HESI-RN Comprehensive Exam B

When assessing a normal newborn, which findings should the nurse expect? (Select all that apply.) A. Umbilical cord contains one vein and two arteries B. Slightly edematous labia in the female newborn C. Absence of Babinski reflex D. Presence of white plaques on the cheeks and tongue E. Nasal flaring noted with respirations

A, B Rationale:These are normal findings (A and B). The others indicate abnormalities or complications and should be reported to the primary health care provider (C, D, and E).

After the LPN/LVN placed a nasogastric (NG) tube, what is the nurse's next action? A. Call transportation to take the client to radiology. B. Ask the LPN/LVN, "How did the client tolerate the procedure?" C. Ask the LPN/LVN, "What was the pH of the gastric aspirate?" D. Hook up the client to continuous suctioning.

A Rationale:Tube placement must be confirmed by x-ray for the initiation of any treatments. Tolerating the procedure is a nice assessment, but not as important as tube placement. Gastric aspirate can give a clue to placement, but does not verify placement. Continuous suctioning is never appropriate for an NG tube, suctioning is intermittent.

The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The acetaminophen is available 150 mg/5 mL. How many mL will the nurse administer for one dose? _____ (Enter a whole number.)

15 Rationale:66 lb/(2.2 kg/lb) = 30 kg30 kg × (15 mg/kg) = 450 mg(5 mL/150 mg) × 450 mg = 15 mLor(450 mg/150 mg) × 5 mL = 15 mL

The nurse teaches a class on bioterrorism. Which methods of transmission are possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A. Inhalation of powder form B. Handling of infected animals C. Spread from person to person through coughing D. Eating undercooked meat from infected animals E. Direct cutaneous contact with the powder

A, B, D, E Rationale:Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).

A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) A. Abdominal obesity B. Sedentary lifestyle C. History of hypoglycemia D. Hispanic or Asian ethnicity E. Increased triglycerides

A, B, D, E Rationale:Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C).

The quality control (QC) nurse is reviewing multiple chart entries. Which entries will the QC nurse need to bring to the attention of the nurse manager? (Select all that apply.) A. MSO4 administered IVP B. 10 u of insulin administered sub q C. 0.2 mL of normal saline mixed D. 2000 IU of Vitamin D E. Digoxin po qd

A, B, D, E Rationale:Morphine sulfate needs to be written out as it can be confused with magnesium sulfate. Units is always written out as "u" can be confused with o. IU, for international units is written out as it can be confused with IV. Daily needs to be written out for qd.

The nurse is providing care to a client who was newly prescribed clopidogrel. Which black box warning will the nurse review for prior to administering the medication? A. This drug could cause heart attack or stroke when taken by clients with certain genetic conditions. B. Clopidogrel helps prevent platelets from sticking together and forming clots in the blood. C. This drug can be taken in combination with aspirin to reduce the risk of acute coronary syndrome. D. Clopidogrel can reduce the risk of a future heart attack when taken by clients with peripheral artery disease.

A Rationale:A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects. Options B, C, and D are all desired effects of the drug.

The nurse is reviewing the chart of a 26-year-old client with type 1 diabetes mellitus. Which data may indicate that the client is experiencing chronic complications of diabetes? A. Blood pressure, 159/98 mm Hg B. Hemoglobin A1C (HbA1C), 6% C. Creatinine level, 1.0 mg/dL D. Chronic sciatica

A Rationale:A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke. Options B and C are within defined parameters, and Option D is not a recognized chronic complication of diabetes.

When caring for an 80-year-old client with pneumonia, which finding is of most concern to the nurse? A. Decrease in level of consciousness B. BUN level, 20 mg/dL; creatinine level, 1.0 mg/dL C. Reports of a dry mouth and lips D. Fine crackles auscultated in lung bases

A Rationale:A decrease in level of consciousness is a sign of decreased oxygenation and requires immediate intervention. Options B, C, and D are expected findings.

A client admitted to a medical surgical inpatient unit complains to the nurse about feeling hot. The client asks, "Can I have my spouse bring in my favorite fan from home?" What is the nurse's best response? A. "All electrical appliances must be cleared by the hospital's physical plant." B. "Let me get you a cup of ice water to cool you down." C. "If your own fan would help you rest, you can use it at your own risk." D. "The floor has approved fans in the storage closet; let me get you one."

A Rationale:All of the statements are accurate, but only one answers the question. The client wants to bring in an electrical appliance. The appliance must be certified to be safe for use in the facility. A cup of ice water does not answer the question. Using an appliance at the client's own risk does not consider the safety of other inpatients. While a fan might be available, that statement again does not answer the client's question.

The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? A. Usual prepregnant weight B. Weight at the first prenatal visit C. Weight during previous pregnancy D. Recommended pattern of weight gain

A Rationale:Comparing the client's current weight with her prepregnant weight allows for the calculation of weight gain. By the time of the first prenatal visit, she may have already gained weight. Option C may not be relevant to weight gain with the current pregnancy. Option D should be evaluated based on serial weights, not just a single current weight.

A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation will the nurse report to the health care provider? A. Heart palpitations B. Leg cramps C. Nausea D. Tetany

A Rationale:Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that could progress to a medical emergency. Options B and C are also of concern but are not as life threatening. Option D is a symptom of hypocalcemia.

A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign is most important for this client? A. Maternal temperature B. Fetal blood pressure C. Maternal respiratory rate D. Fetal heart rate

A Rationale:Maternal temperature should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. Option B cannot be established with standard bedside monitoring. Option C is not specifically related to ROM. Option D is always monitored during labor; this situation would not prompt the nurse to increase FHR monitoring.

A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone. The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to complete for this client? A. Compliance with medication regimen B. Current thyroid-stimulating hormone (TSH) level C. Occurrence of mania or depression D. A 24-hour diet and exercise recall

A Rationale:Medication compliance is most important for the treatment of psychotic disorders, and because Risperidone is associated with weight gain, it is probable that the client is complying with the treatment plan. The TSH level indicates thyroid function, which regulates basal metabolic rate and influences weight. It is important to obtain information about occurrences of mania and depression since the last visit, but if the client is compliant with the medication regimen, these symptoms are likely to have been controlled. Diet and exercise should also be assessed, but weight gain is a likely indicator of medication compliance.

An 8-year-old child is receiving digoxin for congestive heart failure (CHF). When performing an assessment, the nurse finds the child's apical heart rate is 80 beats/min, with complains of being slightly nauseated. The most recent serum digoxin level is 1.2 ng/mL. What action will the nurse take next? A. Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B. Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C. Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D. Notify the health care provider that the child's pulse rate is below normal for her age group.

A Rationale:Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min, and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, option A is the best of the choices provided because the serum digoxin level is within normal levels. Option B is not warranted by the data presented. The digoxin level is within the therapeutic range, and the child is not showing signs of toxicity. The child's pulse rate is within normal range for her age group.

