I GUESS ITS NEVER REALLY OVER

The nurse is observing a new nursing graduate who is preparing an intermittent intravenous (IV) infusion of phenytoin for a client with a diagnosis of seizures. Which solution used by the nursing graduate should indicate to the nurse an understanding of proper preparation of this medication? 1. 5% dextrose in water 2. 0.9% sodium chloride 3. Lactated Ringer's solution 4. 5% dextrose and 0.45% sodium chloride

2. 0.9% sodium chloride Rationale: Intermittent IV infusion of phenytoin is administered by injection into a large vein, using normal saline solution. Dextrose solutions are avoided because the medication will precipitate in these solutions. Therefore, the options containing dextrose identify incorrect solutions for IV administration with this medication. In addition, lactated Ringer's solution contains electrolytes that can interfere with phenytoin administration

Capecitabine has been prescribed for a client, and the client asks the nurse about the action of the medication. The nurse formulates a response based on which mechanism of action of this medication? 1. Promotes DNA synthesis 2. Interferes with protein synthesis 3. Assists with the processing of RNA 4. Processes enzymes needed for cellular growth

2. Interferes with protein synthesis Rationale: Capecitabine is an antimetabolite that inhibits enzymes necessary for the synthesis of essential cellular components. It interferes with DNA synthesis, RNA processing, and protein synthesis. Capecitabine does not promote DNA synthesis, assist with the processing of RNA, or process enzymes needed for cellular growth.

The nurse notes that a client is receiving lamivudine. The nurse determines that this medication has been prescribed to treat which condition? 1. Pancreatitis 2. Pharyngitis 3. Tonic-clonic seizures 4. Human immunodeficiency virus (HIV)

4. Human immunodeficiency virus (HIV) Rationale: Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and provide prophylaxis in health care workers who are at risk of acquiring HIV infection after occupational exposure to the virus. This medication is not used to treat the conditions identified in the remaining options.

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? A. Anxiety B. Powerlessness C. Disruption of thought processes D. Inability to maintain health

A. Anxiety

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. A. Fatigue B. Anemia C. Weight loss D. Low-grade fever E. Joint deformities

A. Fatigue D. Low-grade fever

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? A. "Do you chew tobacco?" B. "Do you smoke cigarettes?" C. "Have you ever worked in a mine?" D. "Are you frequently exposed to paint products?"

C. "Have you ever worked in a mine?"

A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? A. Insomnia B. Rigidity and akinesia C. Bilateral lung wheezes D. Orthostatic hypotension

C. Bilateral lung wheezes

A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: A. Is a measure of the client's hematocrit level B. Is a measure of the client's hemoglobin level C. Helps predict the risk for the development of chronic complications of diabetes mellitus D. Provides a determination of short-term glycemic control in the client with diabetes mellitus

C. Helps predict the risk for the development of chronic complications of diabetes mellitus

Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication? A. The client has a history of cataracts. B. The client has a history of hypothyroidism. C. The client takes a prescribed antihypertensive. D. The client is allergic to acetylsalicylic acid (aspirin).

C. The client takes a prescribed antihypertensive.

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: A. Corn B. Cocoa C. Peaches D. Sardines

D. Sardines

The nurse presents a seminar on sexually transmitted infections. Which information about syphilis should the nurse include in this presentation? Select all that apply. 1. A blood test will confirm the diagnosis. 2. Syphilis signs and symptoms are divided into stages. 3. Syphilis can be spread through vaginal, anal, or oral sex. 4. Having syphilis once provides lifelong immunity from repeat infection. 5. Syphilis will always be present in a chronic state, as there is no cure for this illness.

1. A blood test will confirm the diagnosis. 2. Syphilis signs and symptoms are divided into stages. 3. Syphilis can be spread through vaginal, anal, or oral sex. Rationale: Syphilis can be cured with the initiation of prompt treatment. A blood test can confirm this diagnosis. Syphilis is staged in relation to signs and symptoms and the length of the infection. Syphilis may be transmitted via vaginal, anal, or oral sex. An individual may be positive for syphilis more than once. Syphilis can be cured by early treatment.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank. 5. Take adequate amounts of vitamin C several days prior to the surgery date.

1. Ask a family member to donate blood ahead of time. 2. Give an autologous blood donation before the surgery. Rationale: A donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is to ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are helpful for iron deficiency anemia but are not helpful in replacing blood lost during the surgery. Vitamin C enhances iron absorption, but also is not helpful in replacing blood lost during surgery

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply. 1. Avoid activities that require bending over. 2. Contact the surgeon if eye scratchiness occurs. 3. Take acetaminophen for minor eye discomfort. 4. Expect episodes of sudden severe pain in the eye. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs. Rationale: Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure (IOP). The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase IOP, such as bending over.

