productivity, in termsof profitability, growth, and expansion. Technology adds to an industry's capacity to develop and implement new or improved work processes. Legislation/regulation in the workplace, such as the blood-borne pathogen standard, affects the workforce in terms of requirements, administration, and control strategies. Occupational safety programs are built around the workforce to strive for maximum internal productivity. Interventions are internal environmental influences of an occupational health and safety program. Socio-economic status is a demographic variable commonly used in epidemiology.

The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase blood pressure to 140/80. urine output to 55 ml/hr. pulse to 132 beats/min. respirations to 24 breaths/min.

urine output to 55 ml/hr. Rationale The expected outcome of this treatment is an increase in urine output due to increased renal perfusion. Dopamine, a catecholamine, provides renal and mesenteric vasodilation at a low dosage level, such as the 3 mcg/kg/minute infusion that was prescribed for this client. A higher dose of dopamine is indicated in a critically ill client who is hypotensive.