A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? A. A 17-year-old who is sexually active with numerous partners B. A 45-year-old lesbian who has been sexually active with two partners in the past year C. A 30-year-old cocaine user who inhales the drug and works in a topless bar D. A 34-year-old male homosexual who is in a monogamous relationship

A Rationale:Option A is at greatest risk for contracting sexually transmitted diseases, including HIV, because the greater the number of sexual partners, the greater the risk for contracting an STD. Option B comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. Option C, who free-bases, would not be sharing needles, so contracting an STD is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV as long as both partners are monogamous and neither is infected.

A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client? A. Watch the client complete a foot examination. B. Have the client describe the actions of the prescribed hypoglycemic medication. C. Ask the client to relay the current occupants of the household. D. Have the client to share the when the diabetes started.

A Rationale:Option A specifically relates to foot care. Options B, C, and D provide worthwhile information to obtain but do not have the importance of option A.

The nurse sees the contents of the client's waste can are on fire. What is the nurse's first action? A. Remove the client from the room. B. Pull the fire alarm. C. Move the waste can away from the bed and curtains in the room. D. Retrieve the fire extinguisher.

A Rationale:RACE stands for rescue, alarm, confine, extinguish.

The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? A. O2 saturation, 89% B. Reports diplopia C. Ptosis to left eye D. Difficulty speaking

A Rationale:Respiratory failure is a life-threatening complication that can occur with myasthenia gravis. Options B, C, and D are signs of the disease but are not as life threatening as decreased oxygen saturation.

A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important? A. Administer a dose of benztropine mesylate PRN. B. Determine if the client has increased photosensitivity. C. Provide comfort measures for sore muscles. D. Assess the client for visual and auditory hallucinations.

A Rationale:Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with chlorpromazine. It is most important for the nurse to administer an anticholinergic such as benztropine mesylate to reverse these effects. Options B, C, and D may be appropriate interventions but are not as urgent as option A.

The care team on the unit is 2 RNs, 1 LPN/LVN and 2 aides. Which client assignment is best for the LPN? A. The surgical client who will need a dressing change B. The client with diabetes awaiting discharge to home C. The confused client in need of daily personal care D. The newly admitted client with asthma with an O2 saturation of 98%

A Rationale:The LPN/LVN can provide skill related care, such as a dressing change. The RN will need to confirm with the LPN/LVN and changes in the wound, but the LPN/LVN can change the dressing. The diabetic client will need reinforced discharge teaching, best provided by the RN since diabetes is not routine and predictable. The aide can bathe the client in need to personal care. While the O2 saturation is good in the newly admitted client with asthma, the condition needs the initial assessment of the RN.

The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the practical nurse (PN)? A. A client with nausea who needs a nasogastric tube inserted B. A client in hypertensive crisis who needs titration of IV nitroglycerin C. A newly admitted client who needs to have a plan of care established D. A client who is ready for discharge who needs discharge teaching

A Rationale:The client mentioned in option A has a need for a skill that is within the scope of practice for the PN. Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated.

The nurse takes a phone call from a frantic mother or a 3-year-old. The mother reports that she found her toddler in the bathroom with an open container of pills and one pill in the toddler's mouth. What is the next nursing action? A. Tell the mother to call 911 and ask for poison control. B. Ask the mother how many pills she thinks the toddler ingested. C. Ask the mother how the toddler got into the pill container. D. Tell the mother to place all medications in a locked cabinet.

A Rationale:This is an emergent situation and poison control is the expert source for these situations. The number of ingested pills, how the toddler got the pills and placing in a locked cabinet are all secondary to getting the care the toddler needs.

A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that further teaching is needed? (Select all that apply.) A. "I will not take my digoxin if my heart rate is higher than 100 beats/min." B. "I should weigh myself once a week and report any increases." C. "It is important to increase my fluid intake whenever possible." D. "I should report an increase of swelling in my feet or ankles." E. "I will call my health care provider if I have diarrhea for more than a day."

A, B, C Rationale:An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider. Diarrhea can predispose the client to digitalis toxicity. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can worsen heart failure.

The nurse is preparing to administer an IV antibiotic the client has never before received. What assessments will the nurse include in the client's plan of care before safely administering the medication? (Select all that apply.) A. Ask the client, "Do you have any allergies to medications?" B. Ask the client, "Please state your name." C. Ask the client, "What is your date of birth." D. Ask the client, "What is your current weight?" E. Ask the client, "Did you eat or drink anything in the last 2 hours?"

A, B, C Rationale:The nurse must assess for allergies before administering any new medication. Also, the nurse must verify the identity of the client by using two identifying measures, prior to administering any medication. Weight and intake are not related to the safety of delivering this medication.

The nurse is providing care to a client who is unresponsive and has curled into the fetal position at the bottom of the bed. The nurse plans on moving the client to a side-lying position, supported by pillows. What will the nurse include in the plan to reposition the client? (Select all that apply.) A. Obtain the assistance of at least two others to assist with the transfer. B. When lifting the client, stand with feet wide apart. C. Coordinate responsibilities with the transfer team. D. Count to three and then initiate the transfer. E. Ask the client if it is okay to transfer to a side-lying position.

A, B, C, D Rationale:Providing ergonomic care is essential to the safety of the health care staff. All selections but E are included in ergonomic care. The nurse is encouraged to talk to the client, but this client is unable to give permission due to the unresponsive state.

The nurse is coordinating care for the terminal client planning for discharge to home. What services will the nurse include in the client's care? (Select all that apply.) A. Primary care provider B. Social worker C. Hospice D. Home nursing services E. Occupational therapy

A, B, C, D, E Rationale:The primary care provider will order the care necessary to support the client at home. Social services, hospice and nursing services work closely together to get the home care supplies, final arrangements, teaching about end-of-life care. The client may need modification to daily living to support the final days/weeks of life.

The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which actions will the nurse include in the procedure? (Select all that apply.) A. Use one syringe. B. Withdraw the regular insulin into the syringe and then add the NPH insulin. C. Add air into the vial of NPH insulin. D. Place the syringe containing the dose of NPH insulin into the vial of regular insulin. E. Inject air into the vial of regular insulin.

A, B, C, E Rationale:The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH. Air should first be injected into the NPH vial and then air should be inserted into the regular vial. NPH and regular insulin are compatible, and can be administered in one syringe. A syringe with NPH insulin is never mixed with regular insulin, for concerns of contamination of the regular insulin by the NPH insulin.

The nurse is providing care to a client admitted with shortness of breath who has recurrent bladder cancer. Which actions will the nurse include in the client's initial plan of care? (Select all that apply.) A. Presence of an advanced directive in the chart B. Determination of the client's oxygen saturation C. Presence of involved family D. Last radiographic results indicating metastasis E. Client's dietary preferences

A, B, D Rationale:An advanced directive gives the nurse information about the client's wishes regarding treatment. The O2 saturation will indicate to the nurse the physiologic response to the shortness of breath. Last radiographic results give the nurse an indication of the extent of the metastasis. While the remaining assessments help with understanding the client, they do not impact the initial plan of care.

A 78-year-old client is preparing for transfer from the hospital to a skilled facility to rehabilitate after a surgical repair of a broken hip. The client's spouse indicates to the nurse at the skilled facility that the client seems to be more confused since the surgery. What will the receiving nurse include in the client's plan of care? (Select all that apply.) A. Place the client close to the nurse's station. B. Place pictures of the family on the client's bedside table. C. Administer prn sleep aids every evening at 1900. D. Place a calendar on the wall opposite the clients' head of the bed. E. Apply restraints when the nurse is not in the room. F. Withhold fluids to decrease the risk of spilling.