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply. 1. Chills 2. Fatigue 3. Sleepiness 4. Chest pain 5. Lower back pain 6. Difficulty breathing

1. Chills 4. Chest pain 5. Lower back pain 6. Difficulty breathing Rationale: The nurse should instruct the client to immediately report signs of a transfusion reaction, which can include chest pain, lower back pain, chills, itching, rash, or difficulty breathing. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue and sleepiness are unrelated to transfusion reaction.

The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. 1. Easy bruising occurs. 2. Gum bleeding occurs. 3. It is a hereditary bleeding disorder. 4. Treatment and care are similar to that for hemophilia. 5. It is characterized by extremely high creatinine levels. 6. The disorder causes platelets to adhere to damaged endothelium.

1. Easy bruising occurs. 2. Gum bleeding occurs. 3. It is a hereditary bleeding disorder. 4. Treatment and care are similar to that for hemophilia. 6. The disorder causes platelets to adhere to damaged endothelium.

A client is undergoing a 2-hour glucose tolerance test. The nurse assesses for which client factors that can interfere with the test period results? Select all that apply. 1. Experiencing stress 2. Fasting before the test period 3. Voiding during the test period 4. Eating a small snack or candy during the test period 5. Having an episode of diarrhea before the test period 6. Being unable to eat the entire test meal or vomiting some or all of the meal

1. Experiencing stress 4. Eating a small snack or candy during the test period 6. Being unable to eat the entire test meal or vomiting some or all of the meal Rationale: Some interfering factors that can result in inaccurate test findings include experiencing stress, being unable to eat the entire test meal or vomiting during the test period, and eating a small snack or candy during the test period. Voiding during the test period, fasting for 4 hours before the test period, and having an episode of diarrhea before the test period would not interfere with the test results.

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH? 1. Fall 2. Rise 3. Double 4. Remain unchanged

1. Fall Rationale: CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

The nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription requires follow-up by the nurse? 1. Full liquid diet 2. Morphine sulfate for pain 3. Nasogastric tube insertion 4. An anticholinergic medication

1. Full liquid diet Rationale: The client with acute pancreatitis is placed on NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

The nurse is participating in a prostate screening clinic for men. Which complaints by a client are associated with prostatism? Select all that apply. 1. Inability to stop urinating 2. Postvoid dribbling of urine 3. Increased episodes of nocturia 4. Unusual force in urinary stream 5. Hesitancy on initiating the urinary stream

1. Inability to stop urinating 2. Postvoid dribbling of urine 3. Increased episodes of nocturia 5. Hesitancy on initiating the urinary stream Rationale: Signs and symptoms of prostatism include reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating, a sensation of incomplete bladder emptying after voiding, postvoid dribbling of urine, and an increase in episodes of nocturia. These signs and symptoms are the result of pressure of the enlarging prostate on the client's urethra.

The nurse is monitoring the client with a serum calcium level of 6.2 mg/dL (1.55 mmol/L). Which findings should the nurse assess for in the client? Select all that apply. 1. Irritability 2. Muscle cramps 3. Tingling sensations 4. Hyperactive reflexes 5. Memory impairment 6. Severe muscle weakness

1. Irritability 2. Muscle cramps 3. Tingling sensations 4. Hyperactive reflexes 5. Memory impairment Rationale: Begin by recalling the normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L) to determine that the client is experiencing hypocalcemia. Signs of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive Trousseau's or Chvostek's sign. Other signs include increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Severe muscle weakness is seen in hypercalcemia, not hypocalcemia.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1. Jaundice 2. Flulike symptoms 3. Clay-colored stools 4. Elevated bilirubin levels 5. Dark or tea-colored urine

1. Jaundice 3. Clay-colored stools 4. Elevated bilirubin levels 5. Dark or tea-colored urine Rationale: There are 3 stages associated with viral hepatitis. The first (preicteric) stage includes flulike symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. Which assessment findings by the nurse are characteristic of this disorder? Select all that apply. 1. Red throat 2. Cracking lips 3. Conjunctival hyperemia 4. Desquamation of the skin 5. Enlargement of the cervical lymph nodes

1. Red throat 3. Conjunctival hyperemia 5. Enlargement of the cervical lymph nodes Rationale: Kawasaki disease is known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory disease. Assessment findings in the acute stage include fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. Desquamation of the skin, cracking lips, joint pain, cardiac manifestations, and thrombocytosis are characteristics of the subacute stage.

A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. 1. Remain calm. 2. Time the seizure. 3. Ease the child to the floor. 4. Loosen restrictive clothing. 5. Keep the child on her back.