A, B, D Rationale:Increased confusion can occur after surgery secondary to anesthesia. This is generally reversible and the client will return to baseline. During the period of confusion, the client will need to be monitored closely. The nurse needs to keep the client oriented and place familiar objects in the surroundings. There is no indication the client needs a sleep aid and they can increase levels of confusion. Restraints are a last resort; the nurse needs to attempt alternatives to restraints first. There is no indication in the stem that the client is at risk, and restraints are needed. Not all confused clients' needs restraints. There is no indication that the client is on a fluid restriction. Maintain toileting routine instead of restricting fluids.

The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which findings are indicative of abruptio placentae? (Select all that apply.) A. Dark red vaginal bleeding B. Rigid boardlike abdomen C. Soft abdomen on palpation D. Complaints of severe abdominal pain E. Painless bright red vaginal bleeding

A, B, D Rationale:These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E).

The nurse is speaking at a senior center about the physiologic changes that occur that can impact driving. Which factors will the nurse include in the teaching plan? (Select all that apply.) A. Muscle strength changes B. Reflexes become slower C. Blood volume increases D. High frequency tones less audible E. Decreased vision F. Decreased sensitivity to touch

A, B, D, E, F Rationale:These are all physiologic change in the elderly that could impact the alertness, reflexes, or sensory input needed to drive, except for blood volume. Blood volume decreases with age, impacting overall oxygenation.

The nurse is preparing for the admission of a client who had surgically placed radiation. What will the nurse include in the client's plan of care? (Select all that apply.) A. Place the client in a private room. B. Place a no visitors sign on the client's door. C. Place a linen hamper in the client's room. D. Place a lead-lined container in the client's room. E. Offer only soft foods while in the hospital.

A, C, D Rationale:The patient can have non-pregnant adult visitors while in the hospital as long as they stay approximately 5 feet from the client. Children and pregnant clients should not visit. As there is no indication where the radiation was placed, it is not known if the diet will be impacted. Since the implant was surgically placed, advance the diet as ordered for any postsurgical client. Keep the linens in the room for the duration of the client's stay since they have close proximity to the client and will absorb some of the radiation. Place a lead-lined container in the room in the event the radiation is dislodged. Never pick up a radiation implant with bare hands.

The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment (PPE) indicates the student requires further teaching regarding PPE? (Select all that apply.) A. Head covering B. fitted respirator or mask C. Sterile gloves D. Goggles E. Gown

A, C, D, E Rationale:The use of personal protective equipment (PPE) for airborne precautions includes a properly prefitted N95 respirator or mask. Options A, C, D, and E do not provide the appropriate respiratory equipment for airborne precautions. A surgical mask is used for preventing transmission of droplet precautions.

The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individuals? (Select all that apply.) A. An Rh-negative woman who has had a miscarriage at 24 weeks B. The father of a baby of an Rh-positive fetus C. An Rh-negative mother after delivery of an Rh-positive infant with a negative direct Coombs test D. An Rh-positive infant within 72 hours after birth E. An Rh-negative mother with a negative antibody titer at 28 weeks

A, C, E Rationale:(A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D).

The nurse is providing care to a newborn in the labor, delivery, recovery and postpartum unit. Which vaccinations should the nurse include in the newborns plan of care? (Select all that apply.) A. Hepatitis B B. Human papilloma virus (HPV) C. Varicella D. Meningococcal vaccine E. Vitamin K

A, E Rationale:The hepatitis B vaccination should be given to all newborns before hospital discharge. Vitamin K is administered shortly after birth as the newborn has no clotting mechanisms. HPV is not recommended until adolescence. Varicella immunization begins at 12 months. Meningococcal vaccine is administered beginning at 2 years.

When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A. Ascending numbness from the feet to the knees B. Decrease in cognitive status of the client C. Blurred vision and sensation changes D. Persistent unilateral headache

B Rationale:A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic status.

When caring for a client in labor, which finding is most important for the nurse to report to the primary health care provider? A. Maternal heart rate, 90 beats/min B. Fetal heart rate, 100 beats/min C. Maternal blood pressure, 140/86 mm Hg D. Maternal temperature, 100.0°F

B Rationale:A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress because the average FHR at term is 140 beats/min, and the normal range is 110 to 160 beats/min. Options A, C, and D are normal findings for a woman in labor.

The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? A. High level of anxiety present B. History of previous suicide attempt C. Family history of depression D. Self-care deficit is noted.

B Rationale:A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan. Options A, C, and D may also be risk factors but are not as significant as a history of previous attempts.

A nurse is assessing a client with heart failure who has been prescribed digoxin. Which finding concerns the nurse with the medication management? A. Regular heart rate of 88 beats/min B. Serum potassium level, 2.9 mEq/L C. Weight decreases by 1 lb daily. D. Serum sodium level, 138 mEq/L

B Rationale:A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbated when the potassium level is low. Options A, C, and D are all expected findings when caring for a client with congestive heart failure.

A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? A. Administer an antianxiety medication PRN. B. Assess the client's vital signs. C. Notify the primary health care provider. D. Determine coping mechanisms used in the past.

B Rationale:Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the client and rule out physiologic causes. Nonpharmacologic measures should be taken first. Options C and D may be considered but are not as high priority as the initial physiologic assessment.

The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? A. Ammonia odor is noted when the catheter is emptied. B. 240 mL of urinary output is produced in 12 hours. C. A 16-French catheter was used for an adult female. D. Drainage system is hanging below the level of the bladder.

B Rationale:An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr. Ammonia odor is an expected finding. Size 14- to 18-French catheters are common sizes used in the adult female. Below the level of the bladder is the correct position for the drainage bag.

Which data obtained during a respiratory assessment for a 58-year-old client is most important for the nurse to report to the primary health care provider?

B Rationale:An oxygen saturation lower than 90% indicates hypoxia. Options A, C, and D are all normal findings.

A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? A. Two-month-old who is unable to roll from back to abdomen B. Ten-month-old who cannot sit without support C. Nine-month-old who cries when his mother leaves the room D. Eight-month-old who has not yet begun to speak words

B Rationale:As a developmental milestone, infants should sit unsupported by 8 months. The milestone of rolling over is achieved at 5 to 6 months for most infants. Stranger anxiety is common from 7 to 9 months. Speaking a few words is expected at about 12 months.

When blood or blood products are administered, which task can be assigned to the licensed practical nurse (PN)? A. Initiation of the blood product B. Obtaining vital signs after infusion has begun C. Assessment of client's condition prior to blood administration D. Evaluation of client's response after receiving blood product

B Rationale:Blood and blood products must be initiated by the registered nurse (RN); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. Options A, C, and D are all part of the nursing process and the scope of the RN.