1. Remain calm. 2. Time the seizure. 3. Ease the child to the floor. 4. Loosen restrictive clothing. Rationale: When a child is having a seizure, the nurse should remain calm, time the seizure, ease the child to the floor if the child is standing or seated, keep the child on the side (to prevent aspiration), and loosen restrictive clothing.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

1. The client is aphasic. 2. The client has weakness on the right side of the body. 4. The client has weakness on the right side of the face and tongue. Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

1. U waves 3. Inverted T waves 4. Depressed ST segment Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

The nurse is admitting a client and knows that clients typically share information about herbal supplements or therapies only if they are specifically asked. What are some additional things the nurse needs to do when dealing with this topic with clients? Select all that apply. 1. Use open-ended questions. 2. Ask the client where she bought the supplements. 3. Respond to clients with comments that invite an open-minded discussion. 4. Ask the client if the health care provider knows the client is taking these. 5. Document the use of any herbal product(s) or dietary supplements in the client record. 6. Create an accepting and nonjudgmental attitude when assessing use of or interest in herbal products or dietary supplements.

1. Use open-ended questions. 3. Respond to clients with comments that invite an open-minded discussion. 5. Document the use of any herbal product(s) or dietary supplements in the client record. 6. Create an accepting and nonjudgmental attitude when assessing use of or interest in herbal products or dietary supplements. Rationale: The nurse's role in assessing a client regarding the use of any herbal supplements or therapies includes the following: using open-ended questions such as, "What types of herbs, vitamins, or supplements do you take?" and "What effects have you noticed from using them?" The nurse should respond to clients with comments that invite an open-minded discussion and should document the use of any herbal product(s) or dietary supplements in the client record. The nurse's role does not include asking the client where they were bought or questioning the client about the HCP's awareness of this issue.

The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk? 1. "What are you feeling right now?" 2. "Do you have a plan to commit suicide?" 3. "How many times have you attempted suicide in the past?" 4. "Why were your attempts at suicide unsuccessful in the past?"

2. "Do you have a plan to commit suicide?" Rationale: When assessing for suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although the other options are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." 3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." Rationale: Rubella vaccine is a live attenuated virus that provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. Informed consent for rubella and varicella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months (or as indicated by the health care provider) after administration of the vaccine. Abstinence from sexual intercourse is unnecessary. Heat or extreme changes in temperature have no effect on the person who has been vaccinated. The vaccine is not known to cause anaphylactic reactions.

A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position? 1. Flat in bed 2. A semi Fowler's position 3. Lateral on the affected side 4. Lateral on the unaffected side

2. A semi Fowler's position Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as a penetrating injury from a BB or pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2. Ask the client about the amount of drug use and its effect. Rationale: Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed? 1. Older adults tend to report pain less often than do younger adults. 2. Clients in this age group are less sensitive to pain and have a greater pain tolerance. 3. Mental images of pain are a less effective means to assess pain in this group than visual representations. 4. Pain in the cognitively impaired older adult may require more frequent assessments than in clients who are not impaired.

2. Clients in this age group are less sensitive to pain and have a greater pain tolerance. Rationale: Cognitive impairment in the older adult acts as a barrier to pain assessment, and pain may be more accurately reported at the moment when it occurs than when prompted by the nurse. Clients in this age group are not less sensitive to pain and do not necessarily have a greater pain tolerance. The other options are correct statements.

The community health nurse is preparing an educational class on ovarian cancer for a group of women. Which signs and symptoms should the nurse include in the presentation? Select all that apply. 1. Feeling hungry all the time 2. Having urinary urgency or frequency 3. Experiencing pelvic or abdominal swelling 4. Sense of feeling that something is "falling out" 5. Developing a macular-papular rash over the abdomen

2. Having urinary urgency or frequency 3. Experiencing pelvic or abdominal swelling Rationale: Signs and symptoms of ovarian cancer are often very subtle. Urinary urgency or frequency, abdominal or pelvic pain or swelling, vague gastrointestinal disturbances such as dyspepsia or gas, and unexplained weight loss are potential signs and symptoms and require further investigation. Hunger and a rash are not associated with this condition. A sense of something "falling out" may be reported by the client experiencing uterine prolapse.

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. 1. Allergy to pollen 2. History of headaches 3. Previous back injury 4. History of hypertension 5. History of diabetes mellitus

2. History of headaches 3. Previous back injury 4. History of hypertension 5. History of diabetes mellitus Rationale: Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem.

A client with diabetes mellitus is at risk for a serious metabolic disorder from the breakdown of fats for conversion to glucose. The nurse should anticipate that which substance will be elevated? 1. Glucose 2. Ketones 3. Glucagon 4. Lactate dehydrogenase

2. Ketones Rationale: Ketones are a byproduct of fat metabolism. When this process occurs to an extreme, the resulting condition is called ketoacidosis. The remaining options are not associated with the breakdown of fats.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 5. Instruct the client to avoid exposure to the sun. Rationale: Ketoconazole is an antifungal medication. There is no reason for the client to restrict fluid intake; in fact, this could be harmful to the client. The medication is hepatotoxic, and the nurse monitors liver function. It is administered with food (not on an empty stomach) and antacids are avoided for 2 hours after taking the medication to ensure absorption. The client is also instructed to avoid alcohol. In addition, the client is instructed to avoid exposure to the sun because the medication increases photosensitivity.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.