The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1. The health care provider has given the client a schedule for blood glucose testing. In addition to the prescribed schedule, what additional testing times will the nurse include in the clients instructions? A. Any time the client awakens during the night B. Whenever the client has feelings of dizziness C. Right after meals if insulin is not administered 30 minutes before the meal D. Only at scheduled times; additional testing is harmful to fingertips

B Rationale:Clients should be instructed to always check their blood glucose level whenever they feel faint or dizzy. There is great variability in recommendations for the frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, and then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test four times a day or as little as once each week, depending on the consistency of their diet and exercise and stability of their blood sugar level. Options A, C, and D provide inaccurate information.

The nurse is updating a client's plan of care (POC) who has full capacity to include a DNR order and refusal of anything by mouth. Another nurse states, "I think that it is wrong that the patient can refuse food and fluids! That is just inhumane!" What is the nurse's best response to the co-worker? A. "I think you are right. I will take that out of the POC." B. "My client has capacity and has the right to refuse treatment." C. "I don't disagree with you." D. "I will check with the client's spouse next."

B Rationale:Clients with capacity have the right to determination. The nurse must protect the client's autonomy. The focus of the correct statement is on the client and not on the nurse. The nurse is not acting as an advocate if the client's wishes are not adhered to. The client's spouse may know the client, but does not have the right to override the client's wishes when the client has capacity.

The nurse is providing care to a client with non-Hodgkin lymphoma who has been prescribed cyclophosphamide IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? A. Sores on the mouth or tongue B. Chills, fever, and sore throat C. Loss of appetite or weight with diarrhea D. Changes in color of fingernails or toenails

B Rationale:Cyclophosphamide is an immunosuppressive drug used to treat lymphoma and puts the client at risk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately. Options A and C are expected signs and symptoms of non-Hodgkin lymphoma. Option D is a normal side effect of cyclophosphamide.

The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first? A. Administer epinephrine. B. Defibrillate immediately. C. Give a bolus with isotonic fluid. D. Notify the health care provider.

B Rationale:Defibrillation is the first and most effective emergency treatment for ventricular fibrillation. Options A, C, and D may follow the first action.

A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? A. Insert a large-bore IV for fluid resuscitation. B. Prepare to assist with maintaining the airway. C. Cleanse the wounds using sterile technique. D. Administer an analgesic for pain.

B Rationale:High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care. Options A, C, and D are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway.

The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A. Assess the need to change a central line dressing. B. Soak the client's feet in a warm water bath C. Answer a family member's questions about the client's plan of care. D. Teach the client side effects to report related to the current medication regimen.

B Rationale:I Soaking feet is a simple treatment and is an appropriate skill for UAP to perform. Options A, C, and D are skills that cannot be delegated to UAP.

When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A. Sodium level, 137 mEq/L B. Potassium level, 5.5 mEq/L C. Blood urea nitrogen (BUN) level, 18 mg/dL D. Calcium level, 10 mEq/L

B Rationale:Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. Options A, C, and D are normal findings.

The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is <2 within 45 minutes after pain medication has been administered." Formulating the expected outcome reflects which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B Rationale:Planning allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. Assessment, implementation, and evaluation are part of the care for the client but are not the appropriate actions for formulating the expected outcome.

The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A. Suctions oral secretions from mouth B. Positions head of bed flat when changing sheets C. Takes temperature using the axillary method D. Keeps head of bed elevated at 30 degrees

B Rationale:Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration. Options A, C, and D are all acceptable tasks performed by the UAP.

The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? A. 9:30 am B. 10:30 am C. 12:00 pm D. 3:00 pm

B Rationale:Regular insulin is short-acting and peaks between 2 and 3 hours after administration. The client is most at risk for a hypoglycemic reaction during the peak times. Options A, C, and D are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time.

The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law? A. Social Security Act of 1990 B. American with Disabilities Act of 1990 C. Medicaid Act of 1965 D. Mental Health Act of 1946

B Rationale:The Americans with Disabilities Act guarantees the client the right to participate in treatment planning. Option A is a federal insurance program that provides benefits to retired persons, the unemployed, and the disabled. Option C is a program for eligible individuals and/or families with low income and resources. Option D provides for public education regarding psychiatric illnesses.

In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? A. A consistent fasting blood sugar level between 80 and 85 mg/dL B. A 2-hour postprandial level >120 mg/dL C. Client reports taking a 30-minute walk after dinner D. Client describes eating pattern of four to six meals daily

B Rationale:Two-hour postprandial levels >120 mg/dL may indicate the need for the initiation of insulin to maintain adequate blood glucose levels; consequently, a value >120 mg/dL should be assessed further. Fasting blood sugars between 80 and 85 mg/dL are normal. Options C and D are healthy behaviors for a woman with gestational diabetes.

The clinic nurse is performing an intake interview of a mother of the 5-year-old client. The mother reports a fever of 103 to 104°F/39.5 to 40°C for 3 days, muscle pain, fatigue, and a new break out of a red, flat rash along the child's hairline. What is the next nursing action? A. Ask if any siblings exhibit the same signs. B. Review the child's chart for immunizations. C. Ask where the child has been in the past 10 to 14 days. D. Take the child's weight.

B Rationale:The child is showing classic signs of measles. Checking for immunizations will confirm if the child received the MMR vaccine. Measles is highly contagious, and on the rise with the anti-vaccine movement. They were once thought to be eradicated. If this child was not vaccinated, then there is an increased chance that other siblings will not be immunized. However, the focus of the question is on the 5-year-old. Measles take 7 to 14 days to incubate after exposure. The child's weight may be down from lack of appetite, associated with the illness. However, determining the symptoms are possibly measles is the first step.

The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? A. Administer regular insulin IV. B. Start an IV infusion of normal saline. C. Check serum electrolyte levels. D. Give a potassium supplement.

B Rationale:The client in diabetic ketoacidosis (DKA) experiences severe dehydration and must be rehydrated before insulin is administered. Options A, C, and D will follow rehydration.

A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse anticipate the health care provider to prescribe which medication to treat this condition? A. Levofloxacin B. Acyclovir sodium C. Fluconazole D. Esomeprazole

B Rationale:The clinical manifestations listed are consistent with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or shingles. Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in the HIV client. Fluconazole is an antifungal and is used to treat candidiasis in the HIV client. Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease.

Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? A. Limit fluids to prevent infection to the surgical site. B. Place the infant in the prone position. C. Provide a low-residue diet to limit bowel movements. D. Cover sac with a moist sterile dressing.

B Rationale:The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum. Fluids should be increased postoperatively to prevent dehydration. A high-fiber diet should be implemented to prevent constipation. After the repair, the sac is no longer exposed, so option D does not apply.

A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed to control the symptoms. Before the next dose of magnesium is given, which assessment finding indicates that the client is at risk for toxicity? A. Deep tendon reflexes-decrease to 2+ B. 100 mL of urine output in 4 hours C. Respiratory rate decreases to 16 breaths/min D. Serum magnesium level, 7.5 mg/dL

B Rationale:The minimum urine output expected for a repeat dose of magnesium sulfate is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor excretion of magnesium, with a possible cumulative effect. Magnesium sulfate, a central nervous system (CNS) depressant, helps prevent seizures, so option A is a positive sign that the medication is having a desired effect. A decreased respiratory rate indicates that the drug is effective. A respiratory rate below 12 breaths/min indicates toxic effects. The therapeutic level of magnesium sulfate for a PIH client is 4 to 8 mg/dL.