2. Obtain equipment for a manual pelvic examination. Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve? 1. Ask the client to puff out the cheeks. 2. Separate the client's jaw by pushing down on the chin. 3. Place a small amount of sugar on the client's tongue and ask him or her to identify the taste. 4. Ask the client to rotate the head forcibly against resistance applied to the side of his or her chin.

2. Separate the client's jaw by pushing down on the chin. Rationale: The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1. Reduce fluid intake to less than 1500 mL/day. 2. Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy. 5. Keep the client in a supine position as much as possible.

2. Teach diaphragmatic and pursed-lip breathing. 3. Encourage alternating activity with rest periods. 4. Teach the client techniques of chest physiotherapy. Rationale: Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client should be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. 1. Tell the client that testing is not necessary unless arthralgia develops. 2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 5. Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic.

2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect.

A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply. 1. The client is wearing sneakers. 2. The client is wearing knee-high nylon stockings. 3. The client is wearing flat shoes with rubber soles. 4. The client is wearing pants with an elastic waistband. 5. The client is wearing sweatpants with snug elastic ankle bands.

2. The client is wearing knee-high nylon stockings. 5. The client is wearing sweatpants with snug elastic ankle bands. Rationale: Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing such as knee-high stockings or snug elastic ankle bands impedes venous return from the lower legs and thus places the client at higher risk for developing varicosities. Clients should be encouraged to wear pantyhose or support hose. Flat nonslip shoes with proper support are important to assist the pregnant woman to maintain proper posture and balance and to minimize the risk for falls. Pants with an elastic waistband are comfortable and are not constricting

On admission the client tells the nurse that sumatriptan is prescribed. Based on this information, which question should the nurse ask the client? 1. "Do you have frequent earaches?" 2. "Do you experience sinus headaches?" 3. "Have you had migraine headaches?" 4. "Are you allergic to pollen or molds?"

3. "Have you had migraine headaches?" Rationale: Sumatriptan is used to treat migraine headaches. This medication constricts blood vessels around the brain and reduces substances in the body that can trigger headache pain. Sinus earaches, headaches, and allergies to pollen or mold are not treated with this medication.

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments? 1. "I should avoid all contact with my family." 2. "I should avoid large crowds for at least 3 weeks." 3. "I cannot give Legionnaires' disease to other people." 4. "I will have to take antibiotics until my symptoms disappear."

3. "I cannot give Legionnaires' disease to other people." Rationale: Legionnaires' disease is spread through infected aerosolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription; therefore, the remaining options are incorrect.

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." Rationale: The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.

The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply. 1. "Educational topics are always determined by the nurse." 2. "All clients view education about their health status as important." 3. "The population served will determine the culturally sensitive resources to use for teaching." 4. "Assessment of a client's preferred learning approach is essential to facilitate the learning process." 5. "It is important to have an accurate translator when the nurse and client do not speak the same language."

3. "The population served will determine the culturally sensitive resources to use for teaching." 4. "Assessment of a client's preferred learning approach is essential to facilitate the learning process." 5. "It is important to have an accurate translator when the nurse and client do not speak the same language." Rationale: Providing culturally competent care or education is an important aspect of nursing. Care or education must be emphatically based on the client's culture; otherwise the care or education is not specific to the client. The correct options address culturally specific and individualized care. Options 1 and 2 are not individually focused.

The nurse is providing instructions to the parents of a child with a hernia regarding measures that will promote reducing the hernia. The nurse determines that the parents understand care for their child if they make which statement? 1. "We will encourage our child to cough every few hours on a daily basis." 2. "We will make sure that our child participates in physical activity every day." 3. "We will provide comfort measures to reduce any crying periods by our child." 4. "We will be sure to give our child a Fleet enema every day to prevent constipation."

3. "We will provide comfort measures to reduce any crying periods by our child." Rationale: A warm bath, avoidance of upright positioning, and other comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activity and enemas of any type would increase the strain on the hernia.

A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? 1. "Apply warm packs to the leg." 2. "Keep the leg elevated as much as possible." 3. "Your health care provider needs to be contacted to report this problem." 4. "This normally occurs after surgery and will subside when the edema goes down."

3. "Your health care provider needs to be contacted to report this problem." Rationale: A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. The remaining options are inaccurate responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential complications include bruising, tightness along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy the varices and then removes the pieces via aspiration

The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? 1. Elevating the limb 2. Monitoring vital signs every 4 hours 3. Administering opioid analgesics intramuscularly 4. Monitoring the biopsy site for swelling, bleeding, or hematoma

3. Administering opioid analgesics intramuscularly Rationale: Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours or as prescribed to reduce edema. The vital signs are monitored every 4 hours for 24 hours for signs of complications such as infection and bleeding. The client usually requires mild analgesics. More severe pain usually indicates that complications are arising.

The nurse is caring for a child with a diagnosis of hemophilia, and hemarthrosis is suspected because the child is complaining of pain in the joints. Which measure should the nurse expect to be prescribed for the child? 1. Range-of-motion exercises to the affected joint 2. Application of a heating pad to the affected joint 3. Application of a bivalved cast for joint immobilization 4. Nonsteroidal antiinflammatory drugs for the pain

3. Application of a bivalved cast for joint immobilization Rationale: In an acute period, immobilization of the joint would be prescribed. Range-of-motion exercise during the acute period can increase the bleeding and would be avoided at this time. Heat will increase blood flow to the area, so it would promote increased bleeding to the area. Nonsteroidal antiinflammatory drugs (NSAIDs) can prolong bleeding time and would not be prescribed for the child.

A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a client's cardiac monitor. Which is the nurse's first action? 1. Check the blood pressure. 2. Call the health care provider (HCP). 3. Check the client and the chest leads. 4. Initiate cardiopulmonary resuscitation (CPR).

3. Check the client and the chest leads. Rationale: This type of pattern on the cardiac monitor indicates either ventricular fibrillation or lead displacement. The first action of the nurse is always to check the client and the chest leads. If the client is nonresponsive and the leads are not the problem, CPR would be the next choice, along with designating another person to contact the HCP.

Gemfibrozil is prescribed for a client. Which laboratory finding should alert the nurse to the need to withhold the medication and contact the health care provider? 1. Elevated glucose 2. Elevated triglycerides 3. Elevated liver function tests 4. Elevated blood urea nitrogen (BUN)

3. Elevated liver function tests Rationale: Gemfibrozil is used to treat hypercholesterolemia. One adverse effect is hepatotoxicity. The medication does not affect glucose. An elevated triglyceride level is not an indication to hold the medication. An elevated BUN is unrelated to this medication and would not be an indication that the medication should be held.

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply. 1. Quickening 2. Braxton-Hicks contractions 3. Fetal heart rate of 180 beats/minute 4. Consistent increase in fundal height 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP)

3. Fetal heart rate of 180 beats/minute 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP) Rationale: The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/minute in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 110 to 160 beats/minute. An elevated MSAFP should be followed up with more specialized testing to determine if a neural tube problem exists. The remaining options are normal expected findings.

The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses should the nurse give the client about the role of estrogen? Select all that apply. 1. It maintains and relaxes the uterine lining for implantation. 2. It stimulates metabolism of glucose and converts the glucose to fat. 3. It increases the blood flow to mucous membranes and causes them to swell and soften. 4. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. 5. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

3. It increases the blood flow to mucous membranes and causes them to swell and soften. 5. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Rationale: Estrogen is a very important hormone of pregnancy. It is responsible for vasocongestion of the mucous membranes. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat; it is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider (HCP). 4. Encourage increased oral intake of fluids.

3. Notify the health care provider (HCP). Rationale: Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "I will take my child's pulse before administering the medication." 3. "If more than 1 dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose." Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered.

The nurse is teaching a client with renal cancer who is scheduled for a renal artery embolization about the procedure. Which statement by the client indicates that the educational session was effective? 1. "This will reduce the time needed for surgery by at least half because it provides hemostasis." 2. "This will cause the tumor to become tougher and easier to resect in surgery with the scalpel." 3. "This will prevent the risk of pulmonary embolism by occluding the renal artery and its branches." 4. "This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge."

4. "This will decrease the size of the tumor because its blood supply will be removed after placement of an absorbable gelatin sponge." Rationale: Renal artery embolization may be done instead of radiation therapy to shrink the kidney tumor by cutting off its blood supply and impairing its overall vascularity. A secondary benefit is that it reduces the risk of hemorrhage during surgery. This procedure can be accomplished in a number of ways, including placement of an absorbable gelatin sponge, a balloon, a metal coil, or any of various other substances.

A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? 1. Ultraviolet light therapy 2. No treatment unless symptoms develop 3. Treatment with intravenous (IV) penicillin G 4. A 14 to 21 day course of doxycycline

4. A 14 to 21 day course of doxycycline Rationale: Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A 3- to 4-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight

4. A pearly papule with a central crater and a waxy border 5. Location in the bald spot atop the head that is exposed to outdoor sunlight Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.

A client with chronic kidney disease (CKD) has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now presents with mental cloudiness, dementia, and complaints of bone pain. The nurse determines that these assessment data are compatible with which condition? 1. Advancing uremia 2. Phosphate overdose 3. Folic acid deficiency 4. Aluminum intoxication

4. Aluminum intoxication Rationale: Aluminum hydroxide may be prescribed as a phosphate-binding agent. Aluminum intoxication can occur when there is an accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. It can be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. The data in the question are not specifically associated with the other conditions noted in the options.