When caring for a client with a tracheostomy, which action should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Teach the family about signs and symptoms of hypoxia. B. Take the vital signs 5 minutes before the procedure. C. Evaluate the need for tracheal suctioning. D. Revise the plan of care to include tracheostomy care.

B Rationale:The nurse may delegate obtaining vital signs; however, the nurse is responsible for following up on any reported data. Options A, C, and D are all part of the nursing process and should not be delegated under the nurse's scope of practice.

The nurse requests an increase in pain medication for a client with after an open laparotomy and stage 4 colon cancer was revealed. The existing client's order is for meperidine 25 mg IVP every 2 hours as needed for pain. The new order is for meperidine 75 mg IVP every 2 hours as needed for pain. What is the nurse's next action? A. Administer the new order. B. Contact the health care provider. C. Place naloxone at the client's beside. D. Administer half of the ordered medication.

B Rationale:The nurse must realize this is a large increase in pain medication and must clarify the order. Administering this large a dose, after receiving 25 mg places the client at risk for respiratory depression. Narcan at the bedside is a good idea, only after clarifying the dose. The nurse does not have prescriptive authority to determine the dose of medication.

A couple expresses concern and fear prior to having an amniocentesis to determine fetal lung maturity. To assist them in coping with this situation, what is the nurse's best action? A. Explain that harm to the fetus is highly unlikely. B. Answer all their questions regarding the procedure. C. Encourage them to verbalize their feelings. D. Show them a video about the procedure.

B Rationale:The nurse should allay their concerns by providing information about the procedure and answering questions. This action assists the couple in coping with the situation. Option A may offer false reassurance. Option C alone does not resolve the couple's fears. Although option D may be helpful, it is a passive activity, and the nurse's availability to answer questions is likely to be most helpful in calming their fears.

A client who is first day postoperative after a mastectomy becomes increasingly restless and agitated. Vital signs are temperature, 100°F; pulse, 98 beats/min; respirations, 24 breaths/min; and blood pressure, 120/80 mm Hg. Which action should the nurse take next? A. Administer a PRN dose of a prescribed analgesic. B. Assess the incision for any drainage or redness. C. Instruct the UAP to take vital signs hourly. D. Assist the client to a more comfortable position.

B Rationale:The nurse's priority is to observe for possible hemorrhage. The client is at high risk for hypovolemic shock and is exhibiting early symptoms of shock. Remember, in early shock the blood pressure may be stable or increase slightly as a compensatory mechanism. If there is no obvious indication of bleeding, the client should then be assessed for the need of an analgesic and options A, C, and D should be implemented.

The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step. 1. Drop prescribed number of drops into conjunctival sac. 2. Wash hands and apply gloves. 3. Place dominant hand on the client's forehead. 4. Close eye gently. A. 3, 2, 1, 4 B. 2, 3, 1, 4 C. 3, 2, 4, 1 D. 2, 3, 4, 1

B Rationale:Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (2). Placing the dominant hand on the client's forehead (3) stabilizes the hand so the nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (1); asking the client to close the eye gently helps distribute the medication (4).

The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which actions should the nurse expect to implement? (Select all that apply.) A. Administer aspirin with tissue plasminogen activator (t-PA). B. Complete the National Institute of Health Stroke Scale (NIHSS). C. Assess the client for signs of bleeding during and after the infusion. D. Start t-PA within 6 hours after the onset of stroke symptoms. E. Initiate multidisciplinary consult for potential rehabilitation.

B, C, E Rationale:Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

Which instructions should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A. Keep the medication in your pocket so that it can be accessed quickly. B. Call 911 if chest pain is not relieved after one nitroglycerin. C. Store the medication in its original container and protect it from light. D. Activate the emergency medical system after three doses of medication. E. Do not use within 1 hour of taking sildenafil citrate (Viagra).

B, C Rationale:Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with sildenafil (E).

The nurse delegates a dressing change to the LNP/LVN. The nurse provided care to the client immediately after returning from surgery 1 day ago. Which are the best statements for the RN to say to the LPN/LVN? (Select all that apply.) A. "I took care of the client yesterday. The client was very drowsy upon arrival from surgery." B. "Yesterday, the client's midline dressing was dry and intact upon arrival from surgery." C. "I changed the dressing yesterday and noted oozing at the distal portion of the incision." D. "Please let me know if the incision is not well approximated and is still oozing." E. "You can teach the client's spouse about how to change the dressing."

B, C, D Rationale:The RN must supervise the care of the dressing change and notify the care personnel of the condition of the wound. The client would expect to be drowsy upon arrival from surgery and that statement does not pertain to the dressing change. Teaching is the responsibility of the RN and not the LPN/LVN.

The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which actions should the nurse include in this client's plan of care? (Select all that apply.) A. Salt-free diet B. Quiet environment C. Deep tendon reflex assessments D. Neurologic checks E. Daily weights

B, C, D, E Rationale:Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional hyponatremia, which causes neurologic changes when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and assess deep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic deterioration. Daily weights (E) should be monitored to assess for fluid overload. (A) would contribute to dilutional hyponatremia.

A client is admitted with a diagnosis of leukemia. Which assessment findings will the nurse include in the client's plan of care? (Select all that apply.) A. Elevated platelets B. Weight loss C. Hyperplasia of the gums D. Elevated white blood count E. Weakness

B, C, D, E Rationale:Hyperplastic gums, weight loss, weakness, and elevated white blood count are classic signs of leukemia. Elevated platelets are not associated with leukemia.

The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? A. Potassium level, 3.9 mEq/dL B. Creatinine level, 1.1 mg/dL C. Sodium level, 125 mEq/L D. Calcium level, 9 mg/dL

C Rationale:The normal serum sodium level is 135 to 145 mEq/L. This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention. Options A, B, and D are all within normal parameters.

The nurse is providing care to 5 clients. Which nursing actions indicate the nurse is providing culturally competent care? (Select all that apply.) A. The nurse offers a meal tray with meatloaf to a client of the Catholic faith on a Friday between Ash Wednesday and Easter. B. Provide the client of the Jewish faith a menu with Kosher selections. C. Provide the client of the Islamic faith a meal tray during the day during the time of Ramadan. D. Provide the client of the Seventh-Day-Adventist faith a fluids selection of water, milk, or juice. E. Offer a tray with fruits and vegetables to a client who marked Hindu on the admission assessment form.

B, D, E Rationale:Many faiths practice food restrictions at certain times of the year. The nurse must be aware of these restrictions and plan for them while providing care. Those of the Catholic faith often avoid meat during the Lenten season. Those of the Jewish faith only eat animals that are vegetable eaters and are ritually slaughtered (Kosher). Fasting between sun up to sun down is practiced by those of the Islamic faith during Ramadan. Seventh-day-Adventists do not drink alcohol or fluids containing caffeine. Those who are Hindu are often vegetarians and do not eat meat of pork.

A client is admitted to the unit who has a history of seizure activity. What precautions will the nurse implement for this client? (Select all that apply.) A. Place the bed in high position B. Place suction equipment at the bed side C. Place a padded tongue blade at the bed side D. Pad the side rails of the bed E. Keep the lighting dim F. Have a sitter in the room at all times

B, D, E Rationale:Seizure precautions include placing the bed in low position or the mattress on the floor; place suction and oxygen at the bedside, pad the side rails, decrease environmental stimuli. Placing the bed in high position could place the client at risk for a fall. Tongue blades are not used in keeping the client's mouth open. An airway may be placed after the client has been placed in the recovery position. A sitter will not prevent a seizure.

Which actions should the nurse take when administering a new prescription of amitriptyline HCl to a client with a depressive disorder? (Select all that apply.) A. Explain that therapeutic effects should be achieved within 1 to 3 days. B. Administer at bedtime to minimize sedative effects. C. Give 1 hour after the administration of isocarboxazid (Marplan). D. Take blood pressure prior to and after administration. E. Assess for adverse reactions such as dry mouth and blurred vision.

B, D, E Rationale:The drug causes sedation, so it should be given at bedtime (B). Cardiovascular adverse reactions include orthostatic hypotension; therefore, the blood pressure should be assessed (D). This drug can cause anticholinergic effects such as dry mouth, blurred vision, constipation, and urinary retention (E). The drug takes 2 to 6 weeks to achieve therapeutic effects (A). All monoamine oxidase (MAO) inhibitors such as isocarboxazid should be discontinued 1 to 3 weeks prior to the administration of amitriptyline HCl(C).

Which interventions should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) A. Maintain bed rest for the first 6 hours after delivery. B. Palpate and massage the fundus to maintain firmness. C. Have client empty bladder if fundus is above umbilicus. D. Check perineal pad for color and consistency of lochia. E. Apply ice pack or witch hazel compresses to the perineum.

B, D, E Rationale:The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C).

The nurse is reviewing safety precautions with a client preparing to return home after a hip fracture. What instructions will the nurse include in the client's plan of care? (Select all that apply.) A. Move electrical wires under the carpet. B. Keep kitchen utensils in the same place. C. Secure throw rugs with tape around the edges. D. Purchase night lights for bathrooms, hallways, and bedrooms. E. Keep paths free from clutter.

B, D, E Rationale:The home needs to be free from trip hazards. Placing electrical cords under a carpet is a fire hazard. Keeping utensils in the same place decreases the need to move around to find objects. Throw rugs need to be removed. The edges of a taped down rug may curl and make a trip hazard. Nightlights illuminate pathways frequently used at night. Keeping areas free from clutter reduces the risk of falls.

Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? A. The client reports a continuous feeling of needing to void. B. Urinary drainage is pink 24 hours after surgery. C. The hemoglobin level is 8.4 g/dL 3 days postoperatively. D. Sterile saline is being used for bladder irrigation.

C Rationale:A hemoglobin level of 8.4 g/dL is abnormally low and may indicate hemorrhage. Options A, B, and D are all expected findings after a TURP.

Which intervention should the nurse include in the plan of care for a client admitted to the hospital with ulcerative colitis? A. Administer stool softeners. B. Place the client on fluid restriction. C. Provide a low-residue diet. D. Add a milk product to each meal.

C Rationale:A low-residue diet will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. Options A, B, and D are contraindicated and could worsen the condition.

The nurse prepares to administer digoxin, 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? A. Discontinue the digoxin. B. Notify the health care provider. C. Administer the digoxin. D. Reverify the digoxin level.

C Rationale:A therapeutic range for digoxin is 0.5 to 2 ng/mL. The digoxin should be continued to maintain a therapeutic range. Options A, B, and D are not indicated for a therapeutic range.

A 45-year-old client is admitted to the psychiatric unit for evaluation. The spouse states that client has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, and has been terminated. The nurse will build the client's plan of care around with likely diagnosis? A. Claustrophobia B. Acrophobia C. Agoraphobia D. Necrophobia

C Rationale:Agoraphobia is the fear of crowds or of being in an open place. Option A is the fear of being in closed places. Option B is the fear of high places. Option D is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety.

A client is being admitted to the step-down unit from the ICU. Which action will the nurse delegate to the aid who has worked on the unit for 12 years? A. Take the client's vital signs upon admission. B. Evaluate the client's ECG reading. C. Prepare the room with the routine supplies. D. Ask the client's spouse about how long they have been married.

C Rationale:Aides complete routine and predictable care, such as setting up a room in preparation for a client. Vital signs of a transfer client from the ICU may not be routine and the nurse will need to include them in the initial assessment. Assessment is the job of the RN and it includes assessment of the ECG. Asking the spouse about the duration of their marriage is a part of the psychosocial assessment. That does not mean that the aide cannot be friendly to the spouse.

An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl to IM fluphenazine decanoate because of medication noncompliance. What should the nurse teach the client and family about this client's medication regimen? A. Long-acting medication is more effective than daily medication. B. A client with substance abuse must not take any oral medications. C. There will continue to be a risk of alcohol and drug interaction. D. Support groups are only helpful for substance abuse treatment.

C Rationale:Alcohol enhances the side effects of fluphenazine HCl. The half-life of fluphenazine HCl PO is 8 hours, whereas the half-life of the fluphenazine decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting fluphenazine decanoate IM. Options A, B, and D provide incorrect information.

While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? A. Transfer the call into the room of the client. B. Instruct the secretary to explain the reason for the call. C. Ask another nurse to take the phone call. D. Ask the health care provider to see the client on the unit.

C Rationale:Another nurse should be asked to take the phone call, which allows the nurse to stay at the bedside to complete the assessment of the client's chest pain. Options A and B should not be done during an acute change in the client's condition. Requesting the health care provider to come to the unit is premature until the nurse completes assessment of the client's status.

The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? A. Uses descriptive words such as "gurgling" to describe breath sounds. B. Records temperature 30 minutes before and after giving acetaminophen. C. Charts some actions in advance of performing them. D. Includes the client's response to an intervention.

C Rationale:Charting actions prior to implementing them is an example of fraudulent charting, and the graduate nurse should receive further education. Options A, B, and D are appropriate charting examples.

When caring for a hospitalized child with type 1 diabetes mellitus, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Teach the signs and symptoms of hypoglycemia. B. Assess for polydipsia, polyphagia, and polyuria. C. Check the blood glucose level every 4 hours. D. Evaluate the need for a snack between meals.

C Rationale:Checking the blood glucose level is a low-risk task that can be safely delegated to the UAP in most circumstances. Teaching, assessment, and evaluation are all within the scope of practice of the RN and should not be delegated to the UAP.

The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? A. Fine crackles B. Wheezes C. Course crackles D. Stridor

C Rationale:Course crackles are caused by air passing through airways that are intermittently occluded by mucus. Fine crackles are a series of short-duration, discontinuous, high-pitched sounds. Wheezes are continuous, high-pitched, musical or squeaking-type sounds. Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the airway.

A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which measurement tool is best for the nurse to use during the initial assessment of this client? A. CAGE questionnaire for alcoholism B. Addiction Severity Index C. Glasgow Coma Scale D. DSM multiaxial evaluation

C Rationale:Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale, has the highest priority. Option A is useful in helping clients recognize their alcoholism. Options B and D are comprehensive assessments that should be completed after the acute phase is resolved.