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding prevention of the transmission to siblings and other household members. Which instruction should the nurse provide? 1. Isolate the child from others for 2 weeks because the virus is transmitted by breathing and coughing. 2. Wash sheets and towels used by the child separately in bleach to prevent spread of the infection to others. 3. Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection. 4. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva.

4. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva. Rationale: Roseola is transmitted via saliva, so others should not share drinking glasses or eating utensils. The remaining options are not accurate instructions regarding the prevention of the transmission of roseola.

The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of ibuprofen. 2. Increase the frequency of ibuprofen. 3. Encourage the child to lie on the left side. 4. Encourage the child to lie on the right side.

4. Encourage the child to lie on the right side. Rationale: Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort. It would be inappropriate to advise the mother to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.

The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? 1. Administer oxygen to the woman. 2. Transport the woman to the delivery room. 3. Place an external fetal monitor on the woman. 4. Exert upward pressure against the presenting part.

4. Exert upward pressure against the presenting part. Rationale: If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place.

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. 1. Diarrhea 2. Black, tarry stools 3. Hyperactive bowel sounds 4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back

4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back Rationale: Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The client may demonstrate abdominal guarding and may complain of tenderness with palpation. The pain associated with acute pancreatitis is often sudden in onset and is located in the epigastric region or left upper quadrant with radiation to the back. The other options are incorrect.

The nurse is caring for a client who has cytomegalovirus retinitis and is receiving foscarnet. Which assessment finding, if reported by the client, indicates a need for follow-up? 1. Intact hearing capacity 2. Urine noted to be clear yellow 3. Urinary output of 30 mL per hour 4. Impaired balance while ambulating

4. Impaired balance while ambulating Rationale: Cytomegalovirus retinitis is an opportunistic viral infection of the eye. Foscarnet is an antiviral agent that is used to treat viral infections in the client with leukemia. Serious side and adverse effects, such as ototoxicity and nephrotoxicity, can occur as a result of this medication. Impaired balance while ambulating and impaired hearing are signs of ototoxicity. Intact hearing capacity, urine noted to be clear yellow, and a urinary output of 30 mL per hour are normal assessment findings.

The nurse is caring for a client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium. The nurse teaches the client that this medication is from which class of medications? 1. Antiinfectives 2. Vitamin A lotions 3. Coal tar preparations 4. Nonsteroidal antiinflammatory drugs (NSAIDs)

4. Nonsteroidal antiinflammatory drugs (NSAIDs) Rationale: Diclofenac sodium is an NSAID for topical use. It is indicated for use to treat actinic keratosis. The mechanism underlying its benefits is unknown. The most common side effects are dry skin, itching, redness, and rash at the site of application. Diclofenac sodium may sensitize the skin to ultraviolet radiation, and clients should therefore avoid sunlamps and minimize exposure to sunlight. Antiinfectives are used for infections. Vitamin A would be contraindicated in the treatment of actinic keratosis. Coal tar is for psoriasis.

The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents. Which instruction should the nurse give to the parents? 1. Maintain the child on bed rest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the health care provider (HCP) if the child develops a fever. 4. Notify the HCP if the child develops abdominal pain or left shoulder pain.

4. Notify the HCP if the child develops abdominal pain or left shoulder pain. Rationale: Infectious mononucleosis is caused by Epstein-Barr virus. The parents need to be instructed to notify the HCP if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves. Bed rest is unnecessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen or ibuprofen per HCP preference.

A client undergoing hemodialysis is at risk for bleeding from the heparin used during the hemodialysis treatment. The nurse assesses for this occurrence by periodically checking the results of which laboratory test? 1. Bleeding time 2. Thrombin time 3. Prothrombin time (PT) 4. Partial thromboplastin time (PTT)

4. Partial thromboplastin time (PTT) Rationale: Heparin is the anticoagulant used most often during hemodialysis. The hemodialysis nurse monitors the extent of anticoagulation by checking the PTT, which is the appropriate measure of heparin effect. Thrombin and bleeding times are not used to measure the effect of heparin therapy, although they are useful in the diagnosis of other clotting abnormalities. The PT is a test used to monitor the effect of warfarin therapy.

Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints? 1. The client may have contracted the flu. 2. The client is experiencing anaphylaxis. 3. The client is experiencing expected effects of the medication. 4. The client is experiencing a pulmonary reaction requiring cessation of the medication.

4. The client is experiencing a pulmonary reaction requiring cessation of the medication. Rationale: Nitrofurantoin can induce 2 kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage may occur. The remaining options are incorrect interpretations.

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: A. A lower abdominal incision B. An upper abdominal incision C. An incision made in the perineal area D. The urethra, with the use of a cutting wire

A. A lower abdominal incision

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A. Administer the antihypertensive with a small sip of water B. Withhold the antihypertensive and administer it at bedtime C. Administer the medication by way of the intravenous (IV) route D. Hold the antihypertensive and resume its administration on the day after the ECT

A. Administer the antihypertensive with a small sip of water

An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? A. Administering 100% oxygen B. Having a crisis counselor available C. Instituting suicide precautions for the client D. Obtaining blood for determination of the client's carboxyhemoglobin level

A. Administering 100% oxygen

A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. A. Beer B. Apples C. Yogurt D. Baked haddock E. Pickled herring F. Roasted fresh potatoes

A. Beer C. Yogurt E. Pickled herring

A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A. Call the radiography department to obtain a chest x-ray B. Check the client's blood glucose level to serve as a baseline measurement C. Hang the prescribed bag of PN and start the infusion at the prescribed rate D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency

A. Call the radiography department to obtain a chest x-ray

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking the client's blood pressure B. Checking the client's peripheral pulses C. Checking the most recent potassium level D. Checking the client's intake-and-output record for the last 24 hours

A. Checking the client's blood pressure

A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? A. Contacting the child's physician to report the findings B. Administering acetaminophen (Tylenol) to the child to relieve the pain C. Asking that the child not attend the physical education class until the neck pain has subsided D. Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control

A. Contacting the child's physician to report the findings

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority? A. Contacting the physician B. Documenting the findings C. Checking the fluid for protein D. Continuing to monitor the client and the FHR

A. Contacting the physician

A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: A. Depression B. Diabetes mellitus C. Hyperthyroidism D. Coronary artery disease

A. Depression

A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. A. Drinking 2 to 3 L of fluid each day B. Applying heat packs to the affected joint C. Resting and immobilizing the affected area D. Consuming foods high in purines E. Performing range-of-motion exercise to the affected joint three times a day

A. Drinking 2 to 3 L of fluid each day C. Resting and immobilizing the affected area

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. A. Fever B. Vasculitis C. Weight gain D. Increased energy E. Abdominal pain

A. Fever B. Vasculitis E. Abdominal pain

Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: A. Increase fluid intake B. Consume low-fiber foods C. Consume foods that are low in potassium D. Contact the physician if the urine turns yellow-brown

A. Increase fluid intake

A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? A. Recent stroke B. Hypothyroidism C. History of glaucoma D. Peripheral vascular disease

A. Recent stroke

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. A. Seek medical advice if you find a skin lesion. B. Use sunscreen with a low sun protection factor (SPF). C. Avoid sun exposure before 10 a.m. and after 4 p.m. D. Wear a hat, opaque clothing, and sunglasses when out in the sun. E. Examine the body every 6 months for possibly cancerous or precancerous lesions.

A. Seek medical advice if you find a skin lesion. D. Wear a hat, opaque clothing, and sunglasses when out in the sun.

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply. A. Smoking B. A high-calcium diet C. High alcohol intake D. White or Asian ethnicity E. Participation in physical activities that promote flexibility and muscle strength

A. Smoking C. High alcohol intake D. White or Asian ethnicity

A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? A. "When was your last menstrual period?" B. "When was your last bowel movement?" C. "Are you having any difficulty hearing?" D. "Are you having any difficulty breathing?"

C. "Are you having any difficulty hearing?"

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? A. "The test will take about 30 minutes." B. "I need to fast for 8 hours before the test." C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating."

C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test."

A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? A. "It's important to rotate injection sites." B. "I need to store the insulin in a cool, dry place." C. "I need to keep any unopened bottles of insulin in the freezer." D. "I need to check the expiration date on the insulin before I use it."

C. "I need to keep any unopened bottles of insulin in the freezer."

The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: A. Contact the physician B. Hold the next dose of imipramine C. Document the laboratory result in the client's record D. Have another blood sample drawn and ask the laboratory to recheck the imipramine level

C. Document the laboratory result in the client's record

The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: A. To always administer less insulin on the days of soccer games B. That it is best not to encourage the child to participate in sports activities C. That the child should eat a carbohydrate snack about a half-hour before each soccer game D. To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL or higher and ketones are present

C. That the child should eat a carbohydrate snack about a half-hour before each soccer game

A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client: A. To call his physician B. That he needs to drink more fluids C. That this is an occasional side effect of the medication D. That this may be a sign of developing toxicity of the medication

C. That this is an occasional side effect of the medication

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? A. "HIV is rarely an issue in rape victims." B. "Every rape victim is concerned about HIV." C. "You're more likely to get pregnant than to contract HIV." D. "Let's talk about the information that you need to determine your risk of contracting HIV."

D. "Let's talk about the information that you need to determine your risk of contracting HIV."

A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: A. Bradycardia B. Increased heart rate C. Decreased blood pressure D. Improved swallowing function

D. Improved swallowing function

Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: A. Dry mouth B. Restlessness C. Feelings of depression D. Neck stiffness or soreness

D. Neck stiffness or soreness

A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside? A. Bedside commode B. Suctioning equipment C. Electrocardiography machine D. Oxygen cannula and flowmeter

D. Oxygen cannula and flowmeter

A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? A. Fever B. Diarrhea C. Hypertension D. Tongue protrusion

D. Tongue protrusion

A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record? A. Writing that the client is very agitated B. Writing that the client yelled at the nurse C. Writing that the client is able to perform her own care D. Writing down the client's words and placing them in quotation marks

D. Writing down the client's words and placing them in quotation marks

The client who is seropositive for human immunodeficiency virus (HIV) has been taking ritonavir. The nurse tells the client that which follow-up laboratory study will be necessary while taking this medication? 1. Platelet count 2. Triglyceride level 3. Prothrombin time (PT) 4. International normalized ratio (INR)

2. Triglyceride level Rationale: Ritonavir is an antiretroviral (protease inhibitor) used in combination with other antiretroviral medications in the management of HIV infection. It can increase triglyceride levels; therefore, the client's triglyceride levels should be monitored. The platelet count, PT, and INR are not laboratory tests that would be monitored specifically in the client on this medication.

A client is taking benztropine mesylate orally daily. In monitoring this client for medication side effects, the nurse should plan to focus the assessment on which item? 1. Pupil response 2. Voiding pattern 3. Prothrombin time 4. Muscle strength and mobility

2. Voiding pattern Rationale: Benztropine mesylate is an anticholinergic. Because urinary retention is a side effect of benztropine mesylate, the nurse must assess for dysuria, distended abdomen, infrequent voiding in small amounts, and overflow incontinence. Monitoring of the other options is not necessary with this medication.

The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the UAP is observed taking which action? 1. Turning the client's head to one side 2. Using small volumes of fluid to rinse the mouth 3. Using a gloved finger to open the client's mouth 4. Placing an emesis basin under the client's mouth

3. Using a gloved finger to open the client's mouth Rationale: The client who is unconscious is at great risk for aspiration. The UAP turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a gloved finger, to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth.

The nurse in the health care clinic receives a telephone call from the mother of a child who reports that an insect has somehow flown into the child's ear. The mother reports that the child is complaining of a buzzing sound in the ear. Which priority instruction should the nurse provide to the mother? 1. Report to the clinic immediately. 2. Irrigate the ear with diluted alcohol. 3. Use tweezers to try to remove the insect. 4. Use a flashlight to coax the insect out of the ear.

4. Use a flashlight to coax the insect out of the ear. Rationale: Insects that make their way into an ear often can be coaxed out using a flashlight or a humming noise. If this is unsuccessful, then the insect must be killed before removal. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by means of an ear forceps. The mother should be instructed not to irrigate the ear or attempt to remove the insect by using tweezers because this could damage the ear. If the mother is unsuccessful in coaxing the insect out of the ear, she should be instructed to report to the clinic or the hospital emergency department.

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

4. p24 antigen assay Rationale: Infants born to HIV-infected mothers need to be screened for the HIV antigen. The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. A. "I need to avoid salt in my diet." B. "It's fine to take any over-the-counter medication with the lithium." C. "I need to come back the clinic to have my lithium blood level checked." D. " I should drink 2 to 3 quarts of liquid every day." E. "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A. "I need to avoid salt in my diet." B. "It's fine to take any over-the-counter medication with the lithium." E. "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you're feeling." B. "That's a normal response after this type of surgery." C. "It will take time, but, I promise you, you will get over this depression." D. "Every client who has this surgery feels the same way for about a month."

A. "Tell me more about what you're feeling."

A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? A. "What are your feelings right now?" B. "Why don't you feel like washing up?" C. "You aren't talking today. Cat got your tongue?" D. "You need to get yourself cleaned up. You have company coming today."

A. "What are your feelings right now?"

Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: A. 3 minutes B. 10 seconds C. 15 seconds D. 30 minutes

A. 3 minutes

A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: A. Call the nursing supervisor B. Ask the answering service to contact the on-call physician C. Withhold the medication until the physician can be reached in the morning D. Administer the medication but consult the physician when he becomes available

B. Ask the answering service to contact the on-call physician

An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: A. Documenting the findings B. Asking the ED physician to check the client C. Continuing to monitor the client's cardiac status D. Informing the client that PVCs are expected after an MI

B. Asking the ED physician to check the client

A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? A. Anxiety B. Powerlessness C. Ineffective coping D. Disturbed body image

B. Powerlessness

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? A. Clear and yellow B. Thick and opaque C. White and odorless D. Clear, with a foul odor

B. Thick and opaque