A 12-year-old boy complains to the nurse that he is "short" (4′5″ [53 inches]). His twin sister is 5 inches taller than he is (4′10″ [58 inches]). Based on these findings, what conclusion should the nurse reach? A. The boy is not growing as normally expected. B. The girl is experiencing a period of unexpected growth. C. A normal growth spurt occurs in girls 1 to 2 years earlier than boys. D. Male-female twins are not identical; therefore, their growth cannot be compared.

C Rationale:Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age. There are insufficient data to support; growth trends must be assessed to reach such a conclusion. Option B is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female.

The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain. Which finding is most important to report to the primary health care provider? A. Takes medication with milk. B. Blood pressure, 104/64 mm Hg. C. Elevated liver enzyme levels. D. Hemoglobin level, 13 g/dL.

C Rationale:Indomethacin is an antiinflammatory drug and can cause liver damage. Elevated liver enzyme levels indicate a complication with the drug. This medication should be taken with food or milk to reduce gastrointestinal (GI) side effects. Options B and D are normal findings.

When administering an intramuscular injection, which factor will the nurse consider is most important to ensure the best medication absorption? A. Compress the syringe plunger quickly. B. Select a small-gauge needle. C. Inject the needle at a 90-degree angle. D. Select a small-diameter syringe.

C Rationale:Injecting the needle at a 90-degree angle allows the medication to be injected into the muscle so that appropriate absorption can occur. Too rapid injection of the medication may be painful and may cause medication leakage and reduced absorption. Option B will reduce injection discomfort but will not affect absorption. A syringe barrel that is too small increases the pressure during the injection and may traumatize tissue without improving medication absorption.

A client is admitted to a mental health unit because of mild depression. When asked, the client denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which nursing action is most important for this client? A. Orient the client to activities on the unit. B. Document suicide precautions on the shift report. C. Assign the client to a semiprivate room. D. Obtain a verbal no-suicide contract with the client.

C Rationale:It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room. Option A does not have the priority of option C. Options B and D can be implemented if the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is most important to prevent social isolation.

The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A. Draw arterial blood gases. B. Notify the primary health care provider. C. Position in a high Fowler position with the legs down. D. Obtain a chest x-ray.

C Rationale:Positioning the client in a high Fowler position with dangling feet will decrease further venous return to the left ventricle. Options A, B, and D should be performed after the change in position.

Which disaster management intervention by the nurse is an example of primary prevention? A. Emergency department triage B. Follow-up care for psychological problems C. Education of rescue workers in first aid D. Treatment of clients who are injured

C Rationale:Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury. Option A is an example of secondary prevention. Option B is an example of tertiary prevention. Option D is an example of secondary prevention.

The nurse reports to the unit manager, "I almost gave medication to the client in 123A, and it was the client's medication in 123B." What is the manager's best response? A. "Do you know why that happened?" B. "You should be more careful when passing medications." C. "I am glad you reported this near miss." D. "I will have another nurse take over the care for the client in 123A."

C Rationale:Reporting near misses is important for quality client care. Investigating the near miss occurrences helps to alert hospital management to gaps in practice, and helps to plan for future events. Praise the nurse and not make the nurse feel defensive for reporting the near miss. Reporting near misses is just as important as reporting errors, so the root cause can be determined. Having another nurse provide care for the client, e.g. splitting the assignment, does not address foundation of the issues; it only offered a temporary fix.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? A. The apical heart rate is 64 beats/min. B. The serum digoxin level is 1.5 ng/mL. C. The client reports seeing yellow-green halos. D. The potassium level is 4.0 mEq/L.

C Rationale:Reports of yellow-green halos and blurred vision are signs of digoxin toxicity. Options A, B, and D are normal findings.

The nurse is assessing 38-year-old client with tuberculosis who is taking rifampin. Which finding would be most important to report to the primary health care provider immediately? A. Orange-colored urine B. Potassium level, 4.9 mEq/L C. Elevated liver enzyme levels D. Blood urea nitrogen (BUN) level, 12 mg/dL.

C Rationale:Rifampin can cause hepatotoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider. Orange discoloration of the urine is an expected side effect of this medication. The potassium level is normal. A BUN level of 12 mg/dL is within defined parameters.

A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? A. "The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what you say." B. "You can be assured that I will keep all of our conversations confidential because it is important that you can trust me." C. "For your safety and well-being, it may be necessary to share some of our conversations with the health care team." D. "I am legally required to document all of our conversations in the electronic medical record."

C Rationale:Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy. HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue. Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue. Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client.

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

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

Which clinical manifestation in the client with hyperthyroidism is most important for the nurse to report to the health care provider? A. Nervousness B. Increased appetite C. Apical heart rate of 130 beats/min D. Insomnia

C Rationale:The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders. Options A, B, and D are all expected findings that should also be reported but are not as critical.

Which vital sign in a pediatric client is most important for the nurse to report to the primary health care provider? A. Newborn with a heart rate of 140 beats/min B. Three-year-old with a respiratory rate of 28 breaths/min C. Six-year-old with a heart rate of 130 beats/min D. Twelve-year-old with a respiratory rate of 16 breaths/min

C Rationale:The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min. Options A, B, and D are all within normal range for those ages.

The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV

C Rationale:The statement above describes a stage III ulcer, which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle. A stage I ulcer includes intact skin with nonblanchable redness of a localized area. A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed. Full-thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer.

Which of the following cardiac rhythms is represented in the image? A. Normal sinus rhythm B. Sinus tachycardia C. Ventricular fibrillation D. Atrial fibrillation

C Rationale:Ventricular fibrillation is a life-threatening arrhythmia characterized by irregular undulations of varying amplitudes. Options A, B, and D are not represented in the image.

Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A. States having difficulty with color perception B. Presents with opacity of the lens upon assessment C. Complains of seeing a cobweb-type structure in the visual field D. Reports the need to use a magnifying glass to see small print

C Rationale:Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss are expected signs and symptom of cataracts but do not need immediate attention.

The nurse is providing care to an elderly client admitted with influenza. What precautions will the nurse take when providing care to this client? (Select all that apply.) A. Don gloves when providing direct client care. B. Wear a disposable gown when in the client's room. C. Wear a mask when planning on being within 3 feet of the client. D. Place the client in a private room. E. Have the client wear a mask when outside of the assigned room.

C, D, E Rationale:Clients with the flu are on droplet precautions. These precautions include: private room or a room with another client with the flu, mask when in close proximity to the client, have the client wear a mask when leaving the room. The use of gloves outside of standard precautions is not necessary as well as the use of a disposable gown.

The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer for one dose from the bottle supplied as below? A. 0.5 mL B. 0.6 mL C. 5 mL D. 9 mL

D Rationale:15 mg/kg × 15 kg = 225 mg to be administeredSupply = 125 mg/5 mL(5 mL/125 mg) × 225 mg = 9 mLor(225 mg/125 mg) × 5 mL = 9 mL

The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; PCO2, 50 mm Hg; PO2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis

D Rationale:A pH <7.25 and PCO2 >45 mm Hg with a normal HCO3 indicates respiratory acidosis. Options A, B, and C are incorrect analyses of the ABGs.

A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make? A. "It's normal to feel ambivalent about a pregnancy when you are not feeling well." B. "I think you should discuss these feelings with your health care provider." C. "How does the father of your child feel about your having this baby?" D. "Tell me about these second thoughts you are having about this pregnancy."

D Rationale:Although ambivalence is normal during the first trimester, option D is the best nursing response at this time. It is reflective and keeps the lines of communication open. Option A is not the best response because it offers false reassurance. Option B dismisses the client's feelings. The nurse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. Option C may eventually be discussed, but it is not the most important information to obtain at this time.

The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? A. Increase the rate of the heparin infusion using a nomogram. B. Decrease the heparin infusion rate and give vitamin K IM. C. Continue the heparin infusion at the current prescribed rate. D. Stop the heparin drip and prepare to administer protamine sulfate.

D Rationale:An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate. Increasing the rate would increase the risk for hemorrhage. The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin). Keeping the infusion at the current rate would increase the risk for hemorrhage.

The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? A. The pupils become equal and reactive to light. B. The client reports an inability to tolerate light. C. Bilateral visual accommodation is restored. D. The right pupil dilates after drop instillation.`

D Rationale:Atropine is a mydriatic drug which causes pupil dilation and paralysis in preparation for surgery or examination. Options A and C do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery. Light intolerance is an outcome of pupil dilation.

The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing action has the greatest priority when planning this client's care? A. Palpate for pitting edema. B. Provide meticulous skin care. C. Administer phosphate binders. D. Monitor serum potassium levels.

D Rationale:Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be life threatening. One sign of fluid retention is pitting edema, but it is an expected symptom of renal failure and is not as high a priority as option D. Options B and C are common nursing interventions for CRF but not as high a priority as option D.

The nurse witnesses a physical therapist roughly handle a client while transferring from the bed to the chair. Who should the nurse contact with this information? A. The Director of Physical Therapy B. The client's family C. The client's health care provider D. The nurse manager

D Rationale:In this case, the nurse must implement the chain of command. The nurse manager is the person next in the chain. The manager will launch an investigation with this information.

Which monitored pattern of fetal heart rate alerts the nurse to seek immediate action by the health care provider? A. An increase from 142-150 to 160-168 beats/min with fetal movement B. A decrease from the baseline of 138-148 to 128-132 beats/min that mirrors the contraction pattern C. A baseline fetal heart rate from 112 to 120 beats/min between contractions D. A baseline fetal heart rate from 168 to 170 beats/min with a decline in the heart rate after the onset of a contraction

D Rationale:Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous. 130 beats/min is an expected heart rate. Options A and B are not as critical.

The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should the nurse implement first? A. Restrain the client to protect from injury. B. Flex the neck to ensure stabilization. C. Use a tongue blade to open the airway. D. Turn client on the side to aid ventilation.

D Rationale:Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are contraindicated during a seizure and may cause further injury to the client.

A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? A. Increased hemoglobin and hematocrit levels B. Increased serum calcium level C. Decreased white blood cell (WBC) count D. Decreased triiodothyronine (T3) and thyroxine (T4) levels

D Rationale:Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones. It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It does not affect option A. Option B must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the client has an infection preoperatively, antibiotics will be given and option C monitored.

When assessing safety for the older adult, which finding is the nurse's highest priority? A. The client has a cataract in the right eye. B. The client is not married and lives alone. C. The client lives in a two-story building. D. The client reports a history of repeated falls.

D Rationale:Risk assessment for falls is a critical element in caring for the older adult. Options A, B, and C are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again.

An older client calls the clinic and complains of feeling very weak and dizzy. Further assessment by the nurse indicates that the client self-administered an enema of 3 L of tap water because of constipation. What is the most likely cause of the client's symptoms? A. Mucosal bleeding B. Sodium retention C. Fluid volume depletion D. Water intoxication

D Rationale:Tap water is a hypotonic fluid that can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication. This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress. Excessive use of enemas can cause mucosal irritation, which might result in some bleeding, but the client would not experience weakness and dizziness unless she was hemorrhaging. Options B and C can occur with the use of a hypertonic rather than hypotonic solution.

The nurse is planning care at the beginning of the shift. Which client will the nurse see first? A. The client who is waiting to go to the operating room B. The client who received a blood transfusion 4 hours ago C. The client awaiting transfer to the skilled unit D. The client with a new onset of a temperature of 102°F/38.9°C

D Rationale:The change in the client's condition is the indication for the nurse's attention. The remaining clients have no indication that there is a change in condition.

An adult presents to the mental clinic trembling and crying, and becomes distressed when the nurse attempts to conduct an assessment. What is the best nursing action for this client? A. Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B. Explain that treatment is based on information obtained in the assessment. C. Encourage the client to relax so that information can be provided as requested D. Empower the client to share the story of events just prior to coming to the clinic.

D Rationale:The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. Option D is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of blood pressure might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack is argumentative. Option B suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax is likely to increase her anxiety.

The nurse is caring for a client immediately after electroconvulsive therapy (ECT). Which nursing action is next? A. Reorient the client to surroundings. B. Assess blood pressure every 15 minutes. C. Determine if muscle soreness is present. D. Maintain a patent airway.

D Rationale:The client is typically unconscious immediately following ECT, and nausea is a common side effect. The nurse should take measures to prevent aspiration and maintain a patent airway. Clients may be confused after ECT, but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority. Muscle soreness is an expected finding after ECT.

The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A. "I know many women who have survived ovarian cancer." B. "Let's talk about the treatments of ovarian cancer." C. "In my opinion I would suggest getting a second opinion." D. "Tell me about what you are feeling right now."

D Rationale:The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic communication for the client.

The nurse looks up the chart of a cousin who is not under the care of the nurse. The manager is notified by the computer technology department that one of the nurses on the unit accessed a chart of a client not on the unit. What is the manager's next action? A. Inform the manager where the cousin is located. B. Contact the cousin to indicate confidentiality was breeched. C. Schedule the nurse for an appointment. D. Reach out to the Human Resources Department.

D Rationale:The nurse has breached confidentiality with is an offense which can lead to termination. The steps toward lawful termination will need to be reviewed with HR prior to initiating the termination. The manager will need to meet with the offending nurse, but the step to termination occurs before the appointment. Client and manager awareness of the breach of confidentiality occurs after the manager receives steps from Human Resources.

The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A. An 18-year-old woman who had a positive pregnancy test and wants advice on how to tell her parents B. A woman with type 1 diabetes who has just discovered she is pregnant and is worried about her fingerstick glucose C. A woman at 24 weeks of gestation crying about painful genital lesions on the vulva and urinary frequency D. A woman at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn

D Rationale:The woman with epigastric pain should be called first. One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. Options A, B, and C are less serious and should be called after option D.

The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all that apply.) A. Ventricular septal defect (VSD) B. Patent ductus arteriosus (PDA) C. Coarctation of the aorta D. Tetralogy of Fallot E. Transposition of the great vessels

D, E Rationale:Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). (A, B, and C) are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects.