KQB2

A client is admitted for a series of tests to verify the diagnosis of Cushing syndrome. Which of the following assessment findings, if observed by the nurse, support this diagnosis? 1. Buffalo hump 2. Intolerance to heat 3. Hyperglycemia 4. Hypernatremia 5. Intolerance to cold 6. Irribility

1. Buffalo hump 3. Hyperglycemia 4. Hypernatremia - Hypersecreation of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections.

The nurse cares for an older patient scheduled for a colon resection this morning. The nurse notes the patient had polyethylene glycol-electrolyte solution (GoLYTELY) and a soapsuds enema the previous evening. This morning the patient passes a medium amount of soft brown stool. Which of the following conclusions by the nurse is MOST accurate? 1. The bowel preparation is incomplete 2. The patient ate something after midnight. 3. This is an expected finding before this type of surgery. 4. The patient passed the last stool left in the colon.

1) Colon should not have remaining soft stool.

The nurse on the medical/surgical unit reviews lab results. The nurse notes that a client's serum albumin level is 2.5 g/dL, fasting blood sugar is 110 mg/dL, potassium is 4.2 mEq/L, and sodium is 140 mEq/L. It is MOST important for the nurse to assess for which of the following? 1. Edema. 2. Nausea. 3. Muscle weakness. 4. Blurred vision.

1. Edema - normal serum albumin is 3.5-5.5 g/dl; albumin deficit decreases oncotic pressure and fluids shift from vascular area to tissue Strategy: "MOST important" indicates discrimination is required to answer the question

Several hours after an oxytocin infusion is started, the client's contractions are sustained over two minutes. Which nursing action is MOST important for the nurse to take? 1. Discontinue the IV oxytocin 2. Administer oxygen 3. Reposition the client 4. Decrease the IV oxytocin rate

1. Discontinue the IV oxytocin - sustained contractions can lead to a ruptured uterus and/or fetal distress Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for clients in the ED. Prioritize the order in which the nurse will see these clients starting with the most urgent. All options must be used. - The 8-month-old infant crying loudly with facial ecchymosis. - The 34-year-old client with a distended abdomen and splenomegaly. - The 44-year-old client with possible whiplash from an automobile accident. - The 12-year-old child with a possible fractured ankle.

1. The 34-year-old client with a distended abdomen and splenomegaly. - Unstable, circulation; Distended abdomen indicates possible bleeding 2. - The 12-year-old child with a possible fractured ankle. - Unstable: Possible fracture needs to be attended to as soon as possible 3. The 8-month-old infant crying loudly with facial ecchymosis. - Stable, potential airway; Young children need assessment as their problems may not be visible 4. The 44-year-old client with possible whiplash from an automobile accident. - Stable, potential pain; The client with whiplash is stable and not urgent. Strategy: Which clients are unstable? Move from the most unstable to the most stable.

The clinic nurse anticipates the arrival of a Navajo Native American client for follow-up care regarding type 2 diabetes. When planning care for the client, the nurse should expect which behavior? 1. The client may not arrive at the appointed time. 2. The client may be noncompliant with medication. 3. The client may complain about dietary restrictions. 4. The client may offer a firm handshake.

1. The client may not arrive at the appointed time. - Native Americans are present oriented and do not live by the clock. I picked 2. The client may be noncompliant with medication - wrong because they do accept Western medicine along with traditional remedies. Strategy: Think about each answer.

The nurse prepares a client for a paracentesis. It is MOST important for the nurse to take which action? 1. Keep the client NPO 12 hours before the procedure. 2. Ask the client to void just before the procedure. 3. Initiate a bowel preparation program 24 hours before the procedure. 4. Place the client supine during the procedure.

2. Ask the client to void just before the procedure. - prevents puncture of bladder Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

The nurse works in the cardiac clinic of a major medical center teaching hospital. The patients are African American, and the medical house staff is of various ethnicities. The nurse should question a written order for which of the following medications? 1. Hydralazine hydrochloride (Apresoline) 2. Atenolol (Tenormin) 3. Chlorothiazide (Diuril) 4. Nifedipine (Procardia)

2. Atenolol (Tenormin) - beta-blocker; beta-adrenergic inhibitor that slow heart rate and decrease cardiac contractility and cardiac output, thereby lowering blood pressure; beta blockers are less effective in African Americans than they are in Caucasians; the same is true for angiotension-coverting enzyme (ACE) inhibitors, such as captopril (Capoten) Strategy: "Should question a written order" indicates that something is wrong

The nurse in the outpatient clinic assists w/ the application of a cast to the left arm of a pre-school-aged child. After the cast is applied, the nurse should take which of the following actions? 1. Petal the edges of the cast to prevent irritation 2. Elevate the client's left arm on two pillows 3. Apply cool, humidified air to dry the cast. 4. Ask the client to move the fingers to maintain mobility

2. Elevate the client's left arm on two pillows - minimizes swelling, elevated for first 24 hours to 48 hours, protects from pressure and flattening the cast.

The nurse cares for a client with a head injury on a volume-cycled ventilator. Which of the following actions, if performed by the nurse, BEST indicates an understanding of proper management of a patient on a mechanical ventilator? 1. Water is added to the tubing to provide for humidification of inspired air. 2. The sigh setting on the ventilator is adjusted to occur every hour. 3. Ventilator settings are adjusted according to the patient's serum electrolytes 4. A high concentration of oxygen is delivered to prevent tissue ischemia and necrosis.

2. The sigh setting on the ventilator is adjusted to occur every hour. - setting should be set for 1.5 times tidal volume and occur every 1-3 hours. Strategy: Determine the outcome of each answer

The health care provider (HCP) prescribes cimetidine 300 mg PO aid for an elderly client. The nurse instructs the client about the medication. Which statement, if made by the client, indicates further teaching is needed? 1. "I'll take this pill with meals and before bed." 2. "I may experience mild diarrhea for a while." 3. "My stools may change color while I'm on this medication." 4. "I should call my HCP if I get an acne-like rash."

3. "My stools may change color while I'm on this medication." - no change in stool color I picked 2. "I may experience mild diarrhea for a while." - wrong because common side effect, usually subsides Strategy: "Further teaching" indicates incorrect information

The parents of a child diagnosed w/ hemophilia ask the nurse to explain the cause of the disease. Which of the following responses by the nurse is BEST? 1. "The father transmit the gene to his son." 2. "Both the mother and the father carry a recessive trait." 3. "The mother transmits the gene to her son." 4. "There is a 50% chance that the mother will pass the trait to each of her daughters."

3. "The mother transmit the gene to her son."

The home care nurse visits the home of an 8-year-old diagnosed with cerebral palsy. While assessing the client, the client's mother comes into the room and says, "My 2-year-old just swallowed some of my mom's medicine!" Which of the following actions should the nurse take FIRST? 1. Call poison control 2. Empty the child's mouth of pills 3. Assess the child 4. Administer syrup of ipecac

3. Assess the child - assess before implementing; may have to perform CPR or treat other symptoms such as seizures

The nurse determines which diversional activity is most appropriate for a 10-year-old client recovering from a sickle cell crisis? 1. Walking in the hall 20 mins twice a day 2. Watching cartoon channel all day 3. Collecting pictures from magazines 4. Putting together large-pieced wooden puzzles

3. Collecting pictures from magazines - collecting is an activity that is important to school-aged children Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

A 7-year-old girl is seen in the clinic w/ a diagnosis of pituitary dwarfism. Which of the following clinical manifestations is the nurse MOST likely to observe? 1. Abnormal body proportions 2. Early sexual maturations 3. Delicate features 4. Coarse, dry skin

3. Delicate features - Appear younger than chronological age

The nurse cares for a client after cataract surgery. The nurse should intervene if which of the following is observed? 1. Client is in the supine position 2. The head of the bed is elevated 30 degrees 3. The client is lying on the right side 4. An eye shield is over the right eye.

3. The client is lying on the right side. - client should not be positioned w/ operative side in a dependent position or against the bed.

The nurse prepares to administer medication into an established IV line by IV push. Which of the following is the MOST important action for the nurse to take? 1. Select the port farthest form the insertion site. 2. Ensure that the tubing above the injection port is patent 3. Time the medication administration with a watch 4. Explain the procedure to the patient

3. Time the medication administration with a watch - this ensures safe drug infusion; ideally, the watch should have a second hand or digital readout; many medications which are ordered as IV push or bolus need to be given slowly over several minutes Strategy: "MOST important" indicates that discrimination is required to answer the question

The client is returned to the room following an appendectomy. The nurse notices a large amount of serosangulineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which question? 1. "Were there any intraoperative complications?" 2. "Has the dressing been changed?" 3. "Why didn't the recovery room nurse report any drainage?" 4. "Was a tissue drain placed during surgery?"

4. "Was a tissue drain placed during surgery?" - drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced Strategy: Determine how each answer choice relates to an appendectomy.

The nurse administers meperidine (Demerol) 50 mg IV for pain to a client in labor. Which of the following fetal heart rate (FHR) patterns should the nurse anticipate as a result of administering this medication? 1. early decelerations 2. Late decelerations 3. Variable decelerations 4. Decreased variability

4 Decreased variability - irregular fluctuations in the baseline of FHR; Demerol crosses the placenta and is a CNS depressant; FHR variability is affected by narcotic administration Strategy: Think about the action of Demerol

The elderly client has had a subtotal gastrectomy. The client received meperidine 75 mg and hydroxyzine hydrochloride 50 mg IM. The nurse is MOST concerned if which finding was observed? 1. Tachypnea 2. Lethargy 3. Hypertension 4. Disorientation

4. Disorientation - elderly are prone to paradoxical reactions and can become agitated and disoriented Strategy: think about each answer and how it relates to the med

The nurse cares for a client receiving trimethoprim-sulfamethoxazole (Bactrim). The nurse knows which of the following observations indicates the most common side effect of trimethoprim-sulfamethoxazole (Bactrim)? 1. Hypotonia 2. Loss of hearing 3. Hypotension 4. Urticaria

4. Urticaria - mild to moderate rash is the most common side effect of Bactrim Strategy: Think about each answer

The nurse obtains a health history from the mother of a child diagnosed with failure to thrive. Which assessment provides the MOST pertinent data to the nurse? 1. Weight and height 2. Urine output 3. Type of feedings 4. Mother/child interactions

1. Weight and height - physical; provides the most pertinent data in assessing actual growth Strategy: Determine how each answer choice relates to failure to thrive

The nurse cares for clients in the hospital. Which nursing activities best promote nighttime rest for elderly hospitalized clients? 1. Tell the client how to call for help if needed. 2. Place a clock at the bedside 3. Postpone explanation of further tests the client will need. 4. Restrict visitors so that the client is not stimulated in the evening 5. Identify normal evening bedtime routines. 6. Keep bright light in room to prevent falls.

1. Tell the client how to call for help if needed. - If the client does not need to worry about getting up, sleep will be easier. 3. Postpone explanation of further tests the client will need. - Giving the client information that may be troubling will not help with sleep 5. Identify normal evening bedtime routines. - Following normal routines will help the client fall asleep and stay asleep. Strategy: Think about going to sleep and resting, what is needed?

The client is to receive the afternoon dose of nifedipine. The nurse notes the client's pulse is 50. Which action is MOST appropriate? 1. Withhold the medication 2. Check the urinary output 3. Administer the medication 4. Increase the potassium intake

1. Withhold the medication - nifedipine is a calcium-channel blocker used as antihypertensive; bradycardia is untoward effect; withholding medication and checking with the health care provider is appropriate I picked 3. Administer the medication - wrong because unnecessary Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations

The charge nurse on the medical unit reviews physician's orders for four newly admitted patients. The nurse should question which of the following orders? 1. A CT scan for a patient with suspected intracranial bleeding 2. A bone imaging study for a patient with multiple myeloma 3. A chest x-ray for a patient with a positive tuberculin skin test 4. An upper GI tract endoscopy for a patient with cirrhosis

2. A bone imaging study for a patient with multiple myeloma - every contrast medium has a risk of causing reactions; benefit vs risk should be considered; multiple myeloma involves overproduction of plasma cells, with resilient destruction of been and of bone marrow products; multiple myeloma is unique as a neoplastic condition that is better detected with a plain radiograph than with a nuclear scan; if a bone scan is done, false-negative results occur Strategy: "Nurse should question" indicates a complication

The nurse on the medical unit administers acetaminophen (Tylenol) with codeine #3 tab ii PO to a client. The physician ordered acetaminophen (Tylenol) 325 mg tab ii PO. Because the client is allergic to codeine, the physician orders diphenhydramine (Benadryl) 50 mg IM. After informing the client of the error and administering the IM medication, it is MOST important for the nurse to take which of the following actions? 1. Apologize to the client for administering the wrong medication. 2. Ask the client to remain in bed for 3-4 hours. 3. Explain to the client the signs/symptoms of a reaction to codeine. 4. Clarify why the nurse administered the diphenhydramine (Benadryl).

2. Ask the client to remain in bed for 3-4 hours - tylenol with codeine and Benadryl cause drowsiness; maintain client safety Strategy: "MOST important" indicates priority

The nurse cares for a newborn infant diagnosed w/ fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics? 1. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus 2. An infant w/ a small head circumference, low birth weight, and undeveloped cheekbones 3. An infant w/ a large head circumference, low birth weight, and excessive rooting and sucking behaviors 4. An infant w/ a normal head circumference, low birth weight and resp. distress syndrome.

2. An infant w/ a small head circumference, low birth weight, and undeveloped cheekbones - seen w/ fetal alcohol syndrome

The nurse cares for clients in the ED. The nurse notes that there is an increased number of infants admitted with a diagnosis of bronchiolitis and respiratory syncytial virus (RSV). It is MOST important for the nurse to ensure which of the following items are well-stocked to dispense to parents? 1. Antibacterial soaps 2. Bulb syringes 3. Stool sample kits 4. Thermometers

2. Bulb syringes - airway-related; nasopharyngeal secretions can block airway passages; young infants are obligatory nose breathers; instruct parents about how to use syringes before feedings and PRN I picked 1. Antibacterial soaps - wrong because consistent had washing and avoiding touching mucous membranes is more important than the type of soap Strategy: "MOST important" indicates discrimination is required to answer the question

An adult is undergoing testing for amyotrophic lateral sclerosis (ALS). The nurse would expect the client to exhibit which of the following symptoms? 1. Incontinence of bowel and bladder 2. Difficulty swallowing 3. Paresthesia of the face 4. Disorientation to time and place

2. Difficulty swallowing - have difficulty with dysphagia and aspiration; other early symptoms include fatigue with while talking, tongue atrophy, weakness of hands and arms I picked 1. Incontinence of bowel and bladder - wrong because retains control of these functions Strategy: Think about each answer

The physician inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that the primary purpose of the pacemaker is which of the following? 1. Increases the force of myocardial contraction 2. Increases the cardiac output 3. Prevents premature ventricular contractions (PVCs) 4. Prevents systemic overload

2. Increases the cardiac output - Acts to regulate cardiac rhythm

Which action should the nurse instruct the client to complete FIRST to establish a normal urinary pattern? 1. Urinate every 2 hours 2. Record each time the client urinates 3. Keep a record of daily fluid intake 4. Stay near a bathroom

3. Keep a record of daily fluid intake - client needs to know how much and when fluid is ingested I picked 2. Record each time the client urinates - wrong because second thing to do Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired?

To best evaluate home compliance with metoclopramide for a 3-month-old, the nurse should take which action? 1. Observe the mother feeding the infant 2. Ask the mother about the infant's retention of feedings 3. Ask the mother how many wet diapers the baby has each day 4. Weigh the baby, and compare to baseline weight

4. Weigh the baby, and compare to baseline weight - is most accurate indicator of feeding retention Strategy: Topic of question is unstated. Read answer choices for clues

An older client has an order for digoxin 0.25 mg PO daily. Which information would cause the nurse to withhold the medication and contact the health care provider? 1 Apical pulse of 55 bpm 2. Respirations of 16 per min. 3. Plasma digoxin level of 2.1 ng/ml 4. Blood pressure of 122/62 5. Apical rhythm has 20 skipped beats in 1 minute 6. Temperature 100.5F

1 Apical pulse of 55 bpm - Pulse below 60bpm 3. Plasma digoxin level of 2.1 ng/ml - Normal digoxin plasma level are 0.8-2 ng/mL 5. Apical rhythm has 20 skipped beats in 1 minute - Dysrhythmias may be caused by the digoxin Strategy: What are side effects or toxic symptoms related to digoxin?

The nurse prepares a client for a bone scan. Which of the following statements by the nurse to the client is MOST important? 1. "Be sure to drink lots of fluids in the time between the tracer injection and the test." 2. "You will fee some discomfort as the tracer is injected into your muscle" 3. "You will have to assume various positions on a tilting x-ray table." 4. "The scan is painless and will be over before you know it."

1. "Be sure to drink lots of fluids in the time between the tracer injection and the test." - interval between injection of the tracer and the actual scanning is usually 1 to 3 hours; large amounts of fluid maintain hydration and decrease radiation dose to the bladder; client should void immediately before scan to prevent a distended bladder Strategy: "MOST important" indicates priority

The client is seen in the health care provider's office for follow-up after treatment for calcium renal calculi. The nurse discusses methods to prevent a recurrence of the problem. Which instructions by the nurse is beneficial? 1. "Drink at least 3,000 mL of fluid a day." 2. "Increase the amount of milk in your diet." 3. "Increase the amount of whole grains that you eat." 4. "You should eat a diet low in sodium." 5. "Increase your fluids in warm or hot environments." 6. "Limit your intake of coffee intake."

1. "Drink at least 3,000 mL of fluid a day." - prevention program: diet, medications, fluids 3,000 to 4,000 ml/day 4. "You should eat a diet low in sodium." - dehydration is a risk for stone formation 5. "Increase your fluids in warm or hot environments." - high sodium intake increase calcium excretion; increasing risk for stones formation 6. "Limit your intake of coffee intake." - intake of colas, coffee and tea increase risk of stone formation Strategy: Beneficial indicates correct instruction. Determine the outcome of each answer choice. Is it desired?

The health care provider prescribes ciprofloxacin for the client. Which instruction should the nurse include about this med? 1. "Drink plenty of fluids." 2 "You may take this med with your multivitamin" 3. "Eliminate dairy products from your diet" 4. "Always take this med with meals" 5. "You should avoid exposure to the sun while on this med." 6. "Try to avoid caffeine while you take this med."

1. "Drink plenty of fluids" - prevents crystalluria and stone formation 5. "You should avoid exposure to the sun while on this med" - this med makes skin exposure a risk 6. "Try to avoid caffeine while you take this med" - caffeine consumption increases caffeine effects while on this med" Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

The nurse obtains a health history from the parents of a child admitted with acute glomerulonephritis. It is MOST important for the nurse to ask which of the following questions? 1. "Has your child recently had any skin infections?" 2. "Is there a family history of glomerulonephritis?" 3. "Was your child a low-birth weight infant?" 4. "Has your child ever had a bladder infection?"

1. "Has your child recently had any skin infections?" - immune system complex ideas that occurs about 10 days after a skin or throat infection; symptoms include fever, chills, hematuria, dyspnea, weight gain, edema, hypertension, headache, decreased level of consciousness, confusion, abdominal or flank pain I picked 4. "Has your child ever had a bladder infection?" - wrong because usually caused by E. coli; glomerulonephritis caused by streptococcus; nursing care includes medications: antibiotics, corticosteroids, antihypertensives, immumnosuppresives agents; restrict sodium intake, restrict water if oliguric; dialing weights, monitor I and O, bed rest, high-calorie, low protein diet

The nurse cares for clients in the outpatient clinic. A 45y/o male client presents with acute mild-abdominal pain and acute vomiting. It is MOST important for the nurse to ask which of the following questions? 1. "How much alcohol do you think per day?" 2. "Do you have family history of diabetes?" 3. "Do you have a history of peptic ulcer disease?" 4. "How frequently do you take laxatives?"

1. "How much alcohol do you think per day?" - symptoms indicates acute episode of pancreatitis; pancreatitis associated with males age 40-45 with a history of heavy drinking or females ages 50-55 diagnosed with binary disease Strategy: "MOST important" indicates priority

The nurse cares for a client receiving ranitidine (Zantac) 150 mg PO BID. The nurse should further assess if the client states which of the following? 1. "I am going to have allergy testing tomorrow." 2. "I have increased my intake of whole grains and fresh vegetables." 3. "I like to smoke a cigarette immediately before bedtime." 4. "I take an occasional Advil if my knees hurt." 5. "I will take all of the medication in the bottle." 6. "I drink a glass of red wine every night."

1. "I am going to have allergy testing tomorrow." - may cause false-negative results on allergy skin testing; client should avoid medication for 24 hours before testing 3. "I like to smoke a cigarette immediately before bedtime."- smoking interferes with histamine antagonist; client should not smoke when taking medication; if client continues to smoke, should not smoke after the last dose of the day 4. "I take an occasional Advil if my knees hurt." - should avoid NSAIDs because of increased gastric irritation 6. "I drink a glass of red wine every night." - should avoid alcohol because it may increase GI irritation

The nurse cares for clients in the prenatal clinic. The nurse is MOST concerned if the client diagnosed with diabetes in the third trimester makes which statement? 1. "I am taking less insulin now than I did two months ago." 2. "I am eating a large bedtime snack." 3. "I walk 15 mins after lunch each day." 4. "I check my blood sugar two hours after each meal."

1. "I am taking less insulin now than I did two months ago." - placenta produces hormones that make the cells insulin-resistant; as pregnancy progresses, these hormones increase; if insulin requirement is decreased, this indicates that the placenta is not functioning appropriately. Strategy: "MOST concerned" indicates you are looking for a complication

The nurse reviews discharge instructions with a patient receiving risperidone (Risperdal) 4 mg po bid. Which of the following statements, if made by the patient to the nurse, indicates the need for further teaching? 1. "I know I have to take it even though I am no longer depressed." 2. "I will report any changes in my sleeping habits." 3. "I will avoid exposure to extreme heat conditions." 4. "I will use caution when I change positions."

1. "I know I have to take it even though I am no longer depressed." - drug is an antipsychotic, patient has right to know indication for medication Strategy: "Need for further teaching" indicates incorrect information

The nurse changes the dressing on the client who had a mastectomy 2 days ago. After the nurse removes the old dressing, the client turns their head away. Which statement is the BEST response by the nurse? 1. "I notice that you turn your head away as if you don't want to look at your incision." 2. "It's good that you turn your head away while I am doing this sterile procedure." 3. "Your incision looks like it's healing nicely." 4. "Why don't you look at the incision while I have the old dressing off?"

1. "I notice that you turn your head away as if you don't want to look at your incision." - states observation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse in the pediatric clinic instructs the mother of a child diagnosed with asthma about preventative care. The nurse determines that further teaching is necessary if the child's mother states which of the following? 1. "My child likes sleeping on the bottom bunk." 2. "My child sleeps on a foam pillow and mattress." 3. "I wash my child's hair almost every night." 4. "My child wears a mask while I vacuum the carpets."

1. "My child likes sleeping on the bottom bunk." - dust mites are a trigger for asthma; fabric from bedding on upper bunk can harbor dust mites; do not sleep or lie down on upholstered furniture, use furniture that can be wiped with a damp cloth (wood, plastic, vinyl, or leather) Strategy: "Further teaching is necessary" indicates wrong information

A patient receives isoniazid (INH), rifampin (Rifadin), and ethambutol (Myambutol). Which of the following statements, if made by the patient to the nurse, MOST concerns the nurse? 1. "I seem to be becoming color-blind- I can't see green." 2. "My urine and seat are reddish-orange." 3. "Sometimes I wonder what I did to deserve all this." 4. "My big toe has started hurting so I can hardly walk."

1. "I seem to be becoming color-blind- I can't see green." - a major common adverse effect of ethambutol is pic neuritis, which reduced visual activity; lessened ability to see green is a possible initial sign I picked 4. "My big toe has started hurting so I can hardly walk." - wrong because hyperuricemia can occur with pyrazinamide (PZA), resulting in acute gout symptoms, such as severe pain in the great toe; this indicates that the drug should be discontinued Strategy: "MOST concerns" indicates that discrimination is required to answer the question

The client is diagnosed with myasthenia graves. The nurse instructs the client about the disease. Which statement, if made by the client to the nurse, indicates the need for further teaching? 1. "I should have a glass of wine every night." 2. "I should not go places that are crowded" 3. "I should try to stay calm" 4. "I should use my hot tub daily." 5. "I should do all my work in the morning." 6. "I will change to an all thin liquid diet."

1. "I should have a glass of wine every night." - should be avoided 4. "I should use my hot tub daily." - should avoid heat (sauna, hot tubs, sunbathing) 5. "I should do all my work in the morning." - activities should be spread out to decrease fatigue 6. "I will change to an all thin liquid diet." - thicker liquids are easier to swallow than thin Strategy: "Need for further teaching" indicates you are looking for an incorrect statement

The client has an order for hydrochlorothiazide 50 mg qd. The nurse knows that further teaching is needed if the client makes which statement? 1. "I should not operate heavy machinery" 2. "I should drink five glasses of liquid per day" 3. "This medication will cause my urine to turn orange" 4. "I should eat dried apricots each day" 5. "I should take this med on an empty stomach"

1. "I should not operate heavy machinery" - med does not cause drowsiness 2. "I should drink five glasses of liquid per day" - there are no specific restrictions on fluid at this time 3. "This medication will cause my urine to turn orange" - does not occur 5. "I should take this med on an empty stomach" - this med will be taken with food because it causes GI upset Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The home care nurse visits a client undergoing external radiation therapy after a lumpectomy of the right breast. Which of the following statements, if made by the client, indicates nurse's teaching is effective? 1. "I should wear a loose-fitting bra made of 100% cotton" 2. "I should apply cream to the right side of my chest." 3. "I should expose my right breast to the air and sun." 4. "I should apply cold compresses to the right side of the chest."

1. "I should wear a loose-fitting bra made of 100% cotton." - wear cotton clothing to prevent irritation; assess skin for redness and cracking Strategy: Determine the outcome of each answer

The client has been placed on phenelzineu sulfate 11 mg PO daily to assist in treating depression. The nurse determines that teaching is effective if the client makes which statement? (SATA) 1. "I will call my health care provider and stop taking the med if I begin to have severe headaches." 2. "I can drink wine, but I should avoid alcoholic beverages that contain high levels of alcohol." 3. "I know I am going to feel better in a couple of days. I am so glad that I finally got some meds." 4. "I can take the over-the-counter (OTC) cold med that contains pseudo ephedrine." 5. "I will carefully and watch my diet"

1. "I will call my health care provider and stop taking the med if I begin to have severe headaches." - med is a MAO inhibitor; hypertensive crisis may be precipitated by foods containing tyramine; client should be taught to report problems associated with hypertension 5. "I will carefully and watch my diet." - foods containing tyramine interact with this med." Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

The client has been placed on phenelzineu sulfate 11 mg PO daily to assist in treating depression. The nurse determines that teaching is effective if the client makes which statement? 1. "I will call my health care provider and stop taking the medication if I begin to have severe headaches." 2. "I can drink wine, but I should avoid alcoholic beverages that contain high levels of alcohol." 3. "I know I am going to feel better in a couple of days. I am so glad that I finally got some medication." 4. "I can take the over-the-counter cold medications that contain pseudoephedrine."

1. "I will call my health care provider and stop taking the medication if I begin to have severe headaches." - medication is an MAO inhibitor; hypertensive crisis may be precipitated by foods containing tyramine; client should be taught to report problems associated with hypertension Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

Because of the decreased ability to perform activities of daily living, an elderly client diagnosed with type 1 diabetes mellitus moves to a local nursing home. The client brought all of her medications except one. She cannot remember the name of the medication. The client tells the nurse that she is worried that she will not sleep tonight because of the burning and stinging in her lower legs and her feet that the medication usually relieves. Which of the following responses by the nurse is BEST? 1. "I will contact your physician to find out what medication you are taking." 2. "Can you describe the signs and symptoms to me?" 3. "Can you describe what the mediation looks like?" 4. "Did the physician tell you what caused the burning and stinging?"

1. "I will contact your physician to find out what medication you are taking." - nurse's responsibility is to confirm the physician's orders. I picked 4. "Did the physician tell you what caused the burning and stinging?" - wrong because nurse should be able to project the cause; appropriate to assess client's knowledge of the problem, but the current issue is client's anxiety about experiencing the discomfort; can approach client teaching at another time. Strategy: "BEST" indicates discrimination is required to answer the question

The nurse at the preschool learns that a child has developed hepatitis A. The nurse instructs the staff about signs and symptoms of hepatitis A. The nurse informs the staff that which of the following is the MOST likely symptom of hepatitis A in young children? 1. Anorexia 2. Jaundice 3. Arthralgia 4. Clay-colored stools

1. Anorexia - anorexia, malaise, lethargy and easy fatiguability are most common symptoms I picked 4. Clay-colored stools - wrong because will occur if child develops jaundice Strategy: "MOST likely" indicates discrimination may be required to answer the question

The client visits the rape-crisis clinic one week after being assaulted. The client is currently taking alprazolam 0.25 mg PO q 6 hours for anxiety. Which statement, if made by the client to the nurse, reflects a correct understanding of this med? 1. "I will make an appointment when I want to stop taking this." 2. "I should not take this with anything but water." 3. "I guess I need to stop drinking white wine." 4. "This med will help me forget and go on." 5. "I can take it whenever I feel upset"

1. "I will make an appointment when I want to stop taking this." - needs to be withdrawn slowly under supervision 3. "I guess I need to stop drinking white wine." - antianxiety, should not be taken with alcoholic beverages I picked 2. "I should not take this with anything but water." - wrong because it indicates a need for further med teaching Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

The nurse prepares the client for a skin biopsy. Which client statement should the nurse report to the health care provider? 1. "I've been taking aspirin for my sore knees." 2. "Using lotion has helped my dry skin." 3. "I went to the tanning salon yesterday." 4. "I had a big breakfast this morning."

1. "I've been taking aspirin for my sore knees." - aspirin compounds can increase bleeding time and should not be taken prior to a surgical procedure Strategy: Determine how the statements relate to skin biopsy

The nurse cares for a client 2 days after the client sustained an injury in an auto accident. The client is placed in halo vest traction. The nurse is MOST concerned if the client states which of the following? 1. "It hurts when I chew." 2. "My back itches." 3. "I have a headache." 4. "Why did this happen to me?"

1. "It hurts when I chew." - if pain occurs with jaw movement 24 to 48 hours after traction applied, may indicate that skull pins have slipped onto the thin temporal plate; notify physician immediately I picked 3. "I have a headache" - shiny penny - wrong because physician tightens screws 24 to 48 hours after halo is applied, offer analgesic Strategy: "MOST concerned" indicates a complication

The home health nurse visits an elderly client who is diagnosed with diabetes and osteoporosis. The client lives with her daughter in a two-story home. Which of the following statements by the daughter MOST concerns the nurse? 1. "Mother loves a hot bath with her favorite bath oil." 2. "Mother seems to taking more of an interest in things going on around her." 3. "I sometimes feel guilty leaving her alone, even if it is just for half an hour." 4. "I am not sure what we are going to when winter comes."

1. "Mother loves a hot bath with her favorite bath oil." - safety risk; oils in the bath water can result in slippery shower or bathtub surfaces; mother is at risk for falling due to osteoporosis Strategy: "MOST concerns" indicates a complication

The nurse performs an initial assessment on a middle-aged male. It is MOST important for the nurse to follow up on which of the following client statements? 1. "My brother was just diagnosed with prostate cancer." 2. "I take enalapril maleate (Vasotec) 5 mg po daily" 3. "I had a lumbar laminectomy 2 years ago but still have some low back pain." 4. "Lately, I just don't have as much desire to engage in sex."

1. "My brother was just diagnosed with prostate cancer." - middle-aged male is at risk for prostate cancer; having a father or brother with this cancer increases the client's risk by 50% Strategy: "MOST important" indicates discrimination is required to answer the question

The home health nurse visits the home of a mother, father, and their 5-year-old child. The mother's 84-year-old mother has been living with them for 2 months, and the nurse visits to assess the grandmother's health status after hospitalization for a fall and broken arm. Which of the following statements by the 5-year-old MOST concerns the nurse? 1. "My grandma's cat got a cut on his stomach and won't come out of the corner. Can you fix it?" 2. "Sometimes when I drink milk, I throw up." 3. "We never go anywhere any more since Grandma moved in with us." 4. "I want to be a doctor when I grow up and take care of hurt children and animals all over the world."

1. "My grandma's cat got a cut on his stomach and won't come out of the corner. Can you fix it?" - these injuries and behaviors may indicate pet abuse, which can be a sign of other abuse going on in the home, this home has three categories of often-abused people: child, spouse, elder; the 84-year-old was hospitalized for injuries that might have been related to abuse; in this family situation, it is difficult to say who might have been abuses, but there are grounds for suspicion and further investigation Strategy: Think about what the child's words mean

The home care nurse visits a client who is diagnosed with dementia. The client's daughter tells the nurse that after talking with the physician, the client is taking ginkgo. Which of the following statements, if made by the client's daughter to the nurse, requires an intervention? 1. "My mother takes ibuprofen every day for arthritis." 2. "There is a large clock and calendar in my mother's room." 3. "I encourage my mother to take a walk with me every day." 4. "Mother takes digoxin (Lanolin) every day."

1. "My mother takes ibuprofen every day for arthritis." - ginkgo is an anti platelet agent and central nervous system stimulant given for dementia syndromes; increases risk for bleeding when given with NSAIDs Strategy: "Requires an intervention" indicates a complication

A client is placed on gentamicin sulfate (Garamycin) IV q 8 hours. It is MOST important for the nurse to respond to which of the following statements made by the client? 1. "My wife tells me my hearing has changed." 2. "My vision is blurred when I read the paper." 3. "Food just doesn't taste as good to me." 4. "Look at this rash on my arms."

1. "My wife tells me my hearing has changed." - decreased hearing and vertigo occur as a result of involvement of the eighth cranial nerve, which is caused by gentamicin (Garamicin) toxicity. 4. "Look at this rash on my arms." - wrong because rash my indicate hypersensitivity reaction; more important to respond to changes in hearing Strategy: "MOST important to respond" indicates a potential complication

A patient and spouse are visiting the outpatient neurology clinic for the first time. The patient denies any seizure activity, but the spouse states that the patient has "fits". As part of the workup for evaluation of seizure activity, an electroencephalogram (EEG) is ordered for the next day. Which of the following is MOST appropriate for the nurse to include when preparing the patient for the test? 1. "Set your alarm for 2 A.M. and force yourself to stay woke for the rest of the night." 2. "You will need to wash your hair after the test, so do not bother washing it beforehand." 3. "Be careful not to eat or drink anything for at least 6 hours before the test." 4. "There will be harmless prickling sensations during the test as the electricity enters your brain."

1. "Set your alarm for 2 A.M. and force yourself to stay woke for the rest of the night." - patient usually needs to be sleep-deprived (from 2 A.M. or 2 A.M. onward) in order for one part of the test to be effectively carried out; it is during sleep that some abnormalities are most evident Strategy: "MOST important" indicates that discrimination is required to answer the question

The nurse cares for a client following an appendectomy. Several hours after surgery, the nurse finds the knee watch on the client's bed elevated. The client says it feels better with the knee gatch elevated. The nurse should take which action? 1. Check to see when the client last received pain medication 2. Lower the knee watch, and place two pillows behind his knees 3. Check to make sure that the knee watch is not elevated more than 20degrees 4. Help the client turn on the side, and support the back with blankets

1. Check to see when the client last received pain med - client indirectly indicates that they have pain; assess before implementing action Strategy: Answers are a mix of assessments and implementations.

The parents of the child just diagnosed with a chronic illness share with the nurse that they are concerned about the sibling's sudden change in behavior. Which is the BEST response by the nurse? 1. "Your other child is feeling left out right now, but we plan to include them in the care of their sibling" 2. "Your other child is just feeling left out right now, but they will start acting normal soon." 3. "Your other child is worried about your sick child and is just reacting to fear." 4."Your other child is going through a normal developmental stage."

1. "Your other child is feeling left out right now, but we plan to include them in the care of their sibling." - total family participation is accomplished when you include the sibling Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The nurse makes a prenatal visit to the home of a woman who is pregnant with her first child. It is MOST important for the nurse to intervene if which of the following is observed? 1. A cat is sleeping peacefully on the windowsill. 2. Cleaning supplies are in an unlocked cabinet under the kitchen sink. 3. There are throw rugs on the living room floor. 4. The smoke detector is chirping intermittently.

1. A cat is sleeping peacefully on the windowsill. - cat presents a toxoplasmosis risk to the pregnant woman and her unborn/newborn infant; toxoplasmosis is a parasitic disease transmitted in the feces of cats who have eaten infected mice and animals; preventive measures include hand washing after touching cats, have the litter box changed daily (it takes about 48 degrees for the cat's feces to become infectious) by someone other than the pregnant woman, prevent cats from eating raw meat or wild animals, wear gloves when gardening, do not garden in areas frequented by cats, avoid undercooked meat and contact with stray animals Strategy: Think about the outcome of each answer.

The nurse cares for clients on an oncology floor. After receiving the report, which of the following clients should the nurse assess FIRST? 1. A client diagnosed with breast cancer with extensive bone metastasis who is irritable and confused 2. A client who complains of nausea and vomiting 6 hours after receiving chemotherapy 3. A client diagnosed with lung caner who complains of fatigue and mild shortness of breath with ambulation 4. A client with a WBC of 1,600/mm3 who complains of burning with urination

1. A client diagnosed with breast cancer with extensive bone metastasis who is irritable and confused - hyperalcemia (>10.5 mg/dL) may occur as a result of bone destruction by the tumors; elevated levels affect mental status and can negatively affect multiple organ systems Strategy: Determine the most unstable client

The nurse determines that which client is MOST likely to need vitamin B6 (pyridoxine) supplementation? 1. A client diagnosed with tuberculosis 2. A client diagnosed with pernicious anemia 3. A client diagnosed with chronic alcoholism 4. A client at 12 weeks' gestation

1. A client diagnosed with tuberculosis - client is likely to be taking isoniazid (INH); INH is a mainstay in prevention and treatment of tuberculosis, used in combination with other anti tubercular drugs if the disease is active; vitamin B6 is given to prevent the peripheral neuropathy, dizziness, and ataxias that can occur with this drug Strategy: Think about each answer

The nurse who is caring for clients in the outpatient clinic identifies that which of the following clients is at risk for developing hearing problems? 1. A client receiving cisplatin (Platinol-AQ) 2. A client receiving propranolol (Inderal) 3. A client receiving flurazepam (Dalmane) 4. A client receiving cimetidine (Tagamet)

1. A client receiving cisplatin (Platinol-AQ) - antineoplastic that is ototoxic; other side effects include hepatotoxicity, bone marrow suppression, tremors, and confusion I picked 2. A client receiving propranolol (Inderal) - wrong because beta-blocker that is used as an antianginal, anti arrhythmic, and antihypertensive; side effects include weakness, hypotension, bronchospasm, and depression Strategy: Think about each answer

The nurse cares for clients on a cruise ship. The nurse interviews several clients who are experiencing severe vertigo that is unrelieved by dimenhydrinate (Dramamine). After assessing the clients, the nurse determines that which of the following clients should see the physician FIRST? 1. A client with a temp of 100F (38C) complains of hearing loss in the right ear 2. A client complain that objects seem to be moving around him 3. A client complains of a full feeling in her ear followed by a crackling and popping sound 4. A client complains of ringing in his ears and occasional vertigo

1. A client with a temp of 100F (38C) complains of hearing loss in the right ear - symptoms indicate infection; this is the priority client I picked 2. A client complains that objects seem to be moving around him - wrong because describes vertigo; client with possible infection takes priority Strategy: "FIRST" indicates priority

In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss w/ the parents which of the following dietary changes? 1. Adequate protein, low sodium intake 2. Low protein, low potassium intake 3. Low potassium, low calorie intake 4. Limited protein, high carb intake

1. Adequate protein, low sodium intake - If child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted.

The client is receiving regional anesthesia (spinal anesthesia) during surgery. Which finding is the MOST important nursing implication regarding this anesthesia? 1. Adequately hydrate the client 2. NPO client for at least 12 hours 3. Assess the client for allergies to iodine preparations 4. Determine the specific gravy of the urine

1. Adequately hydrate the client - implementation; important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated Strategy: Answers are a mix of assessment and implementation. Do the assessments make sense? No

The nurse observes a client have a tonic clonic seizure lasting about 90 seconds, followed by a period of decreased consciousness lasting 2 minutes. Then the client begins to have another seizure. It is MOST important for the nurse to take which of the following actions? 1. Administer diazepam (Valium) as ordered 2. Monitor serum glucose levels closely 3. Assess the client's blood pressure and pulse 4. Remove excessive clothing

1. Administer diazepam (Valium) as ordered - implementation; give IV to stop seizure activity; support ABCs, protect client from injury, provide oxygen, establish an IV access I picked 4. Remove excessive clothing - wrong because loosen restrictive clothing; protect client from injury Strategy: Determine whether it is appropriate to assess or implement

The nurse performs a home visit on the client diagnosed with progressive multiple sclerosis (MS). The health care provider orders cyclophosphamide and adrenocorticotropic hormone. It is MOST important for the nurse to take which action INITIALLY? 1. Advise the client to purchase a wig or a hairpiece 2. Instruct the client to decrease fluid intake 3. Test the client's serum glucose concentration 4. Observe for indications of GI bleeding

1. Advise the client to purchase a wig or a hairpiece - clients receiving cyclophosphamide usually develop alopecia four to five weeks after starting treatment Strategy: Determine the outcome of each answer choice.

The nursing staff at the new pediatric hospital discusses instituting a community education program regarding mental retardation, particularly prevention. It is MOST beneficial for the nurses to emphasize which of the following areas? 1. Alcoholism treatment 2. Phenylketonuria (PKU) screening 3. Nutritional supplementation 4. Prenatal classes

1. Alcoholism treatment - alcohol is recognizes as the leading cause of preventable mental retardation; mental retardation is included in the fetal alcohol syndrome (FAS) complex of symptoms Strategy: "MOST beneficial" indicates that discrimination is required to answer the question

The nurse supervises care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following? 1. An 18-month-old w/ respiratory syncytial virus. 2. A 4y/o w/ Kawasaki Disease 3. A 10y/o w/ Lyme Disease 4. A 16y/o w/ infectious mononucleosis.

1. An 18-month-old w/ respiratory syncytial virus - Acute viral infection; requires contact precautions; assign to private room or w/ other RSV-infected kids.

Which of the following facts in the health history of an adult patient should cause the nurse to question an order for aspirin (acetylsalicylic acid)? 1. An allergy to tartrazine (FD&C yellow dye #5) 2. A history of lead poisoning in childhood 3. Maternal grandfather died of complications from diabetes 4. Allergies to bee venom and to milk

1. An allergy to tartrazine (FD&C yellow dye #5) - there is a cross-sensitivity between tartrazine and aspirin; an allergic response to one indicates a possible response to the other Strategy: Think about each answer

The nurse cares for a client diagnosed with a cerebrovascular accident (CVA). When creating a teaching plan, which of the following actions by the nurse is MOST important? 1. Ask the client to discuss his perception of his health status. 2. Identify the client's strengths and weaknesses 3. Encourage the client to discuss his concerns with a client who has rehab after a CVA 4. Offer the client a written plan of therapy.

1. Ask the client to discuss his perception of his health status - for teaching to be successful, the nurse should assess client's perception about his health problem I picked 2. Identify the client's strengths and weaknesses - wrong because it is appropriate, but more important to determine client's perceptions Strategy: "MOST important" indicates discrimination is required to answer the question

The nurse cares for a patient who has just been intubated in preparation for mechanical ventilation. Which of the following actions should the nurse take NEXT? 1. Assess lung sounds 2. Call for a stat x-ray 3. Obtain arterial blood gasses 4. Suction the endotracheal tube

1. Assess lung sounds* - priority is to assess for bilateral lung sounds and bilateral chest excursions; assess before implementing Strategy: Assess before implementing

The client on continuous mechanical ventilation desired to go home. In order to determine the client's ability for home care, the nurse should take which action? 1. Assess the ability of others in the home to be trained to provide appropriate care for the client. 2. Confer with the client's health care provider, and discuss the feasibility of the client's request 3. Assess the number of people in the home and the adequacy of space to care for the client 4. Examine the client's reason for wanting to go home, and discuss the implications of home care.

1. Assess the ability of others in the home to be trained to provide appropriate care for the client - to ensure safety and to provide client with quality care at home, assessing ability of others in home is critical before proceeding with efforts to discharge the client I picked 4. Examine the client's reason for wanting to go home, and discuss the implications of home care - wrong because may occur but first determine if someone can care for the client Strategy: Determine how the assessment relates to home care

The home care nurse visits a client with a long leg cast on the right leg due to a fracture of the tibia. The client complains of feeling a hot spot under the cast. Which of the following actions should the nurse take FIRST? 1. Assess the circulation in the right leg 2. Suggest that the client change position 3. Obtain the client's temp 4. Apply ice over the area that is hot

1. Assess the circulation in the right leg - heat is a sign of pressure; nurse should perform neuromuscular assessment before choosing a course of action Strategy: "FIRST" indicates priority

The nurse answers the call light of a patient who is complaining of a severe headache 30 minutes after undergoing a lumbar puncture. Which of the following actions should the nurse take FIRST? 1. Assess the puncture site. 2. Administer an analgesic as ordered. 3. Assess the patient's blood pressure 4. Encourage the patient to lie flat.

1. Assess the puncture site. - headaches are a common side effect of a lumbar puncture procedure, however assessing for leakage of cerebrospinal fluid or the presence of a hematoma that may increase the likelihood of complications is required to determine if further intervention is indicated. Strategy: "FIRST" indicates priority

The nurse works on a newly created unit formed by combing two units. Because one of the former units was a research unit and the other unit was a general med/surg unit, the staff on the new unit does not agree about how to best manage the clients on the combined unit. Despite meetings held for staff to voice concerns about the merger, the nurse notes that there is much divisiveness among the staff that has compromised patient care. It is MOST appropriate for the nurse to make which of the following suggestions to the charge nurse? 1. Assign staff members to patients on both sides of the unit 2. Hold an in-service about the benefits of merging the two units 3. Institute disciplinary action for negative talking by the staff. 4. Require all staff to listen to reports on all of the patients.

1. Assign staff members to patients on both sides of the unit - because meetings allowing staff to voice concerns has not ameliorated the situation, assigning staff to patients on both sides of the unit will force the teams to work together and to experience all of the new unit. I picked 4. Require all staff to listen to reports on all of the patients. - wrong because will expose staff to all patients and their needs, but assigning staff to care for patients on both sides of the unit is the best option Strategy: "MOST appropriate" indicates discrimination is required to answer the question

The 10-year-old child weighing 50 lb (23.6 kg) returns from surgery for a skin graft to the left leg. The child has an IV of D5W infusing into the left arm. The health care provider's orders read: "D5W 2,000 cc/24hr." It is MOST important for the nurse to take which action? 1. Call the health care provider to clarify the IV fluid order. 2. Keep accurate records of the child's intake and output 3. Set the controller on the IV pump to infuse at 88 gtt/min 4. Monitor the child for fluid and electrolyte balance.

1. Call the health care provider to clarify the IV fluid order. - implementation, amount is excessive for child and there are no electrolytes in fluid Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. Is it desired?

The nurse cares for a primipara woman who has been in active labor for 6 hours. The last cervical examination was 2 hours ago, when the cervix was 4 cm dilated and 75% effaced. The fetal head was at 0 station. The client requests analgesia and the nurse performs a cervical evaluation. The nurse anticipates the cervical examination will reveal which of the following? 1. Cervix 6 cm dilated and 100% effaced; +1 station 2. Cervix 8 cm and 100% effaced; 1+ station 3. Cervix 5 cm dilated and 80% effaced; 0 station 4. Cervix 7 cm dilated and 75% effaced; +2 station

1. Cervix 6 cm dilated and 100% effaced; 1+ station - in the primigravidae, progress of labor is cervical effacement, followed by descent and dilation; normal progress of labor at 1-1.2 cm per hour for a primigravida Strategy: Think about each answer

The nurse cares for the client following surgery for a coronary artery bypass graft (CABG). Which symptom would the nurse expect to see if the client was in the early stages of circulatory overload? 1. Change in the character of respirations 2. Fluctuation in the blood pressure 3. Reduced tissue turgor 4. Increase in body temperature

1. Change in the character of respirations. - will see dyspnea, cough, edema, hemoptysis Strategy: Determine how each answer choice relates to fluid overload.

The nurse performs discharge teaching for the client after abdominal surgery. The nurse determines that teaching is effective if the client chooses which foods for lunch? 1. Chicken breast, peas, mashed potatoes, orange, and ice cream 2. Hamburger, boiled potatoes, corn, pudding, and grapefruit juice 3. Chicken salad with lettuce, tomatoes, carrots, zucchini, and broccoli, jello, pears, and soda. 4. Shrimp salad with green beans, and broccoli, peaches, cookies, and coffee 5. Salmon steak, baked potato, lima beans, tangerine, and milk 6. Ham sandwich, lettuce salad, coleslaw, apple, and low fat milk.

1. Chicken breast, peas, mashed potatoes, orange, and ice cream - has high protein, vitamin C, and high calories 2. Hamburger, boiled potatoes, corn, pudding, and grapefruit juice - has high protein, vitamin C, and high calories 5. Salmon steak, baked potato, lima beans, tangerine, and milk - has high protein, vitamin C, and high calories Strategy: Nutrition following surgery needs to have increased protein, calories, and vitamin C for wound healing. What meals contain those items?

A woman is evaluated for infertility, and the physician prescribes clomiphene citrate (Clomid) 50 mg daily for 5 days. The client asks the nurse about how the med works. Which of the following responses by the nurse is BEST? 1. Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary 2. Clomiphene citrate (Clomid) changes the uterine lining to be more conductive to implantation 3. Clomiphene citrate (Clomid) alters the vaginal pH to increase sperm motility 4. Clomiphene citrate (Clomid) produces multiple pregnancy for those who desire twins.

1. Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary - Clomiphene citrate (Clomid) induces by altering estrogen and stimulating follicular growth to produce a mature ovum.

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed-upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement.

1. Confirm that all staff members understand and comply with the treatment plan. - to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and following-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program. I picked 2. Establish mutually agreed-upon, realistic goals. wrong because not of primary importance in designing an effective behavior modification program. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The school nurse notes that one of the children has a copious watery discharge from the left eye, and the eye is red. Which action, if taken by the nurse, is BEST? 1. Contact the child's parents to pick up the child 2. Instruct the child to use a clean tissue each time he wipes his eye 3. Contact the child's health care provider 4. Obtain the child's temp

1. Contact the child's parents to pick up the child - extreme tearing, redness, and foreign body sensation are symptoms of viral conjunctivitis; highly contagious; children restricted from school until symptoms have resolved, 3 to 7 days Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of the interventions.

The nurse cares for the client diagnosed with venous thromboembolism of the left leg. Which nursing goal is appropriate for the client? 1. Decrease inflammatory response in the affected extremity and prevent embolus formation. 2. Increase peripheral circulation and oxygenation of the affected extremity. 3. Prepare the client and family for anticipated vascular surgery on the affected extremity. 4. Prevent hypoxia associated with the development of a pulmonary embolus.

1. Decrease inflammatory response in the affected extremity and prevent embolus formation. - important to prevent the complication of pulmonary embolism in clients at high risk. I picked 4. Prevent hypoxia associated with the development of a pulmonary embolus. - preventing embolism is the first priority Strategy: Think about each answer choice.

The nurse cares for an elderly client who is receiving IV fluids of 0.9% NaCl at 125mL/hr into the left arm. During a routine assessment, the nurse finds that the client has distended neck veins, SOB, and crackles in both lung bases. Which of the following actions should the nurse take FIRST? 1. Decrease the IV rate at 20mL/h and notify the physician 2. Decrease the IV rate at 100mL/h and continue to monitor 3. Discontinue the IV and start O2 at 6L/min 4. Assess for infiltration of the IV solution

1. Decrease the IV rate to 20mL/hr and notify the physician -KVO (20cc/h) will keep access open I picked 3 - wrong because IV line may be necessary; diuretics may be ordered

The adolescent is seen in the ER for an overdose of acetylsalicylic acid. Which action by the nurse is BEST? 1. Determine when the client took the aspirin 2. Intiate an intravenous infusion, and administer protamine sulfate 3. Administer vitamin K 4. Obtain an arterial blood gas, and request respiratory therapy to being respiratory support

1. Determine when the client took the aspirin - charcoal, if given within two hours, will absorb particles of salicylate Strategy: Answers are a mix of assessment and implementations. Is assessment required? Is there an appropriate assessment? yes

The nurse obtains a health history from the client in the medical clinic. The client states, "I think I have an ulcer." Which response by the nurse is BEST? 1. "Do you have a burning pain in the epigastric region?" 2. "Do you have sharp pain in your lower abdomen?" 3. "Do you have right shoulder pain with vomiting?" 4. "Do you have heartburn when you lie down?"

1. Do you have a burning pain in the epigastric region?" - peptic ulcer pain is often referred to as a "burning pain in the back" or a "burning, gnawing" feeling in the midepigastric area Strategy: Determine how each answer relates to an ulcer

The nurse leads a group therapy for a group of clients diagnosed with substance abuse. An alcoholic client who occasionally uses marijuana and cocaine attends the meeting. During the meeting the client states, "I am having trouble sitting still. Am I bothering anybody? Maybe I should not come to these meetings." Which of the following actions by the nurse is MOST appropriate? 1. Encourage the client to share problems with the group 2. Remove the client from the group and further assess needs. 3. Recognize this as manipulative behavior and encourage the client to remain in the group 4. Tell the other group members to ignore the client and continue with the group meeting

1. Encourage the client to share problems with the group - client is probably experiencing some mild level of anxiety; reinforce and encourage the client to share his feelings and attend the meeting Strategy: Determine the outcome of each answer

The client tested positive for the tuberculosis antibody and was placed on isoniazid 4 weeks ago. The nurse observes the client in the outpatient clinic. The nurse is MOST concerned if which finding is observed? 1. Fatigue and dark urine 2. Malaise and glucosuria 3. Proteinuria and lethargy 4. Diluted urine and epigastric distress

1. Fatigue and dark urine - initial indications of hepatic dysfunction I picked 3. Proteinuria and lethargy - wrong because seen with renal problems Strategy: Determine how each answer choice relates isoniazid

During a well-baby checkup, the nurse evaluates the reflexes of the 6-month-old child. The nurse is concerned if which finding is observed? Select all that apply. 1. Finding of a negative Babinski reflex. 2. Extrusion reflex when feeding. 3. Able to grasp objects voluntarily. 4. Rolls from abdomen to back at will. 5. Releases one object to reach for another. 6. Looks ahead when object is dropped.

1. Finding of a negative Babinski reflex. - disappears at approximately 1 year of age 2. Extrusion reflex when feeding. - extrusion reflex disappears between 3 and 4 months of age 6. Looks ahead when object is dropped. - at this age the infant should follow the object when dropped Strategy: Concern indicates an action or finding not expected

The nurse admits a client diagnosed with depression to the psychiatric unit. It is MOSt important for the nurse to take which of the following actions? 1. Give the client a brief orientation to the unit 2. Explain all of the activities to the client 3. Introduce the client to the nursing staff 4. Ask the client to choose activities in which to participate

1. Give the client a brief orientation to the unit - the nurse should explain things clearly and avoid long, complex explanation due to the slowed thinking process of a depressed person I picked 3. Introduce the client to the nursing staff - wrong because do not overwhelm the client; important to provide consistent daily care with the same nurse if possible Strategy: Determine the outcome of each answer. Is it desired?

The RN cares for the 4y/o diagnosed with epiglottis. Which observation indicates to the nurse that the child is experiencing an early complication of hypoxemia? 1. Heart rate of 148 beats per minute (bpm) 2. Bluish discoloration of the skin 3. Bluish coloration around the mouth 4. Throw toys and kicking the bed 5. Difficulty swallowing 6. Nasal flaring with activity

1. Heart rate of 148 beats per minute (bpm) - heart rate correlates with hypoxemia and is an early finding, along with restlessness 4. Throw toys and kicking the bed - Irritability is an early sign of hypoxemia. temper tantrum like behavior is not expected in a 4 year old 6. Nasal flaring with activity - Nasal flaring is an early sign of hypoxemia Strategy: Determine how each answer choice relates to hypoxemia

The nurse cares for a client taking isoniazid (INH) for the past 5 weeks. The client tells the nurse she has been experiencing tingling in her extremities and symmetrical numbness. The nurse knows that the patient is experiencing which common side effect of INH? 1. Peripheral neuropathy 2. Optic neuritis 3. Decreased circulation 4. Hypersensitivity

1. Peripheral neuropathy - a common side effect; administer pyridoxine I picked 3. Decreased circulation - wrong because not a side effect of INH Strategy: Think about each answer

A patient is treated in the telemetry unit for cardiac disease. The patient receives propranolol hydrochloride (Inderal) 20mg PO at 2100. When the nurse enters the room to give the med to the patient wheezing w/ a nonproductive cough and SOB. INITIALLY, the nurse should take which of the following actions? 1. Hold the med and count the resp 2. Hold the med and call the physician 3. Take an apical pulse and then give the med 4. Give the med as ordered

1. Hold the med and count the resp - side effects include increased airway resistance; patient is experiencing bronchospasm; should assess and then call the physician

The nurse is caring for the elderly client diagnosed with type 1 diabetes. The client is scheduled for cataract surgery under general anesthesia at 0900. The client usually receives 30 units of NPH and 10 units of regular insulin each morning at 700. At 0700 the morning of surgery, the nurse expects to take which action? 1. Hold the morning dose of NPH and regular insulin and monitor the blood glucose. 2. Give half the morning dose of NPH insulin together with the regular insulin and monitor the blood glucose when the client returns from surgery. 3. Give the full dose of NPH and regular insulin and monitor the blood glucose every 2-4 hours. 4. Give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.

1. Hold the morning dose of NPH and regular insulin and monitor the blood glucose. - usually use sliding scale with regular insulin based on blood glucose readings I picked 3. Give the full dose of NPH and regular insulin and monitor the blood glucose every 2-4 hours. - client may become hypoglycemic because NPH will peak when client is NPO. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

A client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which of following assessment findings? 1. Hypotension, backache, low back pain, fever 2. Wet breath sounds, severe SOB 3. Chills and fever occurring about an hour after the infusion started 4. Urticaria, itching, respiratory distress

1. Hypotension, backache, low back pain, fever - signs and symptoms of a hemolytic reaction include chills, headaches, backache, dyspnea.

The older client comes to the outpatient clinic for a routine health screening. The nurse learns the client is a retired teacher who lives alone on a limited income. A history indicates the client drinks about 1,500 mL a day and the client's diet consists primarily of starches. It is MOST important for the nurse to encourage the client to take which action? 1. Increase protein intake 2. Increase intake of vitamins 3. Reduce caloric intake 4. Reduce fluid intake

1. Increase protein intake - protein needed to slow down degeneration process of aging I picked 2. Increase intake of vitamins - wrong because necessary but not most important Strategy: "MOST important" indicates priority. Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired?

A client with a history of pulmonary disease comes to the ER with pronounced wheezing and mild dyspnea. The nurse obtains arterial blood gasses and the results are: pH 7.32, PaCO2 48, HCO3 24, PaO2 51. The client is given 1L/min of oxygen per nasal cannula and placed in Fowler position. An hour later the ABGs are: pH 7.35, PaCO2 38, HCO3 24, PaO2 60. Which of the following actions, if taken by the nurse is BEST? 1. Increase the oxygen flow rate 2. Prepare the client for ICU admission 3. Continue to monitor the client 4. Place the client in semi-Fowler position

1. Increase the oxygen flow rate - acidosis has improved, but PaO2 remains decreased; normal is 80-100 Strategy: Determine the outcome of each answer

The charge nurse meets with the head nurse to discuss the staff's concerns about implementing a new delivery of care model. The charge nurse gives the head nurse a document providing extensive rationales about why the staff has voted not to implement the new model. Which of the following actions by the head nurse is MOST appropriate? 1. Inform the charge nurse that the process was inappropriately initiated 2. Reprimand the charge nurse is writing for insubordination 3. Instruct nurse to inform the staff that the delivery model will be implemented. 4. Meet with the staff to obtain feedback regarding their concerns about the delivery model.

1. Inform the charge nurse that the process was inappropriately initiated. - the role of the charge nurse is to support agency decisions; charge nurse should have informed staff that voting would not negate the process I picked 4. Meet with the staff to obtain feedback regarding their concerns about the delivery model - wrong because it does not deal with the charge nurse's decision Strategy: Topic of question is unstated

The nurse cares for clients on the med/surg unit. While irrigating a client's NG tube, an LPN/LVN approaches the nurse to report that another client is hemorrhaging from the rectum. Which of the following actions by the nurse is MOST appropriate? 1. Instruct the LPN/LVN to take over the irrigation of the NG tube while the nurse assess the other client. 2. Direct the LPN/LVN to contact the physician to report the client is bleeding 3. Ask the LPN/LVN to obtain the client's vital signs and immediately report them 4. Tell the LPN/LVN to find another nurse and report about the client's difficulties.

1. Instruct the LPN/LVN to take over the irrigation of the NG tube while the nurse assess the other client. - irrigating an NG tube is within the scope of LPN/LVN practice and client is stable. Strategy: "MOST appropriate" indicates discrimination is required to answer the question

The nurse cares for the woman completing the first stage of labor. The woman's significant other is at her side and has been coaching her according to exercises they learned in childbirth classes. Suddenly the woman begins to shake and screams, "I can't stand this anymore!" The nurse should encourage the significant other to take which action? 1. Instruct the women to use shallow respirations during the contractions. 2. Offer the women ice chips or sips of water to distract her from the pain. 3. Stroke the women's abdomen between contractions 4. Review with the women the breathing pattern needed at each stage of labor.

1. Instruct the women to use shallow respirations during the contractions. - entering transition phase of first stage of labor, rapid shallow breaths needed (pant breathing) I picked 3. Stroke the women's abdomen between contractions - used in conjunction with controlled breathing for Lamaze Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse is the leader of a group of developmentally disabled adults. The nurse instructs the group members to ignore another client whenever the client interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should take which action? 1. Measure improvement by counting the number of times the client succeeds. 2. Measure improvement by counting the number of interruptions 3. Assess the ability of the group to control the client's interruptions 4. Count the number of tokens and earned privileges given for interruptions

1. Measure improvement by counting the number of times the client succeeds. - correct—nurse leader will be able to measure improvement by counting the number of times the client succeeds in controlling his interruptions when others are speaking; tokens can be awarded for successes and then exchanged for privileges; tokens would not be given for continued interruptions; belonging to a group and being allowed to go to group sessions can be a reward for the members; power of group helps decrease socially unacceptable behavior Strategy: Determine the outcome of each answer choice. Think about what the words mean

The fire alarm is ringing at a 50-bed nursing facility. Arrange the following actions by the nurse in the appropriate order from MOST important to LEAST. All options must be used. - Pull the fire alarm - Locate all of the residents - Move clients away from the fire - Close all of the fireproof doors

1. Move clients away from the fire - remember the acronym RACE (rescue/remove, alarm, confine/close, evacuate) 2. Pull the fire alarm - Pull the fire alarm after removing clients 3. Close all of the fireproof doors - prevents fire from spreading 4. Locate all of the residents - appropriate if evacuation required Strategy: Determine the outcome of each answer

The 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which action by the nurse is BEST? 1. Observe the child at mealtime 2. Inquire about the child's eating patterns 3. Weigh the baby each month 4. Attempt to feed the baby for the mother

1. Observe the child at mealtime - assessment; will provide the most information I picked 2. Inquire about the child's eating pattern - wrong; assessment; may or may not secure an accurate picture Strategy: Answers are a mix of assessment and implementations. Is validation required? Yes

On the morning after surgery to repair a fractured hip, the nurse finds an older client struggling to get out of bed. the client tells the nurse, "I have to clean the kitchen now." Which action, if taken by the nurse, is MOST appropriate? 1. Obtain blood gas studies 2. Instruct the client to remain in bed 3. Take the client's B/P 4. Ask the family to remain with the client

1. Obtain blood gas studies - assessment; fat embolism is common with fractures of long bones, results in pulmonary or cerebral emboli, interferes with adequate circulation; confusion is first symptom Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes

The nurse cares for the infant that tested positive for phenylketonuria (PKU). The nurse determines which is the priority for this infant? 1. Offer the infant Lofenalac 2. Administer middle-chain triglyceride (MCT) oil with each feeding. 3. Provide genetic counseling for the family. 4. Place infant on a mixture of oleic and erucic acids; Lorenzo's Oil

1. Offer the infant Lofenalac - infant lacks the enzyme necessary to convert phenylalanine to tyrosine; phenylalanine accumulates in the tissues and leads to mental retardation; Lofenalac is low in phenylalanine but contains minerals and vitamins required by the infant Strategy: Physical needs take priority

The nurse recognizes which of these symptoms as characteristics of a panic attack? 1. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy 2. Decreased blood pressure, chest pain, choking feeling 3. Increased blood pressure, bradycardia, SOB 4. Increased RR, increased perceptual field, increased concentration ability

1. Palpitations, decreased perceptual field, diaphoresis, fear of going crazy. - Panic disorders are characteristics by recurrent, unpredictable attack of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, SOB, a decrease in perceptual field, and a fear of "losing it" or going crazy.

The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? 1. Place a trochanter roll on the outer aspect of the thigh 2. Perform resistive range of motion of the left leg 3. Adduct and internally rotate the left leg. 4. Instruct the patient to maintain the left leg in a neutral position.

1. Place a trochanter roll on the outer aspect of the thigh - holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be help by props placed below knee. I picked 4. Instruct the patient to maintain the left leg in a neutral position. Wrong because leg will externally rotate unless propped in proper alignment. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

During a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which of the following actions should the nurse take NEXT? 1. Place an ID bracelet on each child 2. Go back for an adequate supply of water 3. Notify the parents of the children's location 4. Comfort children who are anxious

1. Place an ID bracelet on each child - aids in communication after rescue or recovery I picked 3. Notify the parents of the children's location - wrong because identification takes priority over notification Strategy: Determine the outcome of each answer

The nurse admits a client diagnosed with chronic lung disease to the acute pulmonary unit. The nursing assessment reveals respiratory rate of 50, pulse 140 and irregular, skin pale and cool to touch, and client confused to person, place, and time. Orders include oxygen per nasal cannula at 4L/min, bedrest, soft diet, and pulmonary function tests in the A.M. Place the following nursing activities in the proper sequence beginning with MOST important. All options must be used. - Administer oxygen at 4l/min -Place the client in semi-fowler position - Ask a staff member to stay with the client - Contact the physician

1. Place the client in semi-Fowler position - allows for maximal lung expansion 2. Ask a staff member to stay with the client - do not leave the client alone 3. Contact the physician - client appears unstable: support respiratory function first 4. Administer oxygen at 4L/min - oxygenates the client Strategy: Determine the outcome of each answer

The nurse cares for the client recovering from abdominal surgery. During ambulation, the client reports a dull ache in the left leg. Which action should the nurse take FIRST? 1. Place the client on bedrest with extremity elevated 2. Place a pillow under the client's knee 3. Encourage the client to ambulate more frequently 4. Obtain thigh-high compression stockings.

1. Place the client on bedrest with extremity elevated - promotes venous return and decrease venous pressure, relieving pain and edema I picked 4. Obtain thigh-high compression stockings. wrong because it's used to prevent DVT, should be on bedrest initially Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse on the orthopedic unit cares for a patient who sustained a T5 spinal cord injury 4 weeks ago. Upon entering the room, the nurse observes that the patient is diaphoretic, nauseated, and complaining of a severe headache. Which of the following actions should the nurse take FIRST? 1. Place the patient in a sitting position 2. Have the patient empty his bladder 3. Examine the rectum 4. Administer hydralazine hydrochloride (Apresoline) as ordered.

1. Place the patient in a sitting position - symptoms reflect autonomic dysreflexia; emergency life-threatening condition which can occur with spinal cord injuries above T6 after spinal shock resolves, which is 1 to 6 weeks after injury; causes include visceral distension and noxious stimuli such as skin pressure, temperature extremes; a primary symptom, and of most major concern, is severe rapid hypertension; other symptoms include bradycardia; placing patient in sitting position should be done immediately to help decrease the blood pressure and prevent increased pressure with cerebral hemorrhage and seizures I picked 2. Have the patient empty his bladder - wrong because not first, distended bladder is the most common cause of autonomic dysreflexia and must be assessed very quickly, e.g., right after sitting patient up

The 2-year-old child is hospitalized. The nurse assesses the child and asks the parent about the activities the child does at home. Which activity would the nurse anticipate this child to perform? 1. Plays beside other children, but not with them. 2. Builds 6-7 block towers 3. Can put toys away alone 4. Names colors 5. Can retrieve objects when asked to do so. 6. Uses sentences of 4-5 words.

1. Plays besides other children, but not with them. - Participates in parallel play 2. Builds 6-7 block towers - Able to build tower this high 5. Can retrieve objects when asked to do so. - Can follow simple directions/commands Strategy: Think of the growth and development of a 2-year-old.

The client has a cataract removed from the left eye. Which action is important for the nurse to take in the immediate postoperative period? 1. Position the client on the right side with the head slightly elevated 2. Place the client on the left side to protect the eye 3. Perform sensory neurological checks every two hours 4. Maintain complete bedrest for the first 48 hours 5. Assess client's level of consciousness 6. Assess client knowledge of home care

1. Position the client on the right side with the head slightly elevated - should be positioned on back or unaffected side to prevent trauma to surgical eye 5. Assess client's level of consciousness - assessing the level of anesthesia is necessary immediately post op Strategy: Answers are all implementation. Determine the outcome of each answer choice. Is it desired?

The client has a cataract removed form the left eye. Which is the MOST important nursing intervention in the immediate post-op period? 1. Position the client on the right side with the head slightly elevated 2. Place the client on the left side to protect the eye 3. Perform sensory neurological checks every 2 hours 4. Maintain complete bedrest for the first 48 hours

1. Position the client on the right side with the head slightly elevated - should be positioned on back or unaffected side to prevent trauma to surgical eye Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

The nurse admits an elderly woman to the unit. The client demonstrates decreased ability to problem-solve, psychomotor retardation, and social isolation. Which of the following nursing actions is MOST appropriate? 1. Prepare a schedule of activities and monitor the client's participation in the activities. 2. Encourage the client to choose her own activities 3. Allow the client time to get acclimated to the milieu before scheduling activities 4. Allow the client to rest quietly to restore her energy level

1. Prepare a schedule of activities and monitor the client's participation in the activities - client displays symptoms of depression; a regular daily routine of scheduled activities structure and decreases the problem solving; participating in activities will increase self-esteem I picked 3. Allow the client time to get acclimated to the milieu before scheduling activities - wrong because will increase social isolation Strategy: "MOST appropriate" indicates discrimination is required to answer the question

The nurse prepares a client for computerized axial tomography (CAT) scan without the use of contrast dye. It is MOST important for the nurse to assess for which of the following? 1. Problem client may have with being in a closed space 2. Allergies to medication 3. Intact swallow and gag reflex 4. Range of motion of all extremities

1. Problem client may have with being in a closed space - provides three-dimensional assessment of the lungs and thorax; if client is claustrophobic, scan may cause sever anxiety

A patient comes to the ED with a possible pneumothorax. The nurse should assess for which of the following? 1. Rapid respirations 2. Deep, rapid respirations 3. Respiratory depression 4. Periods of hypernpea alternating with periods of apnea

1. Rapid respirations - describes tachypnea I picked 3. Respiratory depression - wrong because it occurs with drug overdose Strategy: Think about each answer

A patient came to the ED after witnessing a friend shot to death on her front balcony. The patient is shaking, crying, and states she feels very nervous. The nurse observes the patient to be severely anxious. The nurse's plan of care should include which of the following? 1. Remain with the patient 2. Contact the police to interview the patient 3. administer lorazepam (Ativan) 1 mg IM 4. Encourage patient to describe the incident 5. Provide privacy for the patient 6. Write down important information

1. Remain with the patient - always remain with the patient; assist patient to clarify thoughts and feelings 3. administer lorazepam (Ativan) 1 mg IM - antianxiety to assist client to cope with anxiety; side effects include drowsiness, light-headedness, hypotension 5. Provide privacy for the patient - especially important if activities around the patient are overstimulating the patient 6. Write down important information - may have difficulty listening to and understanding info if anxiety is severe Strategy: Determine the outcome of each answer. Is it desired?

The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which action, if taken by the nurse, is BEST? 1. Send the staff member home 2. Assess the staff member's compliance with standard precautions 3. Assign the staff member only to clients with chronic diseases 4. Reassign the staff member to clean the supply closet

1. Send the staff member home - extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis; highly contagious, infected employees cannot work until symptoms have resolved in 3 to 7 days; the nursing supervisor should be notified Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse is MOSt likely to provide teaching regarding which of the following to a 10-year-old child and his parents? 1. Sports safety 2. Water safety 3. Suicide prevention 4. Obesity prevention

1. Sports safety - bicycle and sports related injuries and proper nutrition are the two greatest concerns in school age children I picked 4. Obesity prevention - wrong because encourage child to eat a balanced diet and to get daily physical activity Strategy: Think about each answer

The nurse cares for a client diagnosed with cutaneous anthrax. The nurse should follow which precaution during care of the client? 1. Standard precautions 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

1. Standard precautions - standard precautions used for cutaneous anthrax; infectious disease caused by Bacillus anthraces, spread to humans by contact with infected animal hair and hides Strategy: Think about each answer

The nurse in the outpatient clinic teaches a young adult with a sprained right ankle to walk with a cane. While teaching the client to use the cane, how should the nurse be positioned? 1. Standing on the client's left side and slightly behind the client. 2. Standing on the client's right with one hand on the client's waist. 3. Standing directly in front of the client with both hands on the client's arms. 4. Standing in front of the client on the right side.

1. Standing on the client's left side and slightly behind the client. - stand slightly behind client on strong side I picked 2. Standing on the client's right with one hand on the client's waist. - wrong because incorrect positioning Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The nurse cares for the client admitted in the first trimester of pregnancy. The client experiences hyperemesis gravidarum. The client presents with decrease in weight, poor skin turgor, and a chloride deficiency. Which nursing order should the nurse implement? 1. Start an IV upon admission 2. Complete an intake and output record every 4 hours 3. Provide oral fluids every hour 4. Perform a weight check every morning 5. Hold all anti-nausea meds 6. Place client on bed rest

1. Start an IV upon admission - parenteral hydration is the best way to re-hydrate the client 2. Complete an intake and output record every 4 hours - contains a plan to evaluate the status of hydration 4. Perform a weight check every morning - assessment; is an appropriate action for evaluating the client, but it does not meet hydration needs 6. Place client on bed rest - best rest is ordered for the client to conserve energy Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations

The nurse cares for a client admitted in the first trimester of pregnancy. The client experiences hyperemesis gravidarum. The client presents with decrease in weight, poor skin turgor, and a chloride deficiency. Which nursing order should the nurse implement first? 1. Start an IV upon admission 2. Complete an intake and output record every 4 hours 3. Provide oral fluids every hour 4. Perform a weight check every morning

1. Start an IV upon admission - parenteral hydration is the best way to re-hydrate the client I picked 3. Provide oral fluids every hour - wrong because the client will be NPO to rest the GI tract Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations

An elderly client diagnosed with Alzheimer's disease frequently wanders down the halls of the extended care facility and displays restless agitation. The health care provider orders a vest restraint. When the nurse takes the restraint to the room, the client refuses to put it on. It is MOST important for the nurse to take which action? 1. Take the restraint away, and check the client frequently. 2. Notify the health care provider immediately that the client refused the restraint. 3. Ask a coworker to hold the client and gently apply the restraint. 4. Exchange the vest restraint for wrist restraints.

1. Take the restraint away, and check the client frequently. - as long as behavior is not unsafe, nurse should try other methods to engage client in activities to reduce wandering I picked 2. Notify the health care provider immediately that the client refused the restraint. - wrong; not first or most important action of nurse; client is primary responsibility Strategy: "MOST important" indicates a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse supervises the nursing assistive personnel (NAP) administer a soapsuds enema to a client prior to abdominal surgery. Which action, if performed by the NAP, requires an intervention by the nurse? 1. The NAP holds the irrigation set 30 inches above the client's rectum 2. The NAP inserts the irrigation tube 3 inches into the client's rectum 3. The NAP positions the client in Sims' position 4. The NAP warms the water to 105F (40C)

1. The NAP holds the irrigation set 30 inches above the client's rectum - should be 12-18 inches; too high causes rapid distention and pressure in intestine causing rapid expulsion of solution, poor defecation, and damage to mucous membranes Strategy: "Require an intervention" indicates incorrect behavior

The nurse assesses the child diagnosed with cystic fibrosis. The nurse is MOST concerned if which finding is observed? 1. The child is expectorating thick, yellow mucus 2. there is increased mucus production with postural drainage 3. Exertional dyspnea increases during the day 4. The child reports difficulty breathing

1. The child is expectorating thick, yellow mucus Strategy: Determine the significance of each answer choice and how it relates to cystic fibrosis

The nurse evaluates care in the long-term care facility. Which observation provides the best evidence that the nursing intervention to deal with the client's self-care deficit in relation to feeding is effective? 1. The client eats at least one-half of all meals and drinks a minimum of 2,000mL/day 2. The client's dentures have been replaced, and they are able to chew. 3. The client will eat without verbalizing suspicion when a particular nurse sits with them 4. The client appears to have increased energy to complete grooming activities.

1. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day - concrete measure of the client's eating patterns indicates adequate intake of a well-balanced diet Strategy: Determine the outcome of each answer choice. Is it desired?

Which observation indicates to the nurse the need for further teaching for a postoperative client using the incentive spirometer? Select all that apply: 1. The client exhales with the spirometer in his mouth. 2. The client inhales with the spirometer in his mouth. 3. The client splints his incision before using the spirometer. 4. The client raises the head of his bed before using the spirometer. 5. The client breath rate is 20/minute while using the spirometer. 6. The client exhales and holds his breath for two to three seconds.

1. The client exhales with the spirometer in his mouth. - incentive spirometry is designed to promote lung expansion by encouraging sustained maximal inspirations 5. The client breath rate is 20/minute while using the spirometer. - breath should not exceed 10/min to 12/min 6. The client exhales and holds his breath for two to three seconds. - should hold breath at end of maximal inspiration I also picked 3. the client splints his incision before using the spirometer - wrong; benefits the post-op client during use of spirometry Strategy: Answers are implementation. Determine the outcome of each answer choice. Is it desired?

After receiving report, the nurse is assigned to these clients. Place them in the order the nurse should see them beginning with the FIRST client. All options must be used. - The client in sickle-cell crisis with an infiltrated IV. - The client with leukemia receiving 0.5 unit of packed cells. - The client needing ordered sedative for a bronchoscopy scheduled in 45 minutes. - The client reporting a leaky colostomy bag.

1. The client in sickle-cell crisis with an infiltrated IV. - The client with a sickle cell crisis is least stable and fluids are crucial for this client. 2. The client needing ordered sedative for a bronchoscopy. - The sedative is time sensitive and needs to be given about 30 minutes before the procedure. 3. The client with leukemia receiving 0.5 unit of packed cells. - Clients receiving blood products need to be assessed about every 15minutes. 4. The client reporting a leaky colostomy bag. - The leaky colostomy bag is the least important. Strategy: Identify the least stable client to see first.

The nurse cares for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. In what order should the nurse return the messages? (Place in the correct order starting with the first message to return. All options must be used.) - The client is nauseated and has vomited 6 times in the previous 24 hours - A client reports leg pain after walking half a mile - The client with cold symptoms has an oral temp of 103F - The client with stage 2 decubitus ulcer reports the dressing has come off.

1. The client is nauseated and has vomited 6 times in the previous 24 hours - Unstable, circulation. The client with nausea and vomiting needs to be called first as dehydration may be a significant problem; need to find out what is causing the vomiting 2. The client with cold symptoms has an oral temp of 103F - Unstable, the temp of 103 is quite elevated for any client and additional information needs to be obtained 3. The client with stage 2 decubitus ulcer reports the dressing has come off. - Stable, infection. The decubitus ulcer dressing needs to be addressed soon, but is not of as much importance as the previous two. 4. A client reports leg pain after walking half a mile - Stable, Client is not in pain at the time. May be intermittent claudication and needs to have this addressed by they are the most stable. Strategy: Identify the two most stable clients. Use the ABCs to determine the most unstable client.

The nurse performs a home visit on a client diagnosed with Alzheimer's disease. It is MOST important for the nurse to follow up on which of the following observations? 1. The client spends most of her time in bed 2. The home appears cluttered 3. The daughter attends her children's school activities 4. The son-in-law helps with the client's care.

1. The client spends most of her time in bed - nurse needs to determine reason why client is not getting up and moving around; reasons can include caregiver burnout, family doesn't understand importance of a regular routine for client Strategy: "Nurse to follow up" indicates something is wrong

The nurse has just received report from the previous shift. In what order should the nurse see these clients? Place in order starting with the first client. Place in the correct order starting with the first message to return. - The client on high doses of antibiotics reporting diarrhea. - The client with type 1 diabetes melitus states, "I have a quivering feeling in my abdomen." - The client with chronic renal failure reporting swollen fingers and ankle edema. - The client 1 day post-op with dried blood on the abdominal dressing

1. The client with type 1 diabetes melitus states, "I have a quivering feeling in my abdomen." - Unstable, unexpected; The diabetic client is likely experiencing hypoglycemia. 2. The client with chronic renal failure reporting swollen fingers and ankle edema. - Stable, unexpected, circulation, renal; The client with renal failure is retaining fluid and needs to be assessed. 3. The client 1 day post-op with dried blood on the abdominal dressing - Stable, expected, circulation; New post-op clients need to be assessed early in the shift. 4. The client on high doses of antibiotics reporting diarrhea. - Stable, expected, circulation; The diarrhea needs to be addressed, but is least important of these clients. Strategy: Identify the least stable clients to see first and the most stable to see last.

In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of the following? 1. The colostomy needs to be irrigated at the same time every day. 2. Irrigate the colostomy after meals to increase peristalsis 3. Insert the catheter about 10 inches into the stoma. 4. The solution should be very warm to increase dilation and flow.

1. The colostomy needs to be irrigated at the same time every day. - colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination.

The home care nurse returns to the office to find four phone messages. Which of the following messages should the nurse return FIRST? 1. The daughter of a client diagnosed with lung cancer states that her father refuses chemotherapy today. 2. A client is asking when staples can be removed from his abdominal incision 3. A client with colostomy complains that the skin is raw around the stoma 4. The wife of a client with a cerebrovascular accident states that her husband is refusing a bath.

1. The daughter of a client diagnosed with lung cancer states that her father refused chemotherapy today. - assess whether client is experiencing side effects I picked 3. A client with colostomy complains that the skin is raw around the stoma - wrong because second call to be returned; ensure that skin sealant does not contain alcohol and instruct client to use stoma powder or paste Strategy: Determine the most unstable client

The nurse cares for clients on the postpartum unit. The nurse determines which of the following clients is at GREATEST risk for developing postpartum hemorrhage? 1. The nurse notes the client has a distended bladder 2. The client has had an episiotomy. 3. The client complains of engorged breasts 4. The nurse massages the client's fundus.

1. The nurse notes the client has a distended bladder - likely to displace uterus to left or right and interferes with uterine contraction Strategy: GREATEST risk" indicates discrimination is required to answer the question.

The nurse on the long-term care unit identifies a higher than expected incidence of impaired skin integrity among the patients. The nurse decides to call a staff meeting to obtain the staff's input about the problem. Which of the following suggestions, if made by a staff member to the nurse, indicates that the staff member feels empowered to solve the problem? 1. The nursing assistant states that the facility's sheets are too irritating and suggests home sheets be requested or donated by employees 2. An LPN/LVN states that incontinence during the night is the main factor and suggests that fluids be restricted after the 6 P.M. meal 3. An LPN/LVN states that shearing force is a contributing factor and suggests that the nursing assistants be more gentle when repositioning the patients. 4. The RN states that patients are left sitting for too long and announces from now on patients will be repositioned every hour.

1. The nursing assistant states that the facility's sheets are too irritating and suggests home sheets be requested or donated by employees - empowerment involves innovation in problem solving; resulting in a sense of accomplishment and feeling of worth I picked 4. The RN states that patients are left sitting for too long and announces from now on patients will be repositioned every hour. - wrong because this staff member is too authoritarian, and the suggestion is unrealistic and non-innovative Strategy: Determine the outcome of each answer. Is it desired?

The nurse admits a patient diagnosed with bipolar disorder. Which of these assessments requires IMMEDIATE attention by the nurse? 1. The patient has not eaten breakfast and lunch 2. The patient has been pacing the hallway for the last 15 minutes 3. The patient is not wearing a bra 4. The patient believes she has a lot of money and power

1. The patient has not eaten breakfast and lunch - must be addressed immediately; physical vs psychological; because of the patient's poor judgment, dehydration and poor nutrition put the patient at risk for injury Strategy: "IMMEDIATE attention" indicates priority

A patient diagnosed with emphysema is brought to the ED by the family. The nurse notes that the patient is breathless and ashen in color. Vital signs include: temp 98.8F (37C), pulse 114, respirations 36, BP 138/108. Oxygen is started per nasal cannula at 2L/min. Which of the following observations MOST concerns the nurse? 1. The patient's skin is pink within the first 20 minutes of oxygen delivery 2. The pulse oximetry reading is 92%. 3. The spouse beings to sob and says living with be difficult if patient dies 4. Blood work reveals hemoglobin 19 g/dL and hematocrit 54%

1. The patient's skin is pink within the first 20 minutes of oxygen delivery - COPD patient who has hypercapnia, which is likely in advanced or exacerbated emphysema, is at risk for oxygen-induced hypoventilation because stimulus for breathing is low oxygen level, not high CO2 level as in average people; signs of hypoventilation will appear in the first 30 minutes of oxygen administration; color will improve due to the increase in PaO2 levels; going from gray or ashen to pink before becoming apnea or going into respiratory arrest; careful monitoring of these patients is critical Strategy: Remember Maslow

The nurse in the psychiatric day hospital program cares for a patient diagnosed with recurrent depression. The referring therapist recommends a cognitive therapy approach. The nurse doing the initial assessment knows that is MOST important to focus the assessment on which of the following? 1. The patient's use of language 2. The patient's insight into the depression 3. The patient's socialization history and skills 4. The patient's attitude toward medications

1. The patient's use of language - cognitive viewpoint on depression sees it as stemming from errors in thinking, which may be negative, illogical, and/or irrational; language is used in thought as well as in speech; speech or writing is used to express thoughts and thereby is an indicator of the patient's automatic thoughts, their schemata or cognitive structure about themselves and the world, and their cognitive distortions I picked 2. The patient's insight into the depression - wrong because emphasis on insight is prominent in traditional psychoanalytic and psychodynamic therapies Strategy: "MOST important" indicates that discrimination is required to answer the question

The nurse obtains a health history from a teen admitted with acute glomerulonephritis. The nurse expects to find which of the following in the patient's health history? 1. The teen had impetigo 2 weeks ago 2. The teen's mother had glomerulonephritis 3. The teen had renal calculi 2 years earlier 4. The teen had an untreated bladder infection 2 months ago

1. The teen had impetigo 2 weeks ago - occurs 5-21 days after infection of pharynx or skin by group A B - hemolytic streptococci; symptoms include fever, chills, hematuria, weakness, pallor, generalized and/or facial and periorbital edema, moderate to sever hypertension I picked 4. the teen had an untreated bladder infection 2 months ago - wrong - symptoms of UTI include urgency, frequency, and burning on urination Strategy: Think about each answer

The client returns to the floor following a bronchoscopy. The client reports thirst and requests ice chips. The health care provider left an order for the client to resume a regular diet. The nurse should take which action? 1. Touch the back of the client's throat with a tongue depressor 2. Observe the client while he sucks on a few ice chips 3. Provide clear fluids to the client and advance to soft foods 4. Assess the client's tissue turgor and intake and output

1. Touch the back of the client's throat with a tongue depressor - assessment; local anesthesia sprayed on throat may interfere with swallowing

The client is admitted with a diagnosis of a fractured right hip. The health care provider writes an order for Buck's traction. Which action, if taken by the nurse, is MOST important? 1. Turn the client every 2 hours to the unaffected side 2. Maintain the client in a supine position 3. Encourage the client to use a bedside commode 4. Place a footboard on the bed.

1. Turn the client every 2 hours to the unaffected side - immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side I picked 4. Place a footboard on the bed. - wrong because would interfere with the traction Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The client undergoes peritoneal dialysis at home. The home care nurse notices the fluid outflow is inadequate. Which action should the nurse take FIRST? 1. Turn the client from side to side 2. Check for kinks in the tubing 3. Close the clamp to the drainage tubing for one half hour, then reopen 4. Milk the drainage tubing firmly every 20 minutes

1. Turn the client from side to side - facilitates drainage I picked 2. Check for kinks in the tubing - wrong; 2nd action Strategy: "FIRST" indicates priority

The nurse assesses a client in the outpatient clinic for treatment of multiple sclerosis (MS). The nurse should assess for which of the following clinical manifestations? 1. Urinary retention 2. Decreased level of consciousness 3. Hypoactive deep tendon reflexes 4. Intestinal obstruction 5. Numbness or tingling sensation 6. Decreased short-term memory

1. Urinary retention - causes progressive demyelination of spinal cord, will see gradual weakness leading to paralysis, alternation in innervation of bladder and urinary tract 5. Numbness or tingling sensation - client will also experience decreased sensitivity to pain, facial pain, and decreased temp perception 6. Decreased short-term memory - cognitive changes are seen late in the disease and include decreased concentration, decreased ability to perform calculations, impaired judgment Strategy: Determine how each answer relates to MS

The nurse cares for the woman with pregnancy-induced hypertension (PIH) treated with magnesium sulfate. The nurse is MOST concerned if which finding is observed? 1. Urine output decreased from 70 to 30 mL/hr 2. Respiratory rate increased from 14 to 18/min 3. Hypertonic patellar reflexes 4. B/P increased from 150/90 to 170/100

1. Urine output decreased from 70 to 30mL/hr - is metabolized and excreted by the kidneys; decrease in the urine output can lead to toxicity Strategy: "MOST concerned" indicates a complication

The nurse performs teaching on the client diagnosed with Bell's palsy. It is MOST important for the nurse to include which instruction? 1. use artificial tears four times per day 2. Wear sunglasses at all times 3. Avoid sudden movement of the head 4. Change the pillowcase daily

1. Use artificial tears four times per day - paralysis of the eyelid allows the cornea to dry; patch can be used to keep the eyelid closed to prevent damage; drops and/or ointments are used to reduce chance of corneal damage Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurse observes that the client's breasts are soft, the uterus is boggy to the right of the midline and 2cm below the umbillicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions? 1. Perform a straight cath 2. Offer the client the bedpan 3. Put the baby to breast 4. Massage the uterine fundus

2. Offer the client the bedpan - boggy uterus deviated to the right indicates full bladder, encourage client to void

A 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which of the following? 1. A pincer grasp 2. Sitting w/ support 3. Tripling of the birth weight 4. Presence of the posterior fontanelle

2. Sitting w/ support - 6-month-old should sit w/ help

A patient developed acute respiratory distress syndrome (ARDS) after an auto accident and is being earned from the ventilator. The nurse knows the best mode to wean the patient from the ventilator is 1. synchronized intermittent mandatory ventilation (SIMV) 2. controlled ventilation 3. assist-control ventilation 4. positive and expiratory pressure (PEEP)

1. synchronized intermittent mandatory ventilation (SIMV) - allows for spontaneous breaths at his own rate and tidal volume between ventilator breaths Strategy: Think about each answer

The nurse cares for a client in her third trimester of pregnancy. The nurse is MOST concerned by which assessment finding? 1. The client reports epigastric pain 2. The client reports shortness of breath 3. The client states she has increased rectal pressure 4. The client has gained of 33 pounds during her pregnancy.

1. the client reports epigastric pain - is usually indicative of an impending convulsion. Strategy: Think about the cause of each symptom and how it relates to pregnancy.

The client comes to the clinic for the hepatitis B vaccine. The client asks if more than one injection is necessary. Which response by the nurse is BEST? 1. "A booster shot is required yearly." 2. "Additional injections are given at one and six months" 3. "Repeat doses are given at two and four months" 4. "Revaccination is not required."

2. "Additional injections are given at one and six months" - hepatitis B vaccine is repeated at 1 and 6 months Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse performs discharge teaching for an elderly female diagnosed with peripheral arterial insufficiency. It is MOST important for the nurse to include which of the following instructions? 1. "Soak in a tub of hot water twice a day." 2. "Apply a heating pad to your abdomen once a day." 3. "Elevate your legs above the level of your heart four times per day." 4. "Sit for a total of 6 hours per day with your feet resting on the floor."

2. "Apply a heating pad to your abdomen once a day" - will cause a reflex vasodilation of the extremities; safer than placing direct heat on the extremities Strategy: Determine the outcome of each answer. Is it desired?

The nurse in the outpatient clinic prepares a client for a pap smear. The client takes atenolol (Tenormin) 50 mg daily. It is MOST important for the nurse to follow up on which of the following client statements? 1. "I haven't had a pelvic exam in 3 years" 2. "Black cohosh helps my hot flashes." 3. "I exercise three times per week." 4. "I don't like it when my partner uses a condom."

2. "Black cohosh helps my hot flashes." - herbal use in management of menopausal symptoms; may cause hypotension when used in combination with antihypertensive drugs Strategy: "MOSt important" indicates that discrimination is required to answer the question

A LPN/LVN contacts the nurse to say that they have shingles on their back. Which statement by the nurse is BEST? 1. "You can't take care of clients for 14 days." 2. "Come to work as scheduled" 3. "You can't care for clients until the lesions are crusted." 4. "Please contact your health care provider"

2. "Come to work as scheduled" - able to care for non-high-risk clients; cover lesions should not care for pregnant women, premature infants, or immunocompromised clients I picked 3. "You can't care for clients until the lesions are crusted." - wrong; able to care for low risk clients if lesions are covered Strategy: The topic of the question is unstated. Read answer choices for clues

The nurse instructs a client receiving acyclovir (Zovirax). The nurse determines that teaching is effective if the client states which of the following? 1. "The medication will cure my disease." 2. "I should take this medication with food." 3. "I'm glad that I only have to take this once a day." 4. "I can apply lotion on the lesions if they begin to hurt."

2. "I should take this medication with food." - may cause nausea and vomiting; antiviral used to treat herpes Strategy: "Teaching is effective" indicates correct information

An adult client is admitted to an acute locked psychiatric unit one month prior to an election. The client requests the opportunity to vote in the upcoming election. Which response by the nurse is BEST? 1. "You are not eligible to vote because you are a psychiatric client." 2. "I'll make the appropriate arrangements for you to vote." 3. "You may vote only if you are discharged by Election Day." 4. "I'll contact the Election Board to see if you are registered to vote."

2. "I'll make the appropriate arrangements for you to vote." - client can vote by absentee ballot Strategy: Determine the outcome of each answer choice

The nurse cares for clients in the senior citizens facility. A client relates to the nurse that, "I had pneumonia once, and I don't want to get it again." To develop an effective teaching plan for this client, it is MOST important for the nurse to obtain an answer to which of the following questions?" 1. "How often do you cough and deep breathe?" 2. "Have you received a flu shot this year?" 3. "Do you avoid crowds?" 4. "How much sleep do you receive each night?"

2. "Have you received a flu shot this year?" - community-acquired pneumonia (most common form of pneumonia) often follows viral infections or influenza; also ask client status of pneumococcal vaccine Strategy: "MOST important" indicates discrimination is required to answer the question

A woman has been recently diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST? 1. "Most women find that they feel better when they are pregnant." 2. "How long have you been in remission?" 3. "Women with lupus frequently have slightly longer gestations." 4. "It is best to become pregnant within the first 6 months of diagnosis."

2. "How long have you been in remission?" - should be in remission for at least 5 months prior to conceiving I picked 1 wrong because maternal morbidity and mortality are increased with SLE. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes

The nurse performs teaching for a patient receiving amitriptyline hydrochloride (Elavil). The nurse should intervene if the patient makes which of the following statements? 1. "I will take Elavil at bedtime." 2. "I always forget to wear sunscreen." 3. "I will stop eating cheese and yogurt." 4. "It may be 3 to 4 weeks before I feel better." 5. "When I start to feel better, I can adjust the dosage of Elavil." 6. "I can exercise as soon as I wake up in the morning."

2. "I always forget to wear sunscreen." - sunblock required 3. "I will stop eating cheese and yogurt." - true for MAO inhibitors (Nardil, Marplan); foods containing tyramine may cause hypertension 5. "When I start to feel better, I can adjust the dosage of Elavil." - patient should never adjust dosage of medication without consulting a physician 6. "I can exercise as soon as I wake up in the morning." - may cause orthostatic hypotension; instruct client to sit on side of bed before arising in the morning Strategy: Determine the outcome of each answer. Is it desired?

The client has an order for aminophylline PO. The nurse should withhold the medication and notify the health care provider if the client makes which statement? 1. "I am allergic to neomycin." 2. "I am taking propranolol." 3. "I have trouble breathing when I exercise." 4. "I have had several urinary tract infections." 5. "I have been taking ciprofloxacin for the last 5 days." 6. "My seizure med is not working very well these days."

2. "I am taking propranolol" - may decrease metabolism and lead to toxicity 5. "I have been taking ciprofloxacin for the last 5 days" - quinolone may decrease hepatic clearance of aminophylline causing risk of toxicity 6. "My seizure med is just not working very well these days." - this med is contraindicated in clients with poorly controlled seizure disorder Strategy: Determine the significance of each answer choice and how it relates to aminophylline

The nurse cares for a client receiving doxycycline (Vibramycin) 50 mg PO BID. The nurse is concerned if the client states which of the following? 1. "I wear sunscreen when I am outdoors." 2. "I have a vaginal discharge." 3. "I take the medication at 10:30am and 10:30pm" 4. "My husband and I use condoms for birth control." 5. "I take all of the medication in the bottle." 6. "I take an antacid immediately before going to bed."

2. "I have a vaginal discharge." - may indicate superinfection 3. "I take the medication at 10:30am and 10:30pm" - medication is taken at regular intervals around the clock but should not be taken within 1 hour of bedtime because it may cause esophageal irritation; nurse should find out what time client usually goes to bed 6. "I take an antacid immediately before going to bed." - do not take antacids within 1 to 3 hours of taking oral tetracycline; statement requires further assessment Strategy: "Nurse is concerned" indicates a potential complication

A patient diagnosed with alcoholism is scheduled to take disulfiram (Antabuse). Which of the following statements, if made by the patient to the clinic nurse, MOST concern the nurse? 1. "I will take it at night so it helps me sleep" 2. "I like to work on crafts, especially unfinished furniture" 3. "I understand that Antabuse loses it effectiveness over time." 4. "I hope this works. I'm tired of being drunk."

2. "I like to work on crafts, especially unfinished furniture" - potential contact with alcohol both by inhalation of pain or wood stain fumes as well as by skin contact with these substances; any contact with any amount or any form of alcohol, even a very small amount, like 7 to 15 mL, will cause an alcohol-disulfiram reaction, which is extremely uncomfortable and may lead to shock and cardiac dysrhythmias Strategy: "MOST concern the nurse" indicates incorrect information

The nurse discusses symptoms of the onset of labor with a 26 year-old primipara. Which statement, if made by the client to the nurse, indicates the client understands the teaching? 1. "I will note an increase in fetal movement." 2. "I may feel a gush of fluid run down my legs." 3. "I may see some blood in my vaginal discharge." 4. "I may experience a low backache." 5. "Labor contractions are always evenly spaced apart."

2. "I may feel a gush of fluid run down my legs" - indicates rupture of membranes, symptom of labor 3. "I may see some blood in my vaginal discharge" - bloody shows a common symptom of labor 4. "I may experience a low backache" - low back ache can be a symptom of labor Strategy: Understands the teaching indicates you are looking for correct response

The home care nurse instructs a client diagnosed with Bell's palsy. Which of the following statements, if made by the client to the nurse, indicates further teaching is necessary? 1. "I should place an eye shield over the affected eye at bedtime." 2. "I should avoid sudden movement when bending over." 3. "I should not go out when there is a cold wind." 4. "I should use heat on the affected side of my face."

2. "I should avoid sudden movement when bending over" - required if client has problems with increased intraocular pressure Strategy: "further teaching is necessary" indicates an incorrect statement

A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which statement, if made by the client, indicates a correct understanding of aseptic technique? 1. "I need to buy sterile gloves to redress this wound." 2. "I should wash my hands before redressing my wound." 3. "I should keep the wound covered at all times." 4. "I should only use whatever my health care provider orders for the dressing change." 5. "I should make sure someone looks at my wound every dressing change." 6. "I will throw the dressing away in the kitchen garage wrapped in my glove."

2. "I should wash my hands before redressing my wound." - indicates understanding of asepsis, hallmark is hand washing 4. "I should only use whatever my health care provider orders for the dressing change." - should use only the prescribe medications on the wound. 5. "I should make sure someone looks at my wound every dressing change." - The wound should be observed with every dressing change 6. "I will throw the dressing away in the kitchen garage wrapped in my glove." - the dressing should be discarded after being wrapped in the non sterile glove

Which of the following statements, if made by a client to the nurse, indicates that the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me" 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine" 4. "If my wife was a better housekeeper I wouldn't have such a problem"

2. "I was unable to take my finale exams because I was unable to write." - client has converted his anxiety over school performance into a physical symptom that interferes w/ his ability to perform.

The nurse performs teaching for a client receiving clonidine (Catapres-TTS) transdermal patch. Which of the following statements, if made by the client to the nurse, indicates teaching is successful? 1. "I like the new heart-healthy meals that can be microwaved." 2. "I will change the patch every 7 days" 3. "I will cut the used patch into four pieces before disposing of it." 4. "I use an electric blanket to keep warm at night."

2. "I will change the patch every 7 days" - Catapres is centrally acting alpha-adrenergic used to treat hypertension; apply to nondairy site every 7 days; side effects include drowsiness, sedation, orthostatic hypotension; heart failure Strategy: "teaching is successful" indicates correct info

The nurse cares for a client receiving fluoxetine (Prozac). The nurse determines that teaching is effective if the client makes which of the following statements? 1. "If I forget to take a dose, I should take it as soon as I remember." 2. "I will chew sugarless gum." 3. "I will sit on the side of the bed before arising." 4. "I will use sunscreen when I go outdoors." 5. "I'm glad that this medication will increase my sex drive." 6. "I should stop the medication if I start having side effects."

2. "I will chew sugarless gum." - may minimize dry mouth; instruct client to rinse mouth frequently and use good oral hygiene 3. "I will sit on the side of the bed before arising." - may cause postural hypotension; Prozac is a selective serotonin reuptake inhibitor (SSRI) to treat depression and obsessive compulsive disorder. 4. "I will use sunscreen when I go outdoors." - appropriate behavior Strategy: "Teaching is effective indicates correct info

The new graduate nurse on the neurology unit reviews plans for caring for a patient with increased intracranial pressure secondary to supratentorial surgery/ head injury. Which of the following statements by the new graduate nurse requires corrective by the preceptor? 1. "I will give the patient a cold sponge bath if a fever occurs." 2. "I will do as many procedures close together as I can." 3. "I will hyperventilate the patient before and after suctioning." 4. "I will be sure to keep the head of the bed elevated 30 degrees."

2. "I will do as many procedures close together as I can." - nursing care should be spaced out to minimize elevation of the ICP; patients are sensitive to sudden and/or noxious stimuli such as touching, jarring, loud noises, and bright lights, all of which can further increase ICP. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The nurse instructs a client about how to collect a 24-hour urine specimen for a creatinine clearance test. The nurse should intervene if the client states which of the following? 1. "I will have to have my blood drawn during the test." 2. "I will go to the lab after I work out in the gym." 3. "I will drink at least one cup of water hourly." 4. "I will void and discard the urine before the test begins."

2. "I will go to the lab after I work out in the gym" - creatinine is waste product of muscle breakdown; should not engage in strenuous exercise during the test Strategy: "Nurse should intervene" indicates correct info

A sequential compression device (SCD) is ordered for a patient recovering from a retropubic prostatectomy. It will be the first time for the nurse to apply such a device. Which of the following statements by the nurse to the nursing manager best reflects correct understanding of the proper procedure? 1. "I will wrap the sleeves snugly, but I will be certain I can fit one finger between each one and the leg." 2. "I will put the anti embolism stockings on before I wrap and secure the sleeves." 3. "I will start my positioning each sleeve under the leg so that the opening is at the ankle" 4. "I will measure the circumference of the mid calf and the mid thigh to ensure that the sleeves are the correct size."

2. "I will put the anti embolism stockings on before I wrap and secure the sleeves." - correct action; it is acceptable, thought not essential to apply anti embolism stockings prior to applying the sequential compression device sleeves; the stockings can decrease the itching, sweating, and heat that can build up under the plastic sleeves and thereby cause discomfort and skin irritation. Strategy: Determine the outcome of each answer. Is it desired?

The nurse performs teaching for the client being discharged on dexamethasone 0.75 mg PO daily. The nurse determines teaching is successful if the client makes which statement? 1. "I will take my med with orange juice in the morning." 2. "I will take my med with breakfast" 3. "I will take my med three hours after eating." 4. "I will take my med before I eat breakfast." 5. "I will avoid any alcohol while taking this med." 6. "I will call the clinic if I experience muscle weakness."

2. "I will take my med with breakfast" - oral steroids have ulcerogenic properties and need to be administered with meals; if ordered daily, administer in morning 5. "I will avoid any alcohol with taking this med." - alcohol should be avoided while taking dexamethasone 6. "I will call the clinic if I experience muscle weakness." - early sign of adrenal insufficiency; potential complication Strategy: "Teaching was successful" indicates a correct response

Which statement by the adult client indicates to the nurse the need for further teaching regarding care of a sigmoid colostomy? 1. "I hope to be able to go without a punch soon." 2. "I'm irrigating my colostomy after each meal." 3. "My stoma is looking better all the time." 4. "It's not hard to change my pouch every several days."

2. "I'm irrigating my colostomy after each meal." - irrigation of sigmoid colostomy is not necessary more than once a day and sometimes every two or three days, if at all Strategy: Determine the outcome of each answer choice. Is it desired?

Polyethylene glycol-electrolyte solution is ordered for the client before a colonoscopy. The nurse explains to the client how to take the solution. Which statement, if made by the client, indicates the need for further instruction? 1. "I need to drink 4 liters of the solution." 2. "If i drink it ice cold, it won't taste as bad." 3. "Once I finish drinking the solution, I can drink only water." 4. "I can use tap water to reconstitute the powder"

2. "If I drink it ice cold, it won't taste as bad." - can cause hypothermia due to large quantity of solution ingested Strategy: "Need for further instruction" indicates you are looking for an incorrect statement

A male patient is discharged from the ED after being diagnosed with a concussion sustained in a fall. Which of the following statements, if made by the patient's wife to the nurse, indicates that further teaching is necessary? 1. "I will wake my husband up every 3 hours whenever sleeping and ask him his name, my name, and where he is." 2. "If my husband complains of a headache and needs aspirin, I will give it to him no more than every 4 hours." 3. "If my husband complains of blurry vision or has difficulty walking, I will bring him to the ED right away." 4. "I will talk to my husband friend about doing the coaching for the soccer team tomorrow."

2. "If my husband complains of a headache and needs aspirin, I will give it to him no more than every 4 hours." - wrong action; patient should not receive aspirin, as it can prolong any bleeding that might occur; acetaminophen (Tylenol) every 4 hours as needed is what should be given Strategy: "Further teaching is necessary" indicates incorrect info

The hospital nursing educator plans are inservice for staff on the topic of working with interpreters. Which of the following statements is MOST important for the nurse to include? 1. "Look directly at the interpreter while you are asking the questions." 2. "Keep your questions short and simple in structure and wording." 3. "Interrupt the patient and interpreter if they seem to be talking longer than the question requires." 4. "Focus primarily on the patient's body language and tone of voice."

2. "Keep your questions short and simple in structure and wording." - easiest for interpreter to understand and translate and for patient to understand and answer; do not use medical jargon, slang, cliches, contractions, and pronouns; phrase questions so that they are focused on getting only one answer at a time. Strategy: Determine the outcome of each answer. Is it desired?

Following total hip arthroplasty, an elderly client is ordered to begin ambulation with a walker. Which statement by the nurse is correct? 1. "Sit in a low chair for ease in getting up to use the walker." 2. "Make sure rubber caps are in place on all four legs of the walker." 3. "You will begin weight bearing on the affected hip soon." 4. "Practice typing your own shoes before you begin ambulating." 5. "Your walker is the correct heigh when your elbows bend at a 50degree angle." 6. "Always wear non skid footwear when you walk."

2. "Make sure rubber caps are in place on all four legs of the walker." - intact rubber caps should be present on walker legs to prevent accidents 4. "Practice typing your own shoes before you begin ambulating." - flexion of the hip greater than 90degrees should be avoided 6. "Always wear non skid footwear when you walk." - non skid footwear is a safety consideration and should always be worn with ambulation. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

A young adult is involved in a motorcycle accident and is brought to the ER. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12."

2. "Morphine sulfate 10 mg IM q3 4h." - narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure. I picked 4 wrong because H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers Strategy: "Question which of the following orders" indicates an incorrect order

A patient comes to the medical clinic for re-eval of primary lymphedema, the praecox type, affecting the left leg and ankle. Which of the following statements by the patient MOST concerns the clinic nurse doing the initial assessment? 1. "I could hardly get my shoes on this morning." 2. "My leg hurts, and it's red and warm to the touch." 3. "sometimes my leg feel numb and tingly." 4. "Sometimes I wish that my leg could just be cut off."

2. "My leg hurts, and it's red and warm to the touch." - redness, warmth, and pain of the affected leg can indicate infection, and a condition for which patients with lymphedema are at high risk I picked 4. "Sometimes I wish that my leg could just be cut off." - psychosocial, physical takes priority; may indicate anger, depression related to disease condition Strategy: "MOST concerns the clinic nurse" indicates a complication

The nurse sees clients in a pediatric clinic. The nurse receives a phone call from the mother of a 3-year-old saying that her child has vomited several times today. Which instruction by the nurse is BEST? 1. "Offer your child some ice cream." 2. "Give your child some apple juice." 3. "Offer your child orange juice." 4. "Make some pudding for your child."

2. "Offer your child apple juice" - clear liquids should be offered first; as child tolerates these fluids, then full liquids may be offered Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

A woman is in active labor with her first child when her membranes rupture. She voices concern to the nurse that she is afraid of having a "dry labor." Which response by the nurse is MOST APPROPRIATE? 1. "The amniotic fluid provides only minimal lubrication for the labor process." 2. "The amniotic sac may impede the progress of labor and is often ruptured artificially 3. "Labor is only slightly more difficult with early rupture of the amniotic sac" 4. "Because there is limited amniotic fluid, additional fluids will be supplied."

2. "The amniotic sac may impede the progress of labor and is often ruptured artificially" - sometimes done to assist or induce labor I picked 3. "Labor is only slightly more difficult with early rupture of the amniotic sac" - wrong because does not make labor more difficult Strategy: "MOST" indicates there may be more than one attractive answer

The nurse in the prenatal clinic receives a call from a client at 37 weeks' gestation stating that, "The baby has not moved in the past 24 hours." The health care provider orders a non-stress test. The nurse determines that the teaching is successful if the client states which of the following? 1. "I will drink 300 cc of water before the test." 2. "The non-stress test is looking for the baby's heart beat to increase with activity." 3. "An infusion of Piton will start contractions to see how the baby's heart beat reacts to the stress." 4. "A good score for the non-stress test is at least a 7 out of 10."

2. "The non-stress test is looking for the baby's heart beat to increase with activity." - non-stress test looks for an acceleration of the fetal heart rate (FHR) in relationship to fetal activity; favorable results is 2 or more FHR accelerations of 15 bp lasting 15 seconds over a 20 minute interval I picked 3. "An infusion of Piton will start contractions to see how the baby's heart beat reacts to the stress." - wrong because a contraction stress test uses Piton, evaluates respiratory function of the placenta Strategy: "Teaching is successful" indicates a correct statement

A parish nurse in a large urban church visits with a client recently diagnosed with polyarteritis nodosa. The client is extremely depressed because an executive at the insurance company where he works died 3 months after being diagnosed with the same problem. Which of the following responses by the nurse is BEST? 1. "Is there anything you would like to talk about?" 2. "Treatment with cortisone now results in a 90% remission rate." 3. "Treatment for depression is available in the mental health department." 4. "Has the physician discussed the status of your health with you?"

2. "Treatment with cortisone now results in a 90% remission rate." - cortisone has increased drastically the survival rate of this client population; before that the prognosis was poor; polyarteritis nodosa is inflammation of the small arteries causing diminished blood Strategy: "BEST" indicates discrimination is required to answer the question

When intervening with a client who is in a state of crisis, which of the following statements by the nurse is MOST effective? 1. "Why is it you feel so upset in this situation?" 2. "What have you done before when you felt this anxious?" 3. "There is no way to prevent this from happening?" 4. "It seems as if this situation is very stressful for you."

2. "What have you done before when you felt this anxious?" - priority is to establish coping methods that have helped in the past; crisis intervention focuses on finding the client's inner strengths to deal with the problem at hand I picked 4. "It seems as if this situation is very stressful for you." - wrong because it is a reflective statement; in crisis, more important to determine coping methods used in the past Strategy: "MOST effective" indicates discrimination is required to answer the question

The nurse prepares the client for a laparoscopic cholecystectomy for treatment of cholelithiasis. It is MOSt important for the nurse to ask which question? 1. "Tell me about your sleep pattern." 2. "Who is going to help you at home during the next couple of days?" 3. "Have you noticed an intolerance to fatty foods?" 4. "Have you had difficulty maintaining your weight?"

2. "Who is going to help you at home during the next couple of days?" - client usually discharged the day of surgery or the next day; ensure that client has help at home for first 24-48 hours" Strategy: "MOST important" indicates discrimination is required to answer the question

The office nurse prepares a patient diagnosed with epilepsy for a positron emission tomography (PET) scan. Which of the following directions to the patient is MOST important for the nurse to include? 1. "Be prepared to feel a warm sensation when the dye is injected." 2. "You'll want to empty your bladder before the test." 3. "Be sure to remove all your jewelry before you go in." 4. "You will be asked to think in different ways during the test."

2. "You'll want to empty your bladder before the test." - ensure that patient will be comfortable and able to lie still throughout the procedure, which may last as long as 2 hours; after radioisotope administration, patient waits 30-45 min on stretcher or table so the substance can circulate to the brain; then the scan is done. I picked 1. "Be prepared to feel a warm sensation when the dye is injected" - wrong because appropriate info but not most important; warm sensation a possibility with use of all contrast agents; a metallic taste in the mouth may also occur Strategy: "MOST important" indicates discrimination is required to answer the question

The client is admitted to the hospital with dry mucous membranes and decreased skin turgor. The client's vital signs are BP 120/70, temp 101F (38.3C), pulse 88, respirations 14. Lab tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the health care provider to order which IV fluids? 1. D5NS 2. 0.45% NaCl 3. 0.9% NaCl 4. Lactated Ringer's

2. 0.45% NaCl - hypotonic solution, shifts fluid into intracellular space to correct dehydration Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

After being diagnosed with advanced chronic renal failure (CRF), an elderly client receives her food tray. It is MOST important for the nurse to remove which of the following items from the client's food tray? 1. 1 slice of wheat toast 2. 6 oz of orange juice 3. 1/2 cup of grits 4. One scrambled egg

2. 6 oz of orange juice - high in potassium; client with this disease has hyper kalmia or is at risk for hyperkalemia Strategy: think about each food

The nurse knows that which of the following clients is at highest risk for developing Dupuytren contracture? 1. A 75y/o woman from Russia with osteoarthritis 2. A 54y/o man from Norway diagnosed with diabetes 3. A 34 y/o woman from Haiti diagnosed with a fractured femur 4. A 11y/o boy from Poland diagnosed with Duchenne muscular dystrophy

2. A 54y/o man from Norway diagnosed with diabetes - age, origin, gender, and diabetes are risk factors I picked 4. A 11y/o boy from Poland diagnosed with Duchenne muscular dystrophy - wrong because no risk factors Info: Dupuytren contracture is a slow progressive contracture of the palmar fascia causing flexion of the fourth and fifth fingers; results from inherited autosomal dominant trait; occurs most often in men over 50 years of age, of Scandinavian or Celtic descent, and is associated with diabetes, gout, arthritis, and alcoholism; age and diagnosis are risk factors

The nursing team consists of an RN, an LPN, and two nursing assistants. The RN should care for which of the following clients? 1. A child recovering from surgical repair of a hypospadias. 2. A client recovering from excision of a malignant melanoma. 3. A client diagnosed with a myocardial infarction requiring assistance to the bathroom. 4. A client diagnosed with urolithiasis recovering from lithotripsy.

2. A client recovering from excision of a malignant melanoma - may require a wide excision that requires nurse to anticipate the need for analgesic medications; psychological support is also necessary because of diagnosis of cancer; requires assessment, teaching, and nursing judgment I picked 1. A child recovering from surgical repair of a hypospadias - ensure potency of urinary diversion after surgery; assign o the LPN/LVN Strategy: "Most concerned" indicates a complication

The nurse at a community health center is notified that a group of clients has been exposed to a hazardous chemical. Which of the following clients should the nurse see FIRST? 1. A client who says the chemical spilled onto his legs 2. A client who says he inhaled the chemical 3. A client who says she has hypertension and type 2 diabetes 4. A client who says he swallowed the chemical.

2. A client who says he inhaled the chemical - results in immediate absorption and can impair oxygen exchange I picked 4. A client who says he swallowed the chemical - wrong because not as life-threatening as impaired gas exchange Strategy: "FIRST" indicates priority

The nurse cares for clients on the urology unit. After assessing the clients, it is MOST important for the nurse to instruct the support staff to monitor which of the following clients? 1. A client diagnosed with diabetic retinopathy and hypertension 2. A client with blood urea nitrogen (BUN) of 35 mg/dL and serum creatinine of 2.5 mg/dL 3. A client with urinary albumin of 30 mg/24h 4. A client with urinary output of 3,000 mL/24h

2. A client with blood urea nitrogen (BUN) of 35 mg/dL and serum creatinine of 2.5 mg/dL - indicates renal failure I picked 4. A client with urinary output of 3,000 mL/24hr - wrong because may or may not indicate renal failure; composition of urine would determine client status Strategy: "MOST important" indicates priority

The nurse performs a physical assessment on a patient diagnosed with bulimia nervosa. Which of the following findings warrant an IMMEDIATE referral to the physician? 1. Bilateral parotid gland enlargement 2. A hoarse voice that is barely audible 3. Grey to black eroded teeth with foul odor 4. Multiple papulpustular skin eruptions on face, chest, and back.

2. A hoarse voice that is barely audible - at high risk for tracheoesophageal fistula from esophageal tear; laryngitis is danger sign I picked 1. Bilateral parotid gland enlargement - wrong because hallmark sign of chronic vomiting; glands become clogged with foreign matter; not priority Strategy: "IMMEDIATE referral" indicates a complication

An elderly alcoholic client receives a long-acting benzodiazepine (Librium) for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which of the following? 1. A reaction to the sedative med 2. A worsening course of the withdrawal syndrome. 3. An exacerbation of the schizo process. 4. The process of aging and the effects of delirium.

2. A worsening course of the withdrawal syndrome. - client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations.

After abdominal surgery, the client reports abdominal gas pain. It is most important for the nurse to take which action? 1. Offer the client fresh fruits 2. Ambulate the client frequently 3. Teach the client how to splint the abdomen during activity 4. Position the client on her right side 5. Provide bisacodyl suppositories prn

2. Ambulate the client frequently - ambulation promotes the return of peristalsis and facilities explosion of flatus 4. Position the client on her right side - positioning on the right side aids in the release of gas in the colon 5. Provide bisacodyl suppositories prn - bisacodyl suppositories stimulate peristalsis and expulsion of gas

A permanent demand pacemaker, set at a rate of 72, is implanted in a client for persistent third-degree block. The nurse is MOST concerned if which finding is observed? 1. Pulse rate 88 and irregular 2. Apical pulse rate regular at 68 3. B/P 110/88, pulse at 78 4. Skin warm and dry to touch

2. Apical pulse rate regular at 68 - any time the pulse rate drops below the preset rate on the pacemaker, the pacer is malfunctioning; the pulse should be maintained at a minimal rate set on the pacemaker Strategy: Determine how each answer relates to a pacemaker

The nurse plans care for a client who had surgery for an ileal conduit 2 days ago. It is MOST important for the nurse to take which action? 1. Remove the application regularly, and clean the skin with antiseptic solution 2. Apply a close-fitting drainage bag to the stoma 3. Massage the skin around the stoma with an emollient 4. Expose the area around the stoma to air twice a day

2. Apply a close-fitting drainage bag to the stoma - primary preventative measure to prevent urine from contacting the skin I picked 4. Expose the area around the stoma to air twice a day - wrong because unnecessary; would not help prevent skin breakdown Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?

The home care nurse performs an initial visit to the home of a client diagnosed with myocardial infarction. The client's nose is bleeding, and he reports that he is unable to stop the bleeding. It is MOST important for the nurse to ask which of the following questions? 1. "Are you allergic to any medication?" 2. "Are you taking any anticoagulant medication?" 3. "Do you regularly use nasal sprays for congestion?" 4. "Are you taking ibuprofen or aspirin?"

2. Are you taking any anticoagulant medication?" - side effects of anticoagulants is bleeding; client may be taking anticoagulant due to heart disease; instruct client to pinch nose closed for 5-10 min with an ice-cold washcloth I picked 4. "Are you taking ibuprofen or aspirin?" - wrong because may cause gastric distress Strategy: "MOST important indicates discrimination is required to answer the question

The RN stabilizes the client with severe multiple trauma injuries from a motor vehicle accident. Which action should the nurse take NEXT? 1. Limit visiting hours to promote optimal rest 2. Arrange for clergy to visit with the client and family as requested. 3. Arrange for a psychologist to visit with the family. 4. Arrange for the family to meet with a social worker to discuss financial aid.

2. Arrange for clergy to visit with the client and family as requested. - provides the appropriate spiritual support necessary during a crisis. Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The nurse in the ED assesses an elderly client. The client's daughter states that her mother has glaucoma, is extremely hard of hearing, and has been experiencing abdominal pain for the past 24 hours. Which of the following actions by the nurse is MOST appropriate? 1. Using a numeric rating scale, determine the intensity of the client's pain 2. Ask the client if she wears hearing aids 3. Administer pain medication 4. Ascertain when the client last saw a physician

2. Ask the client if she wears hearing aids - tools used for rating pain are ineffective if client can't hear what is being asked or if the client can't see the pain rating scale I picked 1. Using a numeric rating scale, determine the intensity of the client's pain - wrong because it is appropriate action; priority is to ensure that client is able to understand what the nurse is asking

The nurse cares for clients in the long-term care facility. A client is diagnosed with Legionnaires' disease. Which of the following actions by the nurse is MOST appropriate? 1. Place the client on droplet precautions 2. Ask the maintenance on the institution's hot water tank. 3. Sterilize the utensils used by the client 4. Place filters on the air ducts of the client's room.

2. Ask the maintenance on the institution's hot water tank - caused by Legionella pneumophila, which is found in warm, stagnant water such as hot water tanks, is spread by aerosolized route from the environmental source to the client Strategy: "MOST appropriate" indicates discrimination may be required to answer the question

The nurse obtains a history from a client scheduled for a permanent pacemaker insertion. It is MOST important for the nurse to convey which information to the physician? 1. The client is diagnosed with obsessive-compulsive disorder. 2. The client wears a hearing aid in the left ear. 3. The client works as a computer programmer 4. The client lives in a two-story house.

2. The client wears a hearing aid in the left ear. - hearing aid battery may affect placement of pacemaker; should not be placed under the left clavicle in this client. Strategy: "MOST important" indicates discrimination is required to answer the question

The nursing care plan for the 5-yaer-old child with a closed head injury should contain which action? 1. Encourage child to sleep and decrease stimuli in the room. 2. Assess orientation to person, place, and time every hour 3. Notify the health care provider regarding a negative Babinski reflex 4. Increase fluid intake to maintain adequate urinary output.

2. Assess orientation to person, place, and time every hour - early signs of increased intracranial pressure are alterations in orientation I picked 1. Encourage child to sleep and decrease stimuli in the room. - wrong because an increase in sleep could indicate a complication with intracranial pressure Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.

The nurse enters the room and discovers that the client has slurred speech, right-sided paralysis, and unequal pupils. Which action should the nurse take FIRST? 1. Call the health care provider 2. Assess the resp. status 3. Determine the level of consciousness 4. Perform a complete neurological evaluation

2. Assess the respiratory status - assessing the respiratory status and ensuring the client has an open airway is the appropriate next step Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes

The 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou smear. The nurse should recommend which preparation to the client? 1. Avoid intercourse for 48 hours before the appointment. 2. Avoid douching for 24 hours before the appointment. 3. Withhold all foods and fluids 12 hours before the appointment. 4. Save first voided urine specimen the morning of the appointment.

2. Avoid douching for 24 hours before the appointment. - douching would affect appearance of cells in vaginal smear, would make test inaccurate by removing potentially abnormal cells I picked 1. Avoid intercourse for 48 hours before the appointment. - wrong because sperm doesn't resemble atypical cells that the test is designed to find but intercourse is avoided 24 hours before the examination. Strategy: All answers are implementations. Think about the outcome of each answer choice. Is it desired?

The nurse performs discharge teaching for the client diagnosed with multiple sclerosis. It is MOSt important for the nurse to include which instruction? 1. Ambulate as tolerated every day 2. Avoid overexposure to heat or cold 3. Perform stretching and strengthening exercises 4. participate in social activities

2. Avoid overexposure to heat or cold - overexposure to heat or cold may cause damage related to the changes in sensation I picked 1. Ambulate as tolerated every day - client is encouraged to ambulate as tolerated but not most important instruction Strategy: All answers are implementation. Determine the outcome of each answer choice. Is it desired?

The MOST appropriate nursing action before administrating captopril (Capoten) is to check the client's 1. apical pulse for 60 sec 2. Blood pressure 3. Urine output 4. Temp

2. Blood pressure - Capoten is an anti-hypertensive that necessitates assessment of blood pressure before admin.

The elderly client is diagnosed with a vitamin K deficiency because of dietary malabsorption. Which nursing intervention is BEST for this client? 1. Encourage the client to remain in bed 2. Carefully check the client's arm after taking the B/P 3. Increase dietary intake of fruits and fiber 4. Observe the client for signs of angina or cardiac dysrhythmia

2. Carefully check the client's arm after taking the B/P - assessment; observe for bruising of the arm after taking a B/P reading Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes

The nurse in the ED assess a client diagnosed with burns. The nurse is MOST concerned if which of the following is observed? 1. Redness and swelling with fluid-filled vesicles noted on right arm 2. Charred, waxy, white appearance of skin on left leg 3. Reddened blotchy painful areas noted on the face 4. Blistering and blanching of the skin noted on the back

2. Charred, waxy, white appearance of skin on left leg - describes full-thickness burn; all skin is destroyed and muscle and bone may be involved; substance that remains is called eschar, dry to touch, doesn't heal spontaneously, requires grafting Strategy: "MOST concerned" indicates a serious situation

The client has a cast applied for a fracture of the right femur. Three hours later, the client reports feelings of heat and pain under the cast. Which is the MOST appropriate action for the nurse to take? 1. Assess the cast for wet spots, and increase air circulation in the room. 2. Check the circulation in the casted extremity, and change the client's position. 3. Take the client's temp, and observe for other signs of infection. 4. Medicate the client for pain, and notify the health care provider.

2. Check the circulation in the casted extremity, and change the client's position. - heat is a sign of pressure, pressure limit circulation I picked 3. Take the client's temp, and observe for other signs of infection - too early to see signs of infection Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes

The nurse admits a patient to the surgical unit with a diagnosis of cancer of the larynx. A total laryngestomy is scheduled. How should the nurse assess laryngeal nerve function? 1. Assess the extent of neck edema 2. Check the client's ability to swallow 3. Observe for excessive drooling 4. Tap the side of the client's far gently and observe for facial twitching

2. Check the client's ability to swallow - assess function of glossopharyngeal and vagus nerve

The nurse cares for clients in labor and delivery. A client in early labor complains of "not being able to hold my urine.". Which of the following actions should the nurse take FIRST? 1. Instruct the client to void more frequently 2. Check the pH of the fluid 3. Assess the client for dilatation and effacement 4. Change the bed linens

2. Check the pH of the fluid - determine if the fluid is amniotic fluid (alkaline) or urine (acid); assess before implementing Strategy: Determine if it is appropriate to assess or implement

The nurse cares for the client in active labor. As labor progresses, the client becomes irritable and reports feeling increasingly uncomfortable. The nurse notes that the client is 8 cm dilated. Which action should the nurse take FIRST? 1. Notify the health care provider of the client's status 2. Coach the client in proper breathing and relaxation techniques 3. Administer the standing order for meperidine 4. Reposition the fetal monitor to allow the client to change positions

2. Coach the client in proper breathing and relaxation techniques - irritability and discomfort expected occurrences I picked 4. Reposition the fetal monitor to allow the client to change positions - wrong; situation is described is normal, not result of placement of fetal monitor Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The nurse prepares the client for a herniorrhaphy. It is MOST important for the nurse to take which action 1 hour before surgery? 1. Administer an enema 2. Confirm the consent form has been signed 3. Perform a preop shave and scrub 4. Evaluate for food or medication allergies.

2. Confirm the consent form has been signed - surgical consent should be rechecked before going to surgery I picked 3. Perform a preop shave and scrub - wrong because should be done earlier than 1 hour before surgery Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate 1 hour before surgery? No. Determine the outcome of each implementation.

Which of the following is an appropriate and cost-effective measure for the charge nurse to implement during a low-census shift? 1. Keep all staff in case the census increases 2. Contact the hospital supervisor 3. Dismiss excessive staff with instructions to stay by the phone 4. Dismiss excessive staff and give them the day off without pay

2. Contact the hospital supervisor - excessive staff may be floated to another unit that requires additional personnel; only supervisor will have this info I picked 3. Dismiss excessive staff with instructions to stay by the phone - wrong because violates labor laws to ask nurse to stay by the phone without paying them Strategy: Determine the outcome of each answer. Is it desired?

The nurse assess a client w/ severe bilateral peripheral edema. Which of the following is the BEST way for the nurse to determine the degree of edema in a limb? 1. Measure both limbs w/ the tape measure and compare. 2. Depress the skin and rank the degree of pitting. 3. Describe the swelling in the affected area. 4. Pinch the skin and note how quickly it returns to normal.

2. Depress the skin and rank the degree of pitting. - severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting)

The home care nurse visits the client reporting episodes of vomiting for 3 days. The client has a low-grade temperature and reports feeling lethargic. Which nursing action is MOST appropriate to evaluate for fluid volume deficit? 1. Obtain a urinalysis for casts and specific gravity. 2. Determine client's weight and assess gain or loss. 3. Ask client to provide a 24-hour intake and output record 4. Determine the quality of the client's skin turgor.

2. Determine client's weight and assess gain or loss. - daily weight is the best way to evaluate for fluid volume deficit. I picked 1. Obtain a urinalysis for casts and specific gravity - wrong because it provides information regarding the fluid volume level, but is not the best action for evaluation. Strategy: Determine how each answer choice relates to fluid volume deficit

The nurse observes late decelerations of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. Which actions should the nurse take? 1. Change the fluids to Ringers lactate 2. Discontinue the oxytocin infusion 3. Assist client to bathroom and measure urine 4. Turn client to the left side 5. Apply oxygen at 8L/min by mask 6. Increase the primary IV infusion flow rate

2. Discontinue the oxytocin infusion - Discontinuing the oxytocin is the first step to take 4. Turn client to the left side - Turning the client to the left side will aid in blood flow to the placenta 5. Apply oxygen at 8L/min by mask - Giving the client oxygen will help provide additional oxygen to the fetus 6. Increase the primary IV infusion flow rate - Increasing the fluid infusion will give more volume for transfer of oxygen to the fetus Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse overhears the supervisor reprimand the head nurse for not discussing feelings with a patient. Shortly after, a patient asks the head nurse for an extra blanket. The head nurse angrily responds, "Get it yourself!" The nurse recognizes the head nurse is displaying which of the following defense mechanisms? 1. Compensation 2. Displacement 3. Conversion 4. Projection

2. Displacement - head nurse is displacing feelings of anger at the supervisor onto the patient who is less threatening Strategy: Think about the answers

The nurse plans care for the client hospitalized with bipolar disorder. While the client is in the manic phase, the nursing plan should include which interventions? 1. Talk to the client, and reinforce behaviors 2. Distract the client, and redirect behaviors 3. Implement limit-setting, and isolate the client 4. Orient and remind the client about the rules of the hospital.

2. Distract the client, and redirect behaviors - client experiences hyperactivity, poor concentration, and distractibility; redirect into activity that promotes rest, nourishment; reduce stimuli Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The client experiences a severe panic attack and has threatened to hurt another client on the unit. The nurse expects to administer which PRN med as ordered? 1. Chlorpromazine 2. Lithium carbonate 3. Haloperidol 4. Phenytoin

3. Haloperidol - haloperidol is particularly effective in reducing assaultive behavior associated with severe anxiety I picked 1. Chlorpromazine -wrong; more likely to be used PRN when a client is experiencing agitation associated with schizophrenia Strategy: Think about the action of each med

The nurse understands that the primary reason elderly adults have problems w/ constipation is because of which of the following? 1. Elderly adults eat a small volume of food w/ decreased bulk. 2. Elderly adults have less activity and decreased muscle tone. 3. Elderly adults have neurological changes in the GI tract. 4. Elderly adults have decreased sensation in the GI tract.

2. Elderly adults have less activity and decreased muscle tone. - Reduced GI motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, side effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat.

The nurse cares for the client reporting moderate pain. Which nursing action is MOST important to provide the client with effective pain relief? 1. Teach the client about the pain 2. Establish a trusting relationship with the client. 3. Determine how various relaxation techniques affect the pain. 4. Provide alternative measures to relieve pain.

2. Establish a trusting relationship with the client - necessary to work with client to identify interventions to relieve pain I picked 3. Determine how various relaxation techniques affect the pain - wrong because it is part of the evaluation phase Strategy: Determine the outcome of each answer choice. Is it desired?

The elderly client undergoes a colonoscopy. During the post procedure period, it is MOST important for the nurse to monitor for which finding? 1. Client's ability to move the legs 2. Fluid and electrolyte balance 3. Characteristics of the client's stool 4. Level of pain the client experiences

2. Fluid and electrolyte balance - bowel prep and NPO status puts client at high risk for imbalances Strategy: Determine how each answer choice relates to colonoscopy

The client diagnosed with tertiary syphilis is admitted to a nursing unit. The client exhibits signs of marked dementia and disorientation. Which action should the nurse take FIRST? 1. Place the call bell within reach 2. Frequently observe the client's behavior 3. Apply a vest-type restraint 4. Provide an around-the-clock sitter

2. Frequently observe the client's behavior - assessment; placing the client on frequent observation status would be the first action to ensure the client's safety Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? yes

A patient is brought to he ED by EMS with a blood glucose level of 32 mg/dL. The patient received 25 cc of 50% dextrose in water before arrival. While assessing the patient, the nurse instructs the patient care tech to do which of the following? 1. Recheck the patient's blood glucose 2. Obtain orange juice for the patient 3. Administer 1 mg of glucagon IM 4. Obtain an EKG on the patient

2. Obtain orange juice for the patient - rapidly absorbed carbohydrates indicates for moderate hypoglycemia I picked 1. Recheck the patient's blood glucose - wrong because although this is an appropriate action, the patient is at increased risk for seizures as a result of hypoglycemia; seizure precautions should be initiated immediately on arrival Strategy: Determine the outcome of each answer. Is it desired?

The client receives chlorpromazine 400mg/day for four weeks. The client experiences an oral temp of 105F (40.5C), severe rigidity, oculogyric crisis, and severe hypertension. It is MOST important for the nurse to take which action? 1. Administer PRN benztropine mesylate immediately 2. Hold the chlorpromazine, and notify the health care provider stat 3. Place the client in isolation on bedrest in semi-Fowler's position 4. Administer acetaminophen 500 mg, and place the client on a cooling mattress

2. Hold the chlorpromazine, and notify the health care provider stat - client is experiencing neuroleptic malignant syndrome; fatal in about 15-20% of cases; is toxic effect of antipsychotic medication Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

A patient returns to the medical unit after placement of a split-thickness autograft to a burn on the right arm. The nurse identifies that the highest priority at this time will need to be given to which of the following interventions? 1. Managing pain at the recipient site. 2. Immobilizing the graft 3. Minimizing light exposure 4. Observing for signs of rejection

2. Immobilizing the graft - graft adherence to the site is essential for vascularization and "taking" or survival of the graft; immobilization of the graft is critical; a think fibrin network develops quickly after graft placement but it takes 7-10 days for the graft to really adhere, and longer than that to mature. Strategy: Determine the outcome of each answer. Is it desired?

The client diagnosed with acute lymphocytic leukemia is admitted with SOB, anemia, and tachycardia. The MOST appropriately stated diagnosis for this client is which nursing diagnosis? 1. Altered protection, immunosuppression: leukemia 2. Impaired gas exchange related to decreased RBCs 3. Risk for infection related to altered immune system 4. Risk of injury related to decreased platelets

2. Impaired gas exchange related to decreased RBCs - leukemia causes a decrease in all blood components; a gas exchange problem results from depletion of oxygen-carrying red cells Strategy: think about each answer choice

The client is returned to the room at 1000 following a laparoscopic gall bladder surgery. The nurse plans to get the client out of bed for the first time at 1800. In preparation for this activity, the nurse should take which action? 1. Ask the client to cough and deep-breathe at 1600 2. Offer pain medication to the client at 1730 3. Turn the client from side to side at noon and 1600 4. Encourage the client to use the incentive spirometer.

2. Offer pain medication to the client at 1730 - reduction of pain will allow client to cooperate with activities designed to reduce post-op complications such as ambulation I picked 4. Encourage the client to use the incentive spirometer. - wrong because used to promote complete lung expansion and prevent respiratory complications following surgery, but would not help with ambulation. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse is caring for the client in the ICU. Hemodynamic monitoring is accomplished by way of a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which information? 1. measures the circulatory volume in the coronary arteries. 2. Indirectly measures the pressure in the ventricles. 3. Analyzes the adequacy of pulmonary circulation 4. Directly measures the adequacy of carbon dioxide exchange

2. Indirectly measures the pressure in the ventricles. - CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle. Strategy: Think about each answer choice.

The nurse notes that a client who practices Judaism has a lunch tray containing beef, green beans, salad, vanilla pudding, and milk. Which of the following actions by the nurse is MOST appropriate? 1. Ask the client if she would like a chicken entree 2. Inform the client that an alternate meal will be requested. 3. Ask the client if the beef is cooked appropriately 4. Offer the client more vegetables

2. Inform the client that an alternate meal will be requested - dietary laws based on biblical and rabbinical regulations; milk/milk products not be eaten at the same meal with meat Strategy: Determine the outcome of each answer. Is it appropriate?

While using palpation techniques during the physical assessment of the adult female with abdominal pain, which action should the nurse take FIRST? 1. Instruct the client to take a deep breath and hold it 2. Inform the client to breathe slowly 3. Use bimanual palpation technique 4. Apply light palpation in the area

2. Inform the client to breathe slowly - breathing slowly will enhance relaxation of the abdominal muscles I picked 4. Apply light palpation in the area - wrong; prior to the and palpation, instruct client to breathe slowly because client likely to protect the and when in pain Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

A spica cast is applied to a 14-month-old with developmental dysplasia of the hips. Which information is MOST appropriate for the nurse to teach the parents? 1. Change diapers frequently to prevent cast soiling 2. Inspect the skin around the cast 3. Turn the client by using the abduction stabilizer bar 4. Keep small toys out of the client's reach

2. Inspect the skin around the cast - assessment; assess for skin breakdown change client's position frequently to prevent skin breakdown Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes

The nurse cares for clients in a physician's office. A client complains of a sore throat and fever. Culture indicates the client has group A beta-hemolytic Streptococcus infection and urinalysis reveals a large amount of protein and a large number of red blood cells. The physician prescribes antibiotics. The client informs the nurse that he would like to schedule a follow-up appointment in 6 weeks after the client returns from an international conference. Which of the following actions should the nurse take NEXT? 1. Determine if the client is allergic to penicillin. 2. Instruct the client to schedule an appointment before leaving the country. 3. Ask the client in which country the conference is to be held. 4. Ascertain when the client is scheduled to leave.

2. Instruct the client to schedule an appointment before leaving the country. - must determine client's renal status; has symptoms of acute glomerulonephritis I picked 1. Determine if the client is allergic to penicillin - wrong because while penicillin is the most common drug for treatment of acute glomerulonephritis, the primary focus is determining client is in good health and able to attend the conference. Strategy: "NEXT" indicates priority

The nurse cares for the client recently diagnosed with AIDS. The nurse identifies the following nursing diagnosis: Risk for Infection. Which intervention by the nurse is BEST? 1. Inspect the skin daily for signs of breakdown 2. Limit the number of health care personnel caring for the client 3. Use standard precautions when administering parenteral medications 4. Monitor the client's vital signs q4h

2. Limit the number of health care personnel caring for the client - implementation, deceases exposure to microorganisms I picked 3. Use standard precautions when administering parenteral medications - wrong because implementation, done with all clients to protect health care workers Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of real implementation.

A nurse cares for a child diagnosed with Wilms tumor. Preoperatively, it is MOST important for the nurse to take which of the following actions? 1. Palpate the child's abdomen 2. Measure the child's abdominal girth 3. Assess for hypotension 4. Monitor the child's intake and output

2. Measure the child's abdominal girth - assesses the size of the tumor; treatment is surgery followed by radiotherapy and chemotherapy Strategy: MOST important indicates discrimination is required to answer the question

The nurse cares for the client with a bleeding duodenal ulcer. The nurse is MOST concerned if the client reported taking which meds? 1. Ranitidine hydrochloride 150 mg PO 2. Metoclopramide hydrochloride 15 mg PO 3. Sucralfate 1 gm PO 4. Famotidine 20 mg PO 5. Naproxen 250 mg PO 6. Fluoxetine 20 mg PO

2. Metoclopramide hydrochloride 15 mg PO - stimulates motility of upper GI tract, contraindicated with possible hemorrhage of GI tract; used to treat nausea of chemotherapy 5. Naproxen 250 mg PO - NSAID medication; increases risk of GI bleeding 6. Fluoxetine 20 mg PO - SSRI, increases risk of GI bleeding Strategy: Think about the action of each med

An infant is admitted w/ vomiting and diarrhea. The infant's anterior fontanelle is depressed and temp is 103.2F. Which of the following nursing actions is MOST appropriate? 1. Obtain daily weight and eval weight loss 2. Observe the infant's ability to take in fluids 3. Place a full bottle of Pedi-Lyte at the bedside 4. Start an IV infusion

2. Observe the infant's ability to take in fluids - assessment; will assist in determining if hydration can be done through oral fluids alone.

Pancrelipases (Pancrease capsules) is ordered for a child. The nurse observes that the child has trouble swallowing the capsule. Which of the following actions by the nurse is BEST? 1. Instruct the child to chew the capsule thoroughly, take a deep breath, close the eyes, then swallow the capsule. 2. Open the capsule, sprinkle the contents into applesauce, and instruct the child to swallow the applesauce without chewing 3. Open the capsule, pour the contents into a glass of milk, and instruct the child to drink the milk slowly. 4. Crush the capsule and give the remains to the child using a spoon and small sips of water.

2. Open the capsule, sprinkle the contents into applesauce, and instruct the child to swallow the applesauce without chewing - capsule can be opened since contents are enteric-coated microspheres; contents should be mixed into a small amount of cool, soft food such as applesauce and the applesauce should then be swallowed immediately without chewing; swallowing whole ensures microsphere will survive until reaching the intestines I picked 3. Open the capsule , pour the contents into a glass of milk, and instruct the child to drink the milk slowly. - wrong because capsules can be opened since their contents are enteric-coated microspheres; however, pancreatic enzymes should not be mixed with milk, ice cream, or similar products because pancreatic enzymes curdle milk and formula Strategy: Determine the outcome of each answer. Is it desired?

The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions? 1. Reduce the client's diet to 1,500 calorie ADA 2. Order three additional units of NPH insulin at 10PM 3. Order an additional 10 units of regular insulin at 8PM 4. Eliminate the client's bedtime snack.

2. Order three additional units of NPH insulin at 10PM - dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia I picked 4. Eliminate the client's bedtime snack. Wrong because would adjust snack, not eliminate it Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse monitors the client diagnosed with cholecystitis. The nurse is MOST concerned if which finding is observed? 1. Nausea 2. Frequent belching 3. Jaundice 4. Right upper abd pain

3. Jaundice - jaundice indicates a possible stone in the bile duct causing obstruction Strategy: "MOST" concerned indicates a complication

The nurse is planning care for a patient hospitalized with anorexia nervosa. Which of the following goals is MOST important? 1. Patient will gain one-fourth pound per week 2. Patient will maintain potassium balance between 3.5 and 5.0 mEq/L 3. Patient will eat 50% of each meal 4. Patient will identify a normal weight for her height.

2. Patient will maintain potassium balance between 3.5 and 5.0 mEq/L - physical need; high risk of fluid and electrolyte imbalance, particularly hypokalemia, and subsequent decreased cardiac output and cardiac dysrhythmias; monitor hydration and electrolytes, especially potassium. Strategy: "MOST important" indicates priority

A school-aged boy injures his right knee and is brought to the outpatient clinic by his mother. During the interview, the nurse learns that the child has hemophilia A. The nurse expects the physician to order which of the following medications? 1. Percodan 2. Percocet 3. Enteric-coated aspirin 4. Motrin

2. Percocet - oxycodone with acetaminophen; assess type, location, and intensity of pain; regular dosing of medication may be more effective than PRN dosing; administer with food or milk to decrease GI irritation Strategy: Think about each drug and how it relates to hemophilia

The nurse cares for the client admitted 4 days ago for treatment of alcohol dependence. The nurse notes the client has slurred speech, ataxia, and uncoordinated movements, and reports a headache. Which action should the nurse take FIRST? 1. Observe the client for 8 hours to collect additional data 2. Perform a complete physical assessment. 3. Collect a urine specimen for a drug screen. 4. Encourage the client to talk about whatever is causing distress.

2. Perform a complete physical assessment. - best way to identify possible physical complications of alcohol dependence is though a complete physical assessment. I picked 3. Collect a urine specimen for a drug screen - should be done after the physical assessment is completed Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? Yes.

An LPN/LVN reports to the nurse that a client admitted with persistent chest pain is experiencing moderate, spastic lower abdominal pain, nausea, and some vomiting. Which of the following actions should the nurse take FIRST? 1. Determine what medications the client is receiving 2. Perform a comprehensive abdominal assessment 3. Ask the client if he has a history of GI problems 4. Notify the physician

2. Perform a comprehensive abdominal assessment - abd pain not usually associated with MI; nurse should assess GI problem I picked 3. Ask the client if he has a history of GI problems - wrong because priority is current physical status Strategy: "FIRST" indicates priority

The nurse cares for the client with a random implant. It is MOST important for the nurse to take which action? 1. Evaluate the position of the applicator every two hours 2. Place the client on a low-residue diet to decrease bowel movements 3. Encourage the use of the bedside commode every one to two hours. 4. Decrease fluids intake to decrease radiation in the bladder.

2. Place the client on a low-residue diet to decrease bowel movements - implementation; bowel movements can dislodge radium implant; this diet will decrease amount of stool and number of bowel movements I picked 3. Encourage the use of the bedside commode every one to two hours - wrong because implementation; client is on strict bedrest Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation

Which nursing action is MOST appropriate after intubating a postoperative client who had a respiratory arrest? 1. Soak the intubation equipment in concentrated Betadine solution 2. Place the intubation blade in a bag, and arrange for gas sterilization 3. Soak the intubation blade in Cidex solution 4. Wash the equipment with soap and water and allow to air-dry.

2. Place the intubation blade in a bag, and arrange for gas sterilization - sterilization of equipment after exposure to body fluids of a client is protocol Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

Which nursing approach is MOST appropriate to use while administering an oral medication to a 4-month-old infant? 1. Place the medication in 45 mL of formula. 2. Place the medication in an empty nipple and allow the infant to suck. 3. Place the medication in a full bottle of formula. 4. Place the medication in a plastic syringe and give with the infant in the reclining position.

2. Place the medication in an empty nipple and allow the infant to suck. - is a convenient method for administering medications to an infant I picked 4. Place the medication in a plastic syringe and give with the infant in the reclining position. - wrong because infant is never placed in a reclining position during procedure due to potential for aspiration Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for clients in the long-term care facility. A confused client constantly tells the nurse that he can't find his room. Which of the following statements by the nurse is BEST? 1. "Here is a map of the facility." 2. "I think you can find your room if you just concentrate." 3. "Your room is on the first floor by the elevator." 4. "You didn't have any trouble finding your room yesterday."

3. "Your room is on the first floor by the elevator." - gives the client information; give client cues using simple words; repeat frequently Strategy: "BEST" indicates discrimination may be required to answer the question

A client with rheumatoid arthritis is taught by the nurse to perform range-of-motion (ROM) exercises. In implementing her care, the nurse should include which of the following actions? 1. Allow the client long rest periods between exercises. 2. Point out small accomplishments that the client makes. 3. Praise her when she makes significant progress. 4. Show appreciation of the client's efforts by doing a few ROM exercises for her.

2. Point out small accomplishments that the client makes. - encourages patient to continue; help client identify elements of control over disease and treatment. I picked 1. Allow the client long rest periods between exercises - wrong because cause reverse of gains; balance rest and activity, use after long periods of inactivity Strategy: Determine the outcome of each answer

The assigned nurse prepares a nursing home unit for the client who had a stroke in right-sided paralysis. Which action by the nurse is MOST appropriate? 1. Post a sign stating, "Keep floor dry and free of debris." 2. Post a sign stating, "Do not use client's right arm for lifting." 3. Post a sign stating, "Client is hard of hearing." 4. Post a sign stating, "Client is paralyzed on the right side."

2. Post a sign stating, "Do not use client's right arm for lifting." - is common injury in clients with paralysis; because paralyzed muscles cannot offer resistance, shoulder can be dislocated Strategy: "MOST appropriate" indicates discrimination is required to answer the question

The OB client comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made. It is MOST important for the nurse to take which action? 1. Start an IV of terbutaline and monitor the client's vital signs closely. 2. Prepare the client for an immediate cesarean section. 3. Maintain the client on bed rest until spontaneous vaginal delivery is achieved 4. Monitor the client's length and duration of contractions.

2. Prepare the client for an immediate cesarean section. - implementation; cannot deliver vaginally Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired?

The client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which beverage, if selected by the client, indicates to the nurse that teaching is effective? 1. Lemonade 2. Prune juice 3. Milk 4. Orange juice 5. Cranberry juice 6. Tomato juice

2. Prune juice - promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon 5. Cranberry juice - promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon 6. Tomato juice - promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon Wrong 3. Milk - excessive amounts of milk promote alkaline urine Strategy: "Teaching is effective indicates a correct statement.

A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis? 1. Risk for constipation related to immobilization. 2. Risk for impaired skin integrity related to immobilization and secretions 3. Risk for wound infection related to involuntary bowel secretions 4. Risk for fluid volume excess related to secretions

2. Risk for impaired skin integrity related to immobilization and secretions - Skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this.

The mother of a 2-year-old boy asks the pediatric clinic nurse, "Do you have any suggestions for what I can say to get my child to go to bed without a fuss?" Which of the following suggestions by the nurse is BEST? 1. Ask your child, "Do you want to go to sleep now?" 2. Say to your toddler, "After we read this story, it will be time for sleep." 3. Say to your toddler, "It's time to go to sleep." 4. Ask your child, "Would you like to take your bear or elephant to bed with you?"

2. Say to your toddler, "After we read this story, it will be time for sleep." - avoids asking toddler's permission to go to sleep; sets clear and reasonable limits; allows time for adjustment; builds trust when parent follows through; bedtime is paired with an enjoyable, calming activity; provides a ritual Strategy: "BEST" indicates discrimination required to answer the question

The charge nurse learns that two staff members are requesting a 12-month leave of absence. One staff member has 5 years of service and is requesting the leave because of an adoption. The other staff member has 2 years of service and will care for a family member diagnosed with terminal cancer. The charge nurse is informed that only one staff member can receive the leave of absence. Which of the following actions should the nurse take FIRST? 1. After consulting agency policy, grant the leave to the nurse with the greatest seniority. 2. Schedule a meeting with the two staff members to discuss the available options. 3. Grant leave to the nurse with the terminally ill husband. 4. Persuade the staff member adopting the baby to waive her rights.

2. Schedule a meeting with the two staff members to discuss the available options. - first step is problem resolution is to identify the problem and generate possible solutions I picked 1. After consulting agency policy, grant the leave to the nurse with the greatest seniority. - wrong because may resort to strict rule enforcement after other options have been explored Strategy: "FIRST" indicates priority

The nurse assess a client diagnosed w/ a spinal cord injury. Which of the following assessment findings by the nurse suggests the complication of autonomic dysreflexia? (SATA) 1. Urinary bladder spasm pain 2. Severe pounding headaches 3. Profuse sweating 4. Tachycardia 5. Severe hypotension 6. Nasal congestion

2. Severe pounding headaches - severe headache results from rapid onset of hypertension 3. Profuse sweating - especially of forehead 6. Nasal congestion - also causes piloerection (goose flesh)

The nurse performs diet teaching for a client with a spinal cord injury at S3. Which meal, if chosen by the client, indicates to the nurse that teaching is effective? 1. Cheeseburger with tomato and onion 2. Spaghetti with meat sauce and green beans 3. Tuna fish sandwich with orange juice 4. Grilled cheese sandwich and chocolate pudding

2. Spaghetti with meat sauce and green beans - high-fiber diet is an important part of bowel program; fiber helps prevent the complication of constipation; includes whole-grain foods, bran, fresh and dried fruits; increased fiber will facilitate defecation, especially with reduction in fat intake. I picked 3. Tuna fish sandwich with orange juice - wrong because should increase intake of fiber foods and decrease intake of fat

The nurse cares for a client receiving a continuous infusion of heparin. The client's aPTT is greater than 150 seconds. Which of the following actions by the nurse is MOST appropriate? 1. Stop the heparin and administer protamine sulfate 2. Stop the heparin and notify the physician 3. Maintain the heparin at the current infusion rate 4. Increase the infusion rate and notify the physician

2. Stop the heparin and notify the physician - heparin is an anticoagulant; lower limit of normal 20 - 25 sec; upper limit of normal 32-39 sec; therapeutic level is 1.5 to 2.5 times control; 150 is above the therapeutic range; protamine sulfated may be needed I picked 1. Stop the heparin and administer protamine sulfate - wrong because may occur, specific dose of protamine must be ordered by physician Strategy: All answers choices are implementations. Determine the outcome of each. Is it desired?

The new graduate registered nurse emerging from a patient's room is asked by the preceptor why the time spent with the patient was longer than expected. The new graduate replies "I taught the patient how to use the incentive spirometer. She did not understand that you had to inhale and hold your breath." The preceptor responds, "It's not inhale with an incentive spirometer, it's exhale." Which of the following actions should the new graduate take FIRST? 1. Return to the patient and explain that the patient should hold the breath on exhalation, not inhalation. 2. Suggest that the preceptor join the new graduate in reviewing the unit's policy and procedure manual and also the manufacturer's guidelines for use of the machine. 3. Remind the preceptor that the new graduate just left school and it was stressed that inhalation, not exhalation, was appropriate for the incentive spirometer. 4. Tell the preceptor that this erroneous information is shocking and is not appreciated, and that the matter obviously needs to be taken to the nurse manager for resolution.

2. Suggest that the preceptor join the new graduate in reviewing the unit's policy and procedure manual and also the manufacturer's guidelines for use of the machine. - referral to supporting legitimate and respected documents defuses emotional nature of the situation and enables resolution; incentive spirometry requires inhalation or holding of the breath 3 to 5 seconds; deep inhalations expand alveoli and therefore prevent atelectasis and other lung complications Strategy: Determine the outcome of each answer. Is it desired?

Providing well-child screening for toddlers in the day care facility, the nurse performs an assessment of a 24-month-old child. The nurse expects which of the following findings? 1. The child jumps with both feet 2. The child kicks a ball without falling 3. The child rides a tricycle 4. The child builds a block tower of six blocks 5. The child uses two-to-three word phrases 6. The child is able to state her first and last name

2. The child kicks a ball without falling - can also pick up an object without falling 4. The child builds a block tower of six blocks - can also turn doorknobs and unscrew lids 5. The child uses two-to-three word phrases - has a 300-word vocabulary Strategy: Picture the child

The home care nurse visits a client diagnosed with dementia. The client lives with a son and his family. The nurse identifies which stressor is MOST critical to the family? 1. The client is unwilling to eat with the family 2. The client does not recognize family members 3. The family is not aware of community resources available to them 4. The client is incontinent

2. The client does not recognize family members - confirms a deteriorating condition and increases the feelings of loss among the family members I picked 4. The client is incontinent - wrong because adds to the stress; toilet early in morning, after meals and snacks, and before bedtime Strategy: Discrimination is required to answer the question

The client is treated for rheumatoid arthritis. Which finding should assume the HIGHEST priority for the nurse when planning the client's care? 1. The client has subcutaneous nodules on the right and left forearms 2. The client has a slight contracture of the right wrist 3. The client has mild erythema of the finger joints 4. The client has an area of ecchymosis approximately 3 mm in diameter on right forearm

2. The client has a slight contracture of the right wrist. - sign of inadequate management; should be treated immediately to prevent further damage Strategy: Determine the significance of each answer choice and how it relates to rheumatoid arthritis

The home care nurse monitors the progress of a client after a laryngectomy. Which of the following observations, if made by the nurse, requires an intervention? 1. The client uses her finger to apply A&D ointment around the stoma 2. The client inserts a few drops of water into the stoma every evening 3. The client leaves the stoma uncovered when taking a bubble bath 4. The client covers the stoma with a cotton scarf when outside

2. The client inserts a few drops of water into the stoma every evening - humidification should be provided with humidified or nebulizer Strategy: Determine the outcome of each answer

The nurse cares for the client diagnosed with schizophrenia. Which statement is MOST descriptive of the affect of a client with schizophrenia? 1. The client answers all questions with one word 2. The client laughs while talking about being raped 3. The client exhibits no energy or interest in tasks. 4. The client cries while talking about parent's death.

2. The client laughs while talking about being raped. - inappropriate affect, expression of feelings bizarre for situation. Strategy: Determine how each answer choice relates to schizophrenia.

The nurse explains the use of transcutaneous electrical nerve stimulation (TENS) to the client diagnosed with sciatica. Which action, if performed by the client, indicates to the nurse that further teaching is necessary? 1. The client applies a conducting gel before applying the electrodes. 2. The client places the electrodes on the side of the body opposite from the painful area 3. The client runs up the voltage until they feel a prickly "pins and needles" sensation 4. The client adjusts the voltage based on the relief of pain she/he experiences 5. The client turns up the voltage until mild twitching of the extremity begins 6. The client turns on the unit before applying the electrodes

2. The client places the electrodes on the side of the body opposite from the painful area - should be over, above, or below the painful area 5. The client turns up the voltage until mild twitching of the extremity begins - a "pins and needles" sensation is the max voltage, twitching would be too high 6. The client turns on the unit before applying the electrodes - The client applies all electrodes and set the parameters then turns on the machine Strategy: "Further teaching" indicates an incorrect response

The adult child of the elderly client diagnosed with Alzheimer's disease provides care for the parent in the child's home. The nurse knows that which observation represents caregiver burnout? Select all that apply. 1. The child fails to get the parent into a wheelchair daily. 2. The home environment is extremely cluttered at each visit. 3. The child is always in nighttime clothes at the time of the nurse's visits. 4. The child's spouse is seen assisting with the parent-in-law's care. 5. The child states they have difficulty sleeping. 6. The client states the child never has friends over.

2. The home environment is extremely cluttered at each visit. - cluttered environment may represent depression and burnout 5. The child states they have difficulty sleeping. - disturbed sleep patterns more or less than normal can be signs of burnout 6. The client states the child never has friends over. - social isolation is a sign of burnout Strategy: Think about what the words mean. How do they relate to the caregiver?

The nurse is aware that Rh immune globulin (RhoGAM) is administrated to prevent complications in which of the following situations? 1. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive 2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs 3. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative 4. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.

2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. - RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test.

The nurse and a neighbor participate in the neighborhood effort to clean up vacant lots. At the end of the day, the neighbor informs the nurse that she has to go get some eyedrops for her allergies. The nurse gathers more information and recommends to the neighbor that she see her health care provider. Which of the following information supports this nursing judgment? 1. The neighbor has a history of type 2 diabetes and hypertension. 2. The nurse observes pus-like drainage in the neighbor's left eye. 3. The neighbor is sneezing, with redness noted in both eyes. 4. The nurse notes clear liquid draining from both eyes.

2. The nurse observes pus-like drainage in the neighbor's left eye - indicates signs and symptoms that may be related to an infection; should not use over-the-counter eye medication but should see the health care provider I picked 4. The nurse notes clear liquid draining from both eyes - wrong because it indicates an allergic reaction Strategy: Think about each answer

The nurse observes a nursing assistant providing care on the med/surg unit. The nurse should intervene if which of the following is observed? 1. The nursing assistant performs perineal care for a client diagnosed with a cerebrovascular accident 2. The nursing assistant removes dead leaves from a plant in the client's room 3. The nursing assistant removes the contact lenses from a client with right-sided weakness 4. The nursing assistant collects a clean catch urine specimen from a client diagnosed with pneumonia

2. The nursing assistant removes dead leaves from the plant in the client's room - caregivers should not be caring for plants and clients; plants should be cared for by a different person Strategy: "Nurse should intervene" indicates something is wrong

The nurse supervises care for patient on the hospice unit who practices orthodox Judaism. The nurse determines care is appropriate if which of the following is observed? 1. An unleavened wafer is placed on the tongue of the patient 2. The patient has a continuous intravenous morphine infusion 3. The patient is turned to face east as signs of death appear 4. The patient's forehead is anointed with oil

2. The patient has a continuous intravenous morphine infusion - control of pain (palliative treatment) during end of life is most important to Jewish persons Strategy: "Care is appropriate" indicates correct nursing actions

The nurse supervises care of for a client who just had a short leg cast applied. The nurse determines that care is appropriate if which of the following is observed? Select all that apply: 1. The cast is covered with a light sheet. 2. The staff handles the cast using the palms of their hands. 3. The affected limb is elevated to the level of the heart. 4. The nurse compares the toes of the casted leg with the opposite leg. 5. The staff places a fan in the client's room. 6. The staff turns the client every 4 hours.

2. The staff handles the cast using the palms of their hands - prevents development of pressure area 3. The affected limb is elevated to the level of the heart - decreased edema 4. The nurse compares the toes of the casted leg with the opposite leg - assess for neuromuscular functioning; also assess circulation, motion, and sensation in the casted extremity 5. The staff places a fan in the client's room - increases circulation of air in room to facilitate drying the cast Strategy: Determine the outcome of each answer. Is it desired?

The nurse performs the Rinne tests on a 6-year-old girl. Which of the following is an accurate statement of how this test should be performed? 1. The stem of a vibrating tuning fork is held against the auditory canal until the child indicates that she can no longer hear the sound. Then the turning fork is moved away from the canal. 2. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal. 3. The stem of a vibrating tuning fork is held in the middle of the forehead, and the girl's hearing is assessed in both ears. 4. The stem of a vibrating tuning fork is positioned 2 inches behind the girl's head, and the length of time she hears the sound is documented.

2. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal. - Child should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction.

The nurse observes the student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which action, if performed by the student nurse, requires an intervention by the nurse? 1. The student nurse checks the pH of the contents aspirated from the NG tube 2. The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube 3. The student nurse uses a large-barreled syringe to aspirate for stomach contents 4. The student nurse flushes the NG tube with 30ml of air before aspirating fluid 5. The student nurse places the end of the NG tube in a cap of water and watches for bubble formation.

2. The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube. - air injected to lungs, pharynx or esophagus may transmit similar sound 5. The student nurse places the end of the NG tube in a cap of water and watches for bubble formation. - not considered acceptable procedure; if tube placed in lungs, may cause bubbling Strategy: "Requires an intervention" indicates incorrect behavior

The client receives thrombolytic therapy. The health care provider orders morphine IM for pain. Before administering the injection, the nurse should take which action? 1. Confirm that all lab work has been completed. 2. Verify the order with the health care provider. 3. Check the client's PTT. 4. Determine that all of the thrombolytic agent has infused.

2. Verify the order with the health care provider. - implementation, complications of thrombolytic therapy include bleeding, which can occur with intramusuclar injections; nurse should confer with the health care provider about the appropriateness of the order. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of the implementations. Is it desired?

The nurse asks the nursing assistant to perform soapsuds enemas for a patient scheduled for a diagnostic test. The nurse should 1. observe the returns from the enemas in the patient's beside commode 2. ask the nursing assistant to describe the returns from the enemas 3. ask the patient to describe the returns from the enemas 4. palpate the patient's abdomen, noting firmness and tenderness

2. ask the nursing assistant to describe the returns from the enemas - describing returns from the enema is a part of the responsibilities delegated; nurse should monitor performance and results according to established goals Strategy: Determine the outcome of each answer. Is it desired?

A young adult is admitted to the hospital with a diagnosis of catatonic schizophrenia. When the nurse places the patient's hand over his head, it remains in that position. The nurse identifies that this is 1. conversion hysteria 2. waxy flexibility 3. dystonic reaction 4. neurasthenia

2. waxy flexibility - abnormal posturing; catatonic schizophrenia causes sudden loss of animation and a tendency to remain motionless in a stereotyped position Strategy: Think about each answer

The teenager comes to the clinic reporting fatigue, a sore throat, and flu-like symptoms for the previous 2 weeks. Physical exam reveals enlarged lymph nodes and temp of 100.3F (37.9C). Which statement by the nurse is BEST? 1. "Cover your mouth and nose when you sneeze or cough." 2. "Eat in a separate room away from your family." 3. "Don't share your drinking glass or silverware with anybody." 4. "Stay in your room until all of your symptoms are gone."

3. "Don't share your drinking glass or silverware with anybody." - symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months I picked 1. "Cover your mouth and nose when you sneeze or cough." - wrong because mononucleosis is spread by direct contact Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The home care nurse instructs a client diagnosed with multiple sclerosis. The client relates to the nurse that she has poor concentration and has difficulty pronouncing words. The nurse notes that the client's speech is slow and slurred. Which of the following statements, if made by the client to the nurse, indicates further teaching is necessary? 1. "I will sit up straight when I talk and will feel confident." 2. "I will turn off the TV when speaking and look at the person with whom I am talking." 3. "During a conversation, I will carefully build up to my most important points." 4. "If words fail me, I will draw a picture."

3. "During a conversation, I will carefully build up to my most important points." - building up can lead to confusion and frustration caused by difficulty concentrating and fatigue; most important points should be communicated at the beginning of the sentence. Strategy: "Further teaching is necessary" indicates an incorrect action

The nurse in the outpatient clinic assesses a client complaining of low back pain. The nurse learns that the client is the single mother of two children, volunteers at her children's school, and works as a checker at the toy store. Which of the following questions should the nurse ask NEXT? 1. "Describe your exercise routine." 2. "What is your favorite position to sleep in at night?" 3. "How many breaks do you get while you are working?" 4. "Do your children help with household chores?"

3. "How many breaks do you get while you are working?" - clients with low back pain should avoid standing for long periods of time; important for the nurse to determine how many rest periods clients receive during working hours I picked 1. "Describe your exercise routine." - wrong because exercise is important for health promotion because it helps maintain weight within normal limits and is a stress reducer; obesity and stress contribute to low back pain

The nurse prepares to discharge the client after an abdominal cholecystectomy. The client will go home with a T tube in place. Which statement, if made by the client to the nurse, indicates a need for further teaching? 1. "It will be great to finally get home, take a shower." 2. "If the amount of drainage increase over the next several days, I should call my health care provider." 3. "I can resume swimming laps three times a week." 4. "I will check the skin around the tube once a day." 5. "I will call my health care provider if I have green drainage." 6. "I am glad I can lift whatever I want."

3. "I can resume swimming laps three times a week." - should avoid strenuous exercise and do not immerse T tube in water 5. "I will call my health are provider if I have green drainage." - This is a normal finding do not need to call HCP 6. "I am glad I can lift whatever I want." - light lifting only for approximately 5 weeks Strategy: All answers are implementation. Determine the outcome of each answer choice. Is it desired?

The nurse obtains a health history from the client taking phenytoin sodium. It is MOSt important for the nurse to report which client statement to the health care provider? 1. "I've had several 'blackouts' in the past year." 2. "My mother has seizures, and this med does not work for her." 3. "I don't know when I had my last menstrual period." 4. "I took this med several years ago but stopped when my urine turned pink."

3. "I don't know when I had my last menstrual period." - phenytoin sodium is in pregnancy risk category D; health care provider should be notified of a possibility of a pregnancy Strategy: Determine the significance of each answer and how it relates to Dilantin

The nurse cares for a toddler diagnosed with pneumonia receiving oxygen in an oxygen tent. The toledo's mother reports to the nurse that her toddler's birthday is tomorrow and asks if the parents can have a party. It is MOST important for the nurse to follow up on which of the following statements if made by the mother? 1. "I plan to bring paper streamers to put on the wall." 2. "My child loves to look at Mylar balloons." 3. "I found the neatest candles to put on the cake." 4. "My child's grandparents are planning to come."

3. "I found the neatest candles to put on the cake." - oxygen is combustible and can cause a fire if it comes to contact with a spark from an open flame or electrical equipment; inform mother that candles cannot be lighted Strategy: "MOST important to follow up" indicates a potential complication

The client visits the rape-crisis clinic one week after being assaulted. The client is currently taking alprazolam 0.25 mg PO q 6 hours for anxiety. Which statement, if made by the client to the nurse, reflects a correct understanding of this medication? 1. "I can take it whenever I feel upset." 2. "I should not take this without anything but water." 3. "I guess i need to stop drinking white wine." 3. "This medication will help me forget and go on."

3. "I guess I need to stop drinking white wine." - antianxiety, should not be taken with alcoholic beverages Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The physician has ordered antibiotic eye drops for a client recovering from outpatient cataract surgery. Which of the following statements, if made by the client, indicates to the nurse that further teaching is necessary? 1. "The drops should go into the center of the lower eyelid." 2. "I should not let the drops flow from one eye into the other." 3. "I should squeeze my eye tightly after I put in the drop." 4. "I should tilt my head back to put in the drops."

3. "I should squeeze my eye tightly after I put in the drop." - should blink between drops but should not squeeze eye tightly because it would cause the drop to be expelled; press inner angle of eye after instillation to prevent systemic absorption. I picked 1. "The drop should go into the center of the lower eyelid." - appropriate placement of drops into the lower conjunctival sac; wash hands before instilling drops; look up, pull lower lid down Strategy: "Further teaching" indicates an incorrect response

The nurse counsels an older client about peripheral vascular disease (PVD). Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed? 1. "I should not smoke since it makes my symptoms worse." 2. "I should exercise, even if it causes pain." 3. "I should use warm packs if my hands and feet get cold." 4. "I should stay inside during the extreme weather."

3. "I should use warm packs if my hands and feet get cold." - decreased sensitivity may result in burns, should use gloves and socks instead; warm moist packs hold heat longer than warm packs and increase the risk for injury Strategy: Determine the outcome of each answer

Which of the following should be charted by the nurse to reflect a client's emotional adjustment to being hospitalized in the ICU? 1. "The client is unable to complete activities of daily living w/o assistance." 2. "The client appears to be depressed and anxious regarding his/her surgery" 3. "The client constantly calls for nurses and cries uncontrollably." 4. "The family in unable to visit more often than once a week because they live far away."

3. "The client constantly calls for nurses and cries uncontrollably." - Gives an objective description of the client's behavior and affect.

The nurse instructs a client diagnosed with COPD about how to perform pursed lip breathing. Which of the following statements by the client to the nurse indicates further teaching is necessary? 1. "I will tighten my stomach muscles as I finish breathing out." 2. "I will take twice as long to breathe out as I did to breathe in." 3. "I will breathe in deeply through my nose, hold it, and then breathe out." 4. "I will pretend I am whistling when I breathe out."

3. "I will breathe in deeply through my nose, hold it, and then breathe out." - incorrect action; breath should never be held during pursed lips breathing Strategy: "Further teaching necessary" indicates incorrect information

The nurse on the neurology unit prepares a patient for discharge. The patient has been treated for an exacerbation of multiple sclerosis. Which of the following statements, if made by the patients to the nurse, indicates that teaching is successful? 1. "When I am exercising, I will push a little beyond when I start to feel tired and then stop." 2. "When my muscles seem especially spastic, I will take hot baths to relieve them." 3. "I will sleep on my stomach as much as I can." 4. "I will be firm and steady when I pull a spastic leg open."

3. "I will sleep on my stomach as much as I can." - may minimize spasm of the flexor muscles of the hips and knees of a person with multiple sclerosis; if these spasms are not relived, joint contractions will occur as well as pressure ulcers on the sacrum and hips from difficulty positioning the patient correctly Strategy: "Teaching is successful" indicates correct information

The nurse performs client teaching for a client receiving aluminum hydroxide (Amphoral). The nurse determines teaching is successful if the client makes which of the following statements? 1. "It is important to take my medicine during the evening." 2. "By taking the medication before meals, I will decrease the side effects." 3. "I will take the medication after meals." 4. "As I start to feel uncomfortable, I will take the medication."

3. "I will take the medication after meals." - antacids are most effective after digestion has started, but prior to the emptying of the stomach Strategy: "Teaching is successful" indicates correct information

The nurse cares for clients on the med/surg unit. The nurse instructs a nursing assistant to put elastic stockings on a client scheduled for surgery. It is MOST important for the nurse to follow up on which of the following statements if made by the nursing assistant? 1. "I will apply talcum powder to the client's feet and legs before applying the stockings." 2. "I will elevate the client's legs before applying the stockings." 3. "The client has obese thighs." 4. "I will make sure there are no wrinkles ion the stockings."

3. "The client has obese thighs." - may decrease venous return because of constriction around thighs Strategy: "MOST important" indicates discrimination is required to answer the question

A patient is discharged from the orthopedic unit after receiving treatment for low-back pain. The nurse counsels the patient about how to prevent further back injury. Which of the following statements, if made by the patient to the nurse, indicates correct understanding of appropriate preventive measures? 1. "It is all right to reach up for things, but if I am picking something up from the floor, I will squat rather than bend and reach down." 2. "I will sleep on my side or abdomen rather than lie flat on my back." 3. "If my back starts to hurt, I will immediately stop what I am doing." 4. "I will sit as far back from the pedals on my car as my legs can comfortably stretch, and I will use a firm backrest."

3. "If my back starts to hurt, I will immediately stop what I am doing." - pain is the body's signal that there is a potential for physical harm and that the patient needs to withdraw from the pain-producing situation Strategy: All parts of the answer must be correct for the answer to be correct

The physician orders propranolol (Inderal) for a client with type 1 diabetes mellitus (DDM). The client asks the nurse if there is anything special she needs to know about this medication since she takes NPH and regular insulin each morning. Which of the following responses by the nurse is BEST? 1. "Inderal potentiates the action of insulin and may increase the number of episodes of hypoglycemia you experience." 2. "Inderal interferes with the action of the insulin and may cause you to experience hyperglycemia" 3. "Inderal may mask symptoms of hypoglycemia, removing your body's early warning system 4. "Inderal has no effect on your body's metabolism other than to lower your blood pressure"

3. "Inderal may mask symptoms of hypoglycemia, removing your body's early warning system - beta-blockers bind beta-adrenergic receptors sites, which prevents adrenaline from causing symptoms and glycogenolysis Strategy: Think about each answer

The mother of two daughters and one toddler son who was just diagnosed with moderate hemophilia A is talking to the pediatric office nurse. To which of the following statements by the mother should the nurse respond FIRST? 1. "I feel so guilty-like it is all my fault" 2. "I do not know how we will be able to afford his medications." 3. "It scares me to think that he will be bleeding all the time." 4. "My husband loves sports and was so glad we had a boy this time."

3. "It scares me to t hink he will be bleeding all the time." - this is a common misconception that is easily and readily address and underlies many of the other concerns; it should be addressed first? I picked 2. "I do not know how we will be able to afford his medications." - wrong because it is a realistic concern, but not first; treatment with factor VIII concentrate is quiet expensive, particularly if the hemophilia is severe; corticosteroids and NSAIDs may also be needed Strategy: "FIRST" indicates priority?

A client involved in a homosexual is scheduled for abdominal surgery. During surgery, the client's partner requests information regarding the client's status. Which of the following responses by the nurse is BEST? 1. "The physician will be out to talk with you after the surgery is complete." 2. "I am sorry. I can only give out info to family members." 3. "Let me go back and get an update. I will be right back." 4. "I'm sure she is doing fine, so just sit back and relax."

3. "Let me go back and get up update. I will be right back." - important to respect client's personal lifestyle choice; nurse acts as the client's advocate when providing partner with accurate info Strategy: Remember therapeutic communication

The 4-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by the parent. Which statement does the nurse expect the parent to make about the infant's symptoms? 1. "My infant's bowel movements have turned black and sticky." 2. "I really have to encourage my infant to suck the bottle." 3. "My infant is fussy and seems hungry all the time." 4. "My infant spits up green liquid after feeding."

3. "My infant is fussy and seems hungry all the time." - becomes lethargic, dehydrated, and malnourished I picked 4. "My infant spits up green liquid after feeding." - wrong because would expect emesis to contain milk or formula, should not be bile-colored Strategy: Determine how each statement relates to pyloric stenosis.

The home health nurse evaluates the health status of a 78-year-old female. The nurse would be MOST concerned if the client states which of the following? 1. "I lie down at night, but sometimes I think about things and I can't sleep." 2. "Sometimes I don't eat much because food doesn't taste good to me." 3. "My leg throb when I take my dog for a walk." 4. "It seems like so many of my friends have either died or moved away."

3. "My leg throb when I take my dog for a walk." - assessment; may be indicative of a form of peripheral vascular disease; required immediate follow-up Strategy: "Most concerned" indicates something is wrong

The home health nurse visits a patient diagnosed with systemic lupus erythematous (SLE). It is MOST important for the nurse to follow up on which of the following statements by the patient? 1. "I seem to have much less energy from one day to the next." 2. "I am flying out of town next week to visit my mother for her 70th birthday." 3. "One of my favorite activities is working in my garden." 4. "The face rash is fading. Maybe people will stop staring at me so much once it is gone."

3. "One of my favorite activities is working in my garden." - CORRECT—sun exposure, infection, and joint stress are problems; skin of patients with SLE often has discoid lesions in various body areas and can become especially erythematous on exposure to sun; patients with lupus should avoid all direct exposure to sun and to any other type of ultraviolet light, including tanning beds and certain kinds of fluorescent lights; patients who are immunosuppressed should not work with houseplants or dig in a garden because of risk both for injury, even simple cuts, and for exposure to bacteria in soil; joints of a patient with SLE are usually inflamed by the disease itself in a polyarthritis manner; joint problems may make it difficult, if not impossible, for patient to garden Strategy: Think about what the patient's words mean

Which of the following statements, if made by the nurse, is accurate about the exercise program required for a patient w/ rheumatoid arthritis? 1. "If you are having a 'bad' day, postpone your exercises until the next day." 2. "Passive exercises are better for you than active exercises." 3. "When inflammation is severe, decrease the number of repetitions of the exercise." 4. "You can substitute your normal household tasks for your exercises to provide variety."

3. "When inflammation is severe, decrease the number of repetitions of the exercise." - should reduce repetitions when patient experiences more pain. I picked 2. "Passive exercises are better for you than active exercises." - wrong because active exercises are better than passive or active-passive exercises.

The nurse on the med/surg unit has just received report. Which of the following clients should the nurse see FIRST? 1. A 29y/o woman undergoing peritoneal dialysis. The outflow appears bloody. 2. A 35y/o man diagnosed with acute post infectious glomerulonephritis. The client's B/P is 150/90. 3. A 45y/o woman diagnosed with P. jiroveci pneumonia. The client complains of a persistent dry cough. 4. A 56y/o man diagnosed with angina. The client is scheduled for discharge today.

3. A 45y/o woman diagnosed with P. jiroveci pneumonia. The client complains of a persistent dry cough. - opportunistic infection associated with AIDS; cause progressive hypoxemia and cyanosis. Strategy: Determine the most unstable client

An older client diagnosed w/ pneumonia is admitted to the med/surg unit. The nurse should place the patient in a room w/ which of the following patients? 1. A 20y/o in traction from multiple fractures of the left lower leg 2. A 35y/o w/ recurrent fever of unknown origin 3. A 50y/o recovering alcoholic w/ cellulitis of the right foot 4. An 89y/o with Alzhemier's disease awaiting nursing home placement.

3. A 50y/o recovering alcoholic w/ cellulitis of the right foot. - generalized nonfollicular infection that involves deeper connective tissue, both patients have infections I picked 2 -wrong because we don't know the cause of the fever

The parish nurse knows that it is MOST important to encourage which of the following men to obtain screening for prostate cancer? 1. A 24y/o Caucasian computer programmer diagnosed with cryptorchidism 2. A 42y/o Asian American restaurant owner diagnosed with ulcerative colitis 3. A 55y/o African American factory worker in automobile tire manufacturing 4. A 62y/o Caucasian retired house painter who has been smoking for 40 years.

3. A 55y/o African American factory worker in automobile tire manufacturing - three major risk factors: age, race, employment; prostate cancer is found most commonly in men age 50 and over; African Americans are affected more than other ethnic groups; occupation and environment are other definite risk factors, particularly exposure to carcinogens found in urban areas (higher incidence of prostate cancer) and in occupations such as fertilizer, rubber, and textile industries, as well as in places with heavy metals such as cadmium; cadmium used in low-friction, fatigue-resistant alloys, in nickel-cadmium batteries, and in rustproof electroplating I picked 4. A 62y/o Caucasian retired house painter who has been smoking for 40 years. - wrong because risk factors are for lung or bladder cancer Strategy: "MOST important" indicates that discrimination is required to answer the question

The nurse cares for clients in the dermatology clinic. The nurse understands which of the following clients is the BEST candidate for ultraviolet light (UV) therapy? 1. A client at 26 weeks gestation diagnosed with atopic dermatitis 2. A client diagnosed with schizophrenia and mycosis fungoides 3. A client diagnosed with ulcerative colitis and psoriasis 4. A client diagnosed with skin cancer with a history of cataracts.

3. A client diagnosed with ulcerative colitis and psoriasis - best candidate for UV therapy; psoriasis is a skin condition that may respond to UV therapy; ulcerative colitis is inflammatory condition of the colon characterized by eroded areas of the mucous membrane and tissue beneath it, not a contraindication to UV therapy Strategy: "BEST" indicates discrimination may be required to answer the question

The nurse supervises care given to clients on a med/surg units. The nurse should intervene if which of the following is observed? 1. A nurse and client wears masks during a dressing change for the central catheter used for TPN. 2. A nurse injects insulin through a single-lumen percutaneous central catheter for a client receiving TPN. 3. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen 4. A nurse wears a disposable particular respirator when administering rifampin to a client with TB.

3. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen. - applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur.

The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST? 1. A patient post coronary artery bypass graft (CABG) having the atrioventricular (AV) wires removed later in the day 2. A patient w/ type 1 diabetes scheduled for a cardiac cath later today 3. A patient 1 day post-op w/ an edpidual cath in place 4. A patient diagnosed w/ cardiomyopathy being eval for a heart transplant

3. A patient 1 day post-op w/ an epidual cath in place - Epidual used for pain relief, monitor for urinary incontinence, hypotension, resp. depression and n/v.

The psychiatric home care nurse plans visits for the day. The weather report states that temperature will be around 95 degrees. Which of the following patient should the psychiatric home health nurse see FIRST upon leaving the office? 1. A patient diagnosed with chronic schizophrenia who is frequently noncompliant with medications. The patient lives with his parents in a house without air-conditioning and is a 10-minute drive from the office. 2. A patient diagnosed with obsessive-compulsive disorder who is taking clomipramine (Anafranil). The patient lives with her sister, has a psychiatrist who is on vacation, and is a 30-minute drive from the office. 3. A patient diagnosed with bipolar disorder who lives with his wife. The patient was discharged from the inpatient unit 1 week ago after being started on lithium carbonate (Lithobid), and is a 45-minute drive from the office. 4. A patient diagnosed with depression who lives alone. The patient likes to garden, is taking amitriptyline (Elavil) for depression, and is a 20-minute drive from the office.

3. A patient diagnosed with bipolar disorder who lives with his wife. The patient was discharged from the inpatient unit 1 week ago after being started on lithium carbonate (Lithobid), and is a 45-minute drive from the office. - potentially the least stable patient due to recent hospitalization and taking Lithium; response to the lithium needs to be monitored, including side effects; a particular concern at this time, because of the weather, is to be certain patient is maintaining adequate sodium levels as well as drinking appropriate amounts of water in order to prevent lithium toxicity Strategy: Determine the MOST unstable patient

The nurse admits a 6-month-old with a diagnosis of respiratory syncytial virus (RSV). The nurse should place the child in which of the following rooms? 1. A semiprivate room with an infant diagnosed with influenza 2. A semiprivate room with an infant diagnosed with Kawasaki syndrome 3. A private room with sleeping accommodations 4. A private room without sleeping accommodations

3. A private room with sleeping accommodations - RSV causes bronchiolitis and requires contact precautions; parents are best providers of care for their children, sleeping accommodations are appropriate I picked 1. A semiprivate room with an infant diagnosed with influenza - wrong because requires droplet precautions

An elderly man diagnosed w/ chronic schizo is followed in a partial hospitalization program. The client has been on long-term antipsychotic med and recently developed symptoms of tardive dyskinesia. The nurse's documentation should include which of the following? 1. Assessment of ADL (self-care) ability 2. Mini-Mental Status Exam (MMSE) 3. Abnormal Involuntary Movement Scale (AIMS) 4. Modified Overt Aggressive Scale (MOAs)

3. Abnormal Involuntary Movement Scale (AIMS) - is most widely accepted exam to test for the presence of tardive dyskinesia

The nurse on a psychiatric unit of the hospital refuses to agree to a patient's request to organize a party on the unit for the patient's friends. The patient becomes angry and uses abusive language toward the nurse. Which of the following statements indicates that the nurse has an understanding of the patient's behavior? 1. Allowing the patient to use abusive language will undermine the authority of the nurse. 2. Responding in kind to a patient who uses abusive language will perpetuate the behavior 3. Abusive language is one of the behaviors symptomatic of the patient's illness. 4. The nurse should model acceptable behavior and language for all patients.

3. Abusive language is one of the behaviors symptomatic of the patient's illness. - Symptoms will respond to treatment

A patient diagnosed with type 2 diabetes mellitus is treated with hypertension with propranolol (Inderal). History reveals that the patient is diagnosed with glaucoma and is allergic to sulfa. The nurse is MOST concerned if an order was written for which of the following medications? 1. Glycerin (Osmoglyn) 2. Pilocarpine (Isopto-Caprine) 3. Acetazolamide (Diamox) 4. Timolol maleate (Timoptic)

3. Acetazolamide (Diamox) - contraindicated; cross-sensitivity can occur due to allergy to antibacterial sulfonamides and sulfonamide derivatives Strategy: "Nurse is MOST concerned" indicates a complication

The father of a 1-day-old son works the evening shift (3pm to 11pm) at another hospital. Which plan is the priority to meet the needs of this father? 1. Encourage the father to call his wife after work 2. Instruct the father about visiting policy and suggest AM visitation 3. Adjust visiting hours to meet the new parents' needs 4. Present a change of visiting hours to the appropriate hospital committee

3. Adjust visiting hours to meet the new parents' needs - role of nurse is to be a family and client advocate; this provides individualized care Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired?

The nurse administers morphine 6 mg IV push to a patient for post-op pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed 2. Administer oxygen via face mask or nasal prongs 3. Administer naloxone (Narcan) 4. Place epinephrine 1:1,000 at the bedside

3. Administer naloxone (Narcan) - IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action I picked 2. Administer oxygen via face mask or nasal prongs Wrong because problem is low respirations; this may be administered after medication

The client is brought to the ED by friends who state, "He has been hanging with the wrong crowd. We are worried he is using drugs." The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. The nurse plans care. Which is MOST important for the nurse to anticipate? 1. Increased adventitious breath sounds 2. Decreased blood pressure, temp, and pulse 3. Aggressive behaviors 4. Nausea, vomiting, abdominal cramping

3. Aggressive behaviors - CORRECT symptoms of blank stare, rigid muscles, ataxia, and nystagmus that is both vertical and horizontal indicate probable phencyclidine piperidine (PCP) intoxication; another name for PCP is angel dust; aggression in all forms is another symptom that manifests with PCP; can take the form of assault, belligerence, impulsiveness, and/or suicidality, and is very often bizarre in nature; often occurs in unpredictable outbursts; interventions should be planned to monitor for aggressive symptoms, to prevent them, and to manage them should they occur; decreasing stimuli, avoiding trying to "talk the person down," securing potential injurious objects in the environment, having chemical and physical restraints (along with sufficient staff) available are all measures that can be planned in advance and utilized; PCP is used by itself, but is also frequently used as an adulterant with other drugs I picked 4. Nausea, vomiting, abdominal cramping - wrong because no particular association with PCP; these are symptoms that occur with opiate withdrawal Strategy: The topic of the question is unstated

The client who is terminal is on a unit with limited visiting hours that restrict children younger than 12 years of age from visiting. Which nursing action has the HIGHEST priority? 1. Explain the visiting hours to the client's family 2. Propose a policy change to the medical and nursing staff 3. Allow flexibility with family members' visitation 4. Encourage the family to call the unit between visiting hour

3. Allow flexibility with family members' visitation - role of the nurse is to function as a client advocate; is important to individualize care with all clients Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The spouse of a phobic client confides in the nurse that he is concerned by his wife's sudden fear of elevators. He asks the nurse what to do when his wife becomes frightened. The nurse encourages the husband to FIRST take which of the following actions? 1. Ride on the elevator with his wife 2. Encourage his wife to get into the elevator 3. Allow his wife to avoid the elevator 4. Encourage his wife to discuss her fears

3. Allow his wife to avoid the elevator - while allowing wife to avoid elevator, husband will not increase client's apprehension and anger I picked 4. Encourage his wife to discuss her fears - wrong because more important to allow client to avoid elevator Strategy: "FIRST" indicates priority

The nurse receives verbal patient care reports from the home health aide. Which of the following situations requires an intervention by the nurse? 1. A Mexican American female refuses to bathe because she is menstruating. 2. The family of a terminally ill Hindu man places him on the floor after the bed bath. 3. An African American female's hair is shampooed every third day. 4. A Pakistani male on bedrest genuflects on the floor several times during the day.

3. An African American female's hair is shampooed every third day. - hair and scalp tend to be dry and need oil application rather than common shampoo. Strategy: "Requires an intervention" indicates an incorrect action

The nurse on the medical/surgical unit administers digoxin 0.125 mg by direct IV. During the administration of the digoxin, the unit secretary informs the nurse that a client with extensive head and facial injuries has arrived on the unit. Which of the following actions should the nurse take FIRST? 1. Note the time and place the syringe with the remaining medication on the medication cart 2. Instruct the unit secretary to find another nurse to admit the client 3. Ask the unit secretary to obtain the sheet containing the staff's pager numbers 4. Request that the LPN continue the administrations of the medication

3. Ask the unit secretary to obtain the sheet containing the staff's pager numbers - enables nurse to safely administer the medication, and the nurse determines the appropriate person to care for the clients; when administering digoxin by direct IV, infuse over a minimum of 5 minutes; use diluted solution immediately; observe IV site; extravasation can lead to tissue irritation and sloughing Strategy: "FIRST" indicates priority

The nurse in the ED assesses a patient diagnosed with tonic-clonic epilepsy. The patient's spouse states that the patient has been taking phenytoin (Dilantin) as prescribed but has not been feeling well lately. Which of the following observations of the patient MOST concerns the nurse? 1. Reddish-brown urine, and the patient complains of constipation 2. Acne, hirsutism, gingival hyperplasia 3. Ataxia, slurred speech, nystagmus 4. The left arm is in a sling and the patient walks with a limp.

3. Ataxia, slurred speech, nystagmus - these are common signs of Dilantin overdose/toxicity; usual therapeutic concentration of the drug in the plasma is 10-20 g/mL; nystagmus is usually evident at > 30 g/mL, and ataxia and slurred speech are usually evident at > 30 g/mL

The nurse recognizes that the client diagnosed w/ an obsessive-compulsive ritual is attempting to achieve which of the following? 1. Control of other people 2. Increased self-esteem 3. Avoid severe level of anxiety 4. Express and manage anxiety

3. Avoid severe levels of anxiety - obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety

The nurse cares for the client recovering from lower bowel surgery. The nurse determines that teaching is successful if the client selects which menu? 1. Milk, green beans, whole-wheat bread 2. Creamed chicken soup, broccoli, pudding 3. Baked chicken, buttered rice, plain gelatin 4. Cabbage salad, fried chicken, applesauce

3. Baked chicken, buttered rice, plain gelatin - low-residue diet will leave a relatively small amount of residue, or indigestible material, in the colon; all meats, fish, and poultry must be broiled or baked Strategy: Determine what type of diet is required. Select the menu that reflects the diet

The nurse cares for a post-op client diagnosed w/ type 2 diabetes controlled w/ anti hyperglycemic agents. The client asks why the physician ordered subcutaneous insulin injections after surgery. The nurse's response should be based on which of the following statements? 1. Tissue injury after surgery decreases blood sugar 2. Anesthesia acts to increase glycogen stores 3. Being NPO inhibits normal blood sugar control 4. Surgery often leads to insulin dependency

3. Being NPO inhibits normal blood sugar control - Inability to control diabetes by diet and oral agents, coupled w/ surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of IV fluids

The nurse cares for the client with rheumatoid arthritis. The nurse prepares for the client to be discharged. The nurse knows that the client to manage at home alone the client needs to be able to perform with activity? 1. Climb up and down stairs 2. Lace and tie his/her shoes 3. Comb hair and brush teeth 4. Walk without assistance

3. Comb hair and brush teeth - is part of basic hygiene and grooming that must be done daily to maintain overall health Strategy: Think about the significance of each answer choice and how it relates to arthritis

The client has sudden onset of venous thromboembolism (VTE) is started on IV unfractionated heparin. Which order should the nurse question? 1. arm, moist packs to the affected leg 2. Elevate the foot of the bed 6 inches 3. Complete bedrest for 5 days 4. Elastic stocking on unaffected leg

3. Complete bedrest for 5 days - on bedrest only until heparin started Strategy: "Question orders" indicates an incorrect order

The 4-month-old infant who had a temp of 103F (39.4C) following the last DTaP (diphtheria, tetanus, and pertussis) vaccine is seen in the clinic for another immunization administration. Prior to the nurse's administering the DTaP, which action should be the nurse's priority? 1. Withhold the immunization 2. Give half the dose in this injection 3. Consult the health care provider about giving pediatric DT (diphtheria and tetanus) 4. Instruct the parents to give acetaminophen following administration of a full dose of DTaP

3. Consult the HCP about giving pediatric DT (diphtheria and tetanus) - fever over 103F (39.4C) in first 48 hours after DTaP is a valid contraindication for pertussis vaccine I picked 4. Instruct the parents to give acetaminophen following administration of a full dose of DTaP - wrong; would be confect if just the DT were given Strategy: Answers are implementations. Determine the outcome of each choice. Is it desired?

The nurse in the pediatric clinic receives a call from the mother of an adolescent girl. The girl fell off a balance beam while performing a gymnastic activity two days ago and briefly lost consciousness. The adolescent has hospitalized overnight and discharged home yesterday. The mother reports the adolescent's headache is unrelieved by multiple doses of acetaminophen (Extra Strength Tylenol). Which of the following actions should the nurse take FIRST? 1. Instruct the mother to darken the adolescent's room 2. Determine when the client can receive another dose of medication 3. Contact the physician 4. Reassure the other that this is expected

3. Contact the physician - persistent localized pain suggests a skull fracture; should be evaluated Strategy: "FIRST" indicates priority

The nurse knows that cortisol is responsible for which of the following? 1. Preparing the body for "flight or fight" 2. Regulating the calcium metabolism 3. Converting proteins and fat into glucose 4. Enhancing musculoskeletal activity

3. Converting proteins and fat into glucose - Action of cortisol; is also an anti-inflammatory agent

The nurse cares for an older client diagnosed with partial thickness and full thickness burns over 75% of his body. Which of the following assessments indicates to the nurse the client is developing shock? 1. Epigastric pain and seizures 2. Widening pulse pressure and bradycardia 3. Cool, clammy skin and tachypnea 4. Kussmaul respirations and lethargy

3. Cool, clammy skin and tachypnea - body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for loss of fluid

The client taking chlorpromazine should be instructed to notify the nurse immediately. If the client experiences which sign and symptom? 1. Dry mouth and nasal stuffiness 2. Increased sensitivity to heat 3. Difficulty urinating 4. Weight gain and constipation

3. Difficulty urinating - is an anticholinergic reaction that may become a severe health problem unless treated. I picked 1. Dry mouth and nasal stuffiness - wrong because possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem Strategy: Determine the cause of each answer choice and how it relates to chlorpromazine.

The 5-year-old child is scheduled for a lumbar puncture (LP). Which nursing action BEST prepares the child for the procedure? 1. Explain the procedure in detail 2. Show a video of the procedure 3. Do a mock run-through of the procedure 4. Answer all questions simply and honestly

3. Do a mock run-through of the procedure - excellent method to use with a child because it incorporates actually "feeling" many aspects of the procedure as they are explained. I picked 4. Answer all questions simply and honestly - wrong because child probably doesn't know enough to ask many questions Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

Which plan is MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization? 1. Show a videotape specifically prepared for children about cardiac catheterization 2. Provide the child with a pamphlet about the procedure, and encourage him to read it. 3. Draw a picture of a heart, and explain where the tube will go and what the health care provider will see. 4. Present a puppet show explaining the anatomy and physiology of the heart.

3. Draw a picture of a heart, and explain where the tube will go and what the health care provider will see. - explains procedures in simple terms; allow choices when possible I picked 1. Show a videotape specifically prepared for children about cardiac catheterization - wrong because video will provide correct info but is not best preparation for a school-aged child Strategy: think about the development stage of a 10-year-old

The nurse cares for a 2-month-old infant immediately after a surgical procedure. Which of the following is a priority nursing action? 1. Minimize stimuli for the infant 2. Restrain all extremities 3. Encourage the parents to stroke the infant 4. Explain to the mother how she can assist with her infant's care.

3. Encourage the parents to stroke the infant - tactile stimulation is imperative for infant's emotional development I picked 4. Explain to the mother how she can assist with her infant's care - wrong because it is important, but not as important as providing tactile stimulation to the infant Strategy: Determine the outcome of each answer

The nurse in the ED cares for a client who presents with a bee sting. The nurse notes that the client is sneezing and coughing, is flushed, has generalized hives, and complains of feeling warm. Which of the following actions should the nurse take FIRST? 1. Continue to monitor the client 2. Immediately administer Prednisone. 3. Establish an IV infusion with normal saline 4. Ask the client about previous reactions to bee stings

3. Establish an IV infusion with normal saline - priority is to monitor circulatory status and maintain blood pressure Strategy: Does this situation require further assessment? no

The nurse in the outpatient clinic assess a female client complaining of "burning with urination." It is MOST important for the nurse to take which of the following actions? 1. Ask the client if she has experienced this before 2. Encourage the client to drink cranberry juice 3. Examine the urethral meatus and vaginal introits 4. Instruct the client to wear loose-fitting cotton underwear

3. Examine the urethral meatus and vaginal introits - client may have normal acidic urine that causes burning if labial tissues are inflamed because of vaginal infection I picked 1. Ask the client if she has experienced this before - wrong because appropriate question but not the priority action Strategy: "MOST important" indicates discrimination is required to answer the question

The clinic nurse evaluates a client diagnosed with type 1 diabetes. Which of the following observations indicates to the nurse that the client is not rotating insulin injection sites? 1. A wheal develops at the site of the injection 2. Increased discomfort at the site of the injection 3. Glucose levels rise temporarily 4. Increased muscle mass at the site of the injection

3. Glucose levels rise temporarily - failure to rotate sites results in poor absorption, which increases blood sugar I picked 2. Increased discomfort at the site of the injection - wrong because repeated injections into same site become less painful rather than more uncomfortable Strategy: Determine the significance of each answer choice and how it relates to insulin administration

The nurse cares for an adolescent who has been comatose for 2 years. When entering the client's room, which of the following interventions should the nurse perform FIRST? 1. Elevate the head of the bed for morning tube feedings 2. Check bony prominences for redness 3. Greet the client and tell him the time of day 4. Assess deep tendon reflexes (DTRs)

3. Greet the client and tell him the time of day - reorienting of clients should be conducted at least every 8 hours I picked 2. Check bony prominences for redness - appropriate activity; should not touch client without first speaking to him Strategy: "FIRST" indicates priority

A client has orders for cefoxitin (Mefoxin) 2g IV piggyback in 100mL 5% dextorse in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is MOST important for the nurse to take which of the following actions? 1. Administer the med slowly at 20 to 25 cc/h 2. Change the priarmy IV solution 3 Hang the piggyback infusion bag higher than the primary infusion bag. 4. Obtain an infusion pump prior to administration.

3. Hang the piggyback infusion bag higher than the primary infusion bag. - when using a gravity drip, piggyback fluid level needs to be higher than primary infusion I picked 4 wrong because it is unnecessary for safe infusion

The nurse is called to the room of the client 4 days after abdominal surgery. The client had been coughing and said "It felt like something gave." The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should place the client in which positions? 1. Head of the bed elevated 30 degrees 2. Head of the bed tilted down 3. Head of the bed elevated 15 degrees 4. Head of the bed elevated 90 degrees.

3. Head of the bed elevated 15 degrees - low Fowler's; reduces stress on suture line, may be placed supine with hips and knees bent. I picked 1. Head of the bed elevated 30 degrees - wrong because too high, puts pressure on abdominal area Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cars for a client receiving aluminum hydroxide gel (Amphojel). The nurse determines that teaching is effective if the client states which of the following? 1. I will only take this med before bedtime 2. I will decrease side effects by taking this med before meals 3. I will take the med 1 hr after meals 4. I will take the med when I feel epigastric pain

3. I will take the med 1hr after meals* - antacids neutralize gastric acids, increase gastric pH, and inactivate pepsin; contains sodium, check if patient is on sodium-restricted diet Strategy: "Teaching is effective" indicates correct information

A nurse begins a therapeutic relationship with the client diagnosed with generalized anxiety disorder. It is MOST important for the nurse to obtain which information? 1. What the client's priorities are 2. How the client views self 3. In what situations the client gets anxious 4. Any family history of mental issues.

3. In what situations the client gets anxious - will provide necessary information in baseline assessment of client's anxiety I picked 1. What the client's priorities are - wrong because helpful data; priority is to determine in what situations the client becomes anxious. Strategy: Think about each answer choice.

The nurse cares for the client recovering from streptococcal pneumonia. The client has a chest x-ray that reveals a higher degree of atelectasis in the right lower lobe. Which nursing intervention is MOST appropriate? 1. Instruct the client to take deep breaths more frequently 2. Reposition the client every hour to the right side 3. Increase the frequency of incentive spirometry 4. Change respiratory treatment to every 2 hours

3. Increase the frequency of incentive spirometry - incentive spirometry is a quantifable method of assessing respiratory effort with deep-breathing exercises; increasing the frequency would be a sound nursing decision in an effort to improve the client's pulmonary status Strategy: All answers are implementations. Determine the outcome each answer choice. Is it desired?

The nurse obtains a client's temp of 103F (39.4C). The nurse knows body compensatory mechanisms include which of the following? 1. Decrease Resp rate and bradycardia 2. Normal blood pressure and pulse 3. Increased resp rate and tachycardia 4. Diaphoresis w/ cool, clammy skin

3. Increased resp rate and tachycardia - hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate I picked 4 wrong because diaphoresis may occur, but the skin will be warm.

A child is learning rules and how to play with others. Based on these observations, the nurse knows that the client is in which of the following stages according to Erikson's theory of personality development? 1. Autonomy vs shame and doubt 2. Initiative vs guilt 3. Industry vs inferiority 4. Trust vs mistrust

3. Industry vs inferiority - school aged child (age 6-12); during this stage a child learns to compete and cooperate with others 1. Autonomy vs shame and doubt - 18 months - 3 years of age (toddler) 2. Initiative vs guilt - 3-6 years of age (preschool) 4. Trust vs mistrust - birth to 18 months Strategy: image the behavior

The mother of a 5-month-old contacts the nurse to report that she has a dry cough, fever, headache, and muscle aches. The client breast-feeds her infant. Which of the following actions by the nurse is BEST? 1. Suggest the client discontinue breastfeeding during the illness 2. Ask the client to increase her fluid intake 3. Instruct the client to wear a surgical mask 4. Inform the client to uncover her breasts before washing her hands

3. Instruct the client to wear a surgical mask - put on mask, wash hands, and uncover breasts; wear mask until the feeding is finished and the mom has put the baby down. Strategy: "BEST" indicates discrimination is required to answer the question

Which of the following skin manifestations in an infant MOST concerns the nurse? 1. Irregularly shaped pink patches on the back of the neck 2. Diffuse bluish-purple, bruised-looking areas on the buttocks 3. Large, irregular, flat macular patch on one side of the face 4. Red, raised, rough-surfaced, clearly delineated nodules

3. Large, irregular, flat macular patch on one side of the face - this is a nevus flammeus (port wine stain); its color ranges from pink to red to purple and it may appear purple-black in Africans; grows proportionately as the child grows; does not fade; a laser pulse device is used to significantly lighten or completely clear the stain when the child is older. Strategy: Think about each answer

The 12 year-old client is admitted to a pediatric unit in faso-occlusive crisis from sickle cell anemia. As the nurse prepares the plan of care, which order should the nurse question? 1. Bed rest with bathroom privileges 2. Two liters oxygen via nasal cannula 3. Maintain IV at keep-open rate 4. Administer analgesics as ordered

3. Maintain IV at keep-open rate - adequate hydration must be maintained to prevent sickling and clumping of the affected cells Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Counseling regarding problems of body image 2. Maintain airborne precautions 3. Maintain aseptic technique during procedures 4. Encourage peers to visit on a regular basis.

3. Maintain aseptic technique during procedures - safety is a priority for the client who is at high risk for infection I picked 1. Counseling regarding problems of body image Wrong because psychosocial, not highest priority

The nurse makes rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should take which actions? 1. Encourage the client to drink warm oral fluids 2. Check the client's pulse and respirations 3. Massage the funds until firm 4. Put the infant to the client's breast 5. Assess the bladder for fullness 6. Continue to monitor

3. Massage the funds until firm - Massage is the first action to contract the uterus 4. Put the infant to the client's breast - Having the infant nurse will cause oxytocin to be produced which will contract the uterus. 5. Assess the bladder for fullness - A full bladder will cause the uterus to relax and needs to be emptied. Strategy: Identify all of the actions to help contract the uterus.

A client returns from surgery w/ a fine, reddened rash noted around the area where Betadine Prep had been applied prior to surgery. Nursing documentation in the client's chart should include which of the following? 1. Time and circumstances under which the rash was noted 2. Explanation given to the client and family of the reason for the rash. 3. Notation on an allergy list and notification of the doctor 4. The need for application of corticosteroid cream to decrease inflammation.

3. Notation on an allergy list and notification of the doctor. - suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies.

A newly admitted client has been taking lithium carbonate (Lithane) for 2 years. The client's serum lithium level is 1.5 mEq/L. Which of the following actions should the nurse take FIRST? 1. Administer the next dose on time 2. Increase the client's oral fluid intake 3. Notify the physician 4. Encourage the client to rest

3. Notify the physician - therapeutic level of lithium is 1-1.5 mEq/L; toxic manifestations may occur at levels greater than 1.5 mEq/L; physician should be notified Strategy: Determine the outcome of each answer. Is it desired?

At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. Which action by the nurse is BEST? 1. Refer the client to the health are provider for appropriate medication 2. Refer the client to the dietitian 3. Obtain a diet history 4. Recheck the cholesterol level in 2 years

3. Obtain a diet history - assessment; total cholesterol level for an adult male should be under 200 mg/dL; higher levels require a low-fat diet; obtain diet history before instructing on a low-fat diet Strategy: Answers choices are a mix of assessments and implementations. Does this situation requires assessment? Yes

A client has been taking propranolol (Inderal) 40 mg BID and furosemide (Lasix) 40 mg daily for several months. Two weeks ago, the physician added verapamil (Calan) 80mg TID to the client's regimen. It is MOST important for the nurse to assess for which of the following? 1. Tachycardia 2. Diarrhea 3. Peripheral edema 4. Impotence

3. Peripheral edema - Calan is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricle and oxygen demand, dilates coronary arteries; when used w/ other anti-hypertensives can cause hypotension and heart failure.

The nurse finds a 5-year-old having a grand mal seizure. What action should the nurse take FIRST? 1. Call for help 2. Place a padded tongue blade between his teeth 3. Place a pillow under his head 4. Straddle his legs and hold his arms

3. Place a pillow under his head - need to protect him from injury using padded side rails, airway at bedside, pillow under head, loosen clothing, clear space I picked 1. Call for help - wrong because must protect patient; should call for help but should not be first action; raise side rails or ease client to floor Strategy: Determine the outcome of each answer. Is it desired?

The nurse responds to a call light and finds the patient's IV tubing disconnected from the patient's central line. The patient is restless and complains of difficulty breathing. After the nurse locks the open catheter, which of the following series of interventions is the nurse MOST likely to perform FIRST? 1. Place the patient in a flat supine position, initiate oxygen therapy, and notify the physician. 2. Place the patient in a high fowler's position, initiate oxygen therapy, and notify the physician 3. Place the patient on the left side in Trendelenburg position, initiate oxygen therapy, and notify the physician. 4. Place the patient on the left side with the lower extremities elevated, initiate oxygen therapy, and notify the physician.

3. Place the patient on the left side in Trendelenburg position, initiate oxygen therapy, and notify the physician. - placing the patient in this position increases the likelihood that the air will pass into the right atrium and be dispersed by the way of pulmonary artery I picked 2. Place the patient in a high fowler's position, initiate oxygen therapy, and notify the physician - wrong because position increases the risk for the embolism moving to the brain Strategy: "FIRST" indicates priority

The nurse instructs a group of mothers of toddlers about age-appropriate toys for their children. The nurse recommends that toddlers play with which of the following toys? 1. Educational computer programs 2. Play clothes for dress-up 3. Pounding board 4. Cloth picture books 5. Tricycle 6. Skates

3. Pounding board - provides for physical activity 4. Cloth picture books - stimulates mental development and creativity Strategy: Answers based on textbooks, not one's own children

The nurse determines that a client's tracheostomy requires suctioning. Which of the following actions should the nurse take FIRST? 1. Elevate the head of the client's bed to 90degrees 2. Quickly insert the suction catheter 3. Preoxygenate the client 4. Put on clean gloves

3. Preoxygenate the client - prevents hypoxia associated with tracheal suctioning Strategy: "FIRST" indicates priority

The nurse admits a client to the medical unit after the client came to the emergency department because of repeated seizures. During admission, the client complains to the nurse of pain in her right arm and states that it has been hurting since blood was drawn in the ED. The nurse observes the client's right arm and discovers a tourniquet in place. Which of the following actions should the nurse take FIRST? 1. Notify the physician 2. Assess the arm 3. Remove the tourniquet 4. Complete an incident report

3. Remove the tourniquet - first action is to remove the tourniquet to restore blood flow to the client's arm; prolonged tourniquet pressure can cause vessel, nerve, muscle, and skin damage Strategy: "FIRST" indicates priority

The nurse cares for a child diagnosed w/ pediculosis capitis (head lice) and is being treated w/ 1% gamma benzene hexachloride (Kwell) shampoo. The nurse should include which of the following when instructing the child's parents? 1. Continue treatment every other day for 1 week 2. Wash the child's clothing and personal belongings in soap and cool water 3. Repeat the application of the shampoo in 7-10 days 4. One treatment w/ kwell kills both

3. Repeat the application of the shampoo in 7-10 days.

The nurse cares for a client receiving a blood transfusion for approximately 30 minutes. Which of these assessments, if made by the nurse, indicates an allergic reaction? 1. Hypotension 2. Chills 3. Respiratory wheezing 4. Lower back discomfort

3. Respiratory wheezing - Allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema

The nurse conducts a neurologic assessment on a new patient in the neurology clinic. Assessment of the biceps and patellar deep tendon reflexes does not readily elicit a response. It is MOST important for the nurse to take which of the following actions? 1. Record the reflexes as either 0 or 1+ and proceed to assess the pulses of all four extremities with a Doppler ultrasound device 2. Test again using the opposite side of the reflex (percussion) hammer and strike more firmly 3. Retest the biceps while the patient clenches the teeth, and retest the patellar while the patient interlaces the fingers and pulls them against each other 4. Tap the patient's face just below and in front of the ear and leave a blood pressure cuff inflated on patent's arm for 3 minutes.

3. Retest the biceps while the patient clenches the teeth, and retest the patellar while the patient interlaces the fingers and pulls them against each other - these are known as reinforcement techniques; isometric contraction of other muscles can increase the generalized reflex response/activity of the body; distraction may also be a reason for this effectiveness; as tension can inhibit a reflex being elicited Strategy: "MOST important" indicates discrimination is required to answer the question

The nurse observes a group of children at play. The nurse identifies which type of play as typical for 2-year-olds? 1. Four children playing dodge ball 2. Three children playing tag. 3. Two children in the sandbox building castles side by side. 4. One child digging a hole, another child blowing bubbles.

3. Two children in the sandbox building castles side by side. - parallel play, seen with toddlers; playing alongside, not with, others. Strategy: Think about the type of play

While performing care for the elderly client, the nurse notices that the client has a dry, parched mouth and tongue. The nurse should take which action? 1 Brush the client's teeth with a hard-bristled toothbrush before meals and at bedtime 2. Use glycerin swabs to perform mouth care every 4 hours 3. Rinse the client's mouth with room-temperature tap water before and after meals 4. use a water pick, then rinse with commercial mouthwash every 8 hours to freshen the mouth

3. Rinse the client's mouth with room-temperature tap water before and after meals - will hydrate the mucous membranes and keep mouth clean I picked 2. Use glycerin swabs to perform mouth care every 4 hours - wrong because should be avoided, causes dryness of mucous membranes Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The client admitted with a diagnosis of metastatic cancer has been receiving chemotherapy for 3 months. The client's lab values include RBC 3.8 million/ mm3, WBC 2,000/mm, HgB 9.3 g/dL, platelets 50,000/mm3. Which nursing diagnosis is MOST appropriate for this client? 1. Decreased cardiac output 2. Ineffective thermoregulation 3. Risk for injury 4. Ineffective airway clearance

3. Risk for injury - due to low platelet count, normal platelets 150,000-400,000/mm3, decrease causes problems with blood clotting Strategy: Determine how each answer choice relates to the lab values.

The home care nurse makes an initial visit to a client diagnosed with nephrotic syndrome caused by acute post streptococcal glomerulonephritis (ASGN). After obtaining a client history, it is MOST important for the nurse to instruct the client about which of the following? 1. Take the blood pressure daily. 2. Low fat diet 3. Signs and symptoms of venous thrombosis 4. Low sodium diet

3. Signs and symptoms of venous thrombosis - common complication of nephrotic syndrome I picked 4. Low sodium diet - wrong because disease results in edema and fluid retention is needed for management of disease, but lacks urgency of the risk for clot formation in vital organs Strategy: "MOST important" indicates discrimination is required to answer the question

The client is transferred to the neurology unit after developing right-sided paralysis and aphasia. The nurse should include which implementation in the client's plan of care? 1. Encourage client to shake head in response to questions 2. Speak in a loud voice during interactions 3. Speak using phrases and short sentences. 4. Encourage the use of radio to stimulate the client.

3. Speak using phrases and short sentences. - will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions. I picked 1. Encourage client to shake head in response to questions - wrong because it does not encourage verbal communication Strategy: Topic of question is unstated. Read the answer choices for clues.

The client diagnosed with a tumor of the pituitary gland has a transsphenoidal hypophysectomy. The nurse plans care for the client two days after surgery. It is MOST important for the nurse to monitor which finding? 1. Complete blood count (CBC) 2. temp 3. Specific gravity of urine 4. Intracranial pressure

3. Specific gravity of urine - lack of ADH from pituitary will cause diabetes insidious and diuresis with very low specific gravity Strategy: "MOST important" indicates that this is a priority question. Determine what each assessment measures and how it relates to the situation

The nurse cares for the child diagnosed with a fractured right femur. The child is in balanced suspension traction with a Thomas splint and Pearson attachment. When the nurse checks the client, the nurse finds the weights on the floor, and the child's feet touching the foot of the bed. Which action by the nurse is MOST appropriate? 1. Release the traction weights and reposition the child in bed. 2. Pull on the traction weights while two nurse's aides pull the child up in bed. 3. Steady the traction and ask the child to bend the left leg and push up in bed. 4. Assess the child's right left for proper position and alignment.

3. Steady the traction and ask the child to bend the left leg and push up in bed. - permits patient to reposition self and re-establish pull of traction weights. I picked 2. Pull on the traction weights while two nurse's aides pull the child up in bed. - wrong because pulling on traction weights would alter proper pull on fracture. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each answer choice.

The nurse overhears a conversation in the cafeteria between two nurses regarding a client's home situation. Which action is the MOST appropriate? 1. Report the incident to the nurse manager 2. Join the conversation with the nurses 3. Suggest that the nurses continue their conversation in private 4. Ignore the incident because the nurse is not involved

3. Suggest that the nurses continue their conversation in private - client's confidentiality is being violated; it is nurse's responsibility to intervene to protect the client I picked 1. Report the incident to the nurse manager - wrong; may occur, but the situation requires immediate action that the manager may not be able to provide Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? BULLSHIT QUESTION - Kaplan says follow chain of command first

The nurse prepares to move a patient from bed to chair using a hydraulic lift. It is MOST important for the nurse to perform which of the following actions? 1. While lowering the patient to the chair, ask the patient to extend the legs forward 2. Remove the sling from the patient once the patient is seated in the chair. 3. Suspend the patient in the sling above the bed prior to moving the lift 4. Set the adjustable base of the lift to its most space-conserving position

3. Suspend the patient in the sling above the bed prior to moving the lift - lift supports weight safely and will not tip over; suspending the patient briefly above the bed prior to moving away form its provides reassurance and increases patient's feelings of security Strategy: Determine the outcome of each answer. Is it desired?

A client reports hearing loss. While the nurse is irrigating the client's ear to remove cerumen for better observation of the tympanic membrane, the client reports dizziness. Which action should the nurse take FIRST? 1. Notify the health care provider immediately. 2. Monitor for changes in intracranial pressure 3. Warm the irrigant, and resume the procedure 4. Explore the canal with a cotton applicator

3. Warm the irrigant, and resume the procedure - water that is too cool can elicit dizziness when it comes into contact with the tympanic membrane Strategy: Answers are a mix of assessments and implementations. Are the assessments correct? No. Determine the outcome of the implementations

The nurse performs hypertension screening at the local grocery store. It is MOST important for the nurse to complete which task? 1. Use a b/p cuff that overlaps the arm at least 4 inches 2. Support the client's arm above the level of the heart 3. Take two readings at least 5 minutes apart 5. Take the b/p after the client has exercised for 10 minutes

3. Take two readings at least 5 minutes apart - recognition of adult hypertension should be done after two readings taken at least 5 minutes apart I picked 1. Use a b/p cuff that overlaps the arm at least 4 inches - wrong; unnecessary Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

The nurse cares for clients in the hospital. Which of the following activities BEST promotes rest for an elderly hospitalized client? 1. Place a clock at the bedside 2. Restrict visitors so that the client is alone during the evening 3. Tell the client how to call for help if needed 4. Postpone explanation of further tests that the client will need

3. Tell the client how to call for help if needed - elderly client who feel isolated and unable to obtain help if needed cannot rest properly Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse observes a nursing student assess a client's mobility. The client is lying in the bed and the nursing student asks the client to sit in the chair so the nursing student can complete the assessment. Which of the following responses by the nurse is BEST? 1. Instruct the nursing student to continue the assessment 2. Ask the nursing student to report any difficulties the client may have sitting in a chair 3. Tell the nursing student to begin the assessment while the client is lying in bed. 4. Talk with the nursing student at the completion of the assessment.

3. Tell the nursing student to begin the assessment while the client is lying in bed. - to ensure client safety, begin assessing client's movement when the client is lying in bed, then ask client to sit on side of bed, transfer to the chair, and then observe the client's gait.

The nurse supervises the nursing assistive personnel (NAP) transferring the client from the bed to the chair after a right total hip replacement. The nurse should intervene if which action is observed? 1. The NAP helps the client to a sitting position 2. The NAP positions the chair at a 90degree angle to the bed 3. The NAP stands on the same side of the bed as the client's unaffected side 4. The NAP pivots the client on the unaffected leg

3. The NAP stands on the same side of the bed as the client's unaffected side - should stand on affected side Strategy: "Nurse should intervene" indicates an incorrect action

The nurse cares for a client in acute respiratory distress. The physician initiates mechanical ventilation. Which parameter is MOST important for the nurse to assess immediately following initiation of mechanical ventilation? 1. The respiratory rate 2. The heart rate 3. The blood pressure 4. The oxygen alarm on the ventilator

3. The blood pressure - patient may experience hypotension from decreased cardiac output Strategy: "MOST important" indicates discrimination is required to answer the question.

The nurse cares for the client after a craniotomy. The client's history reveals breast cancer with metastatic lesions to the brain, and the client has received chemotherapy for one month. Post-op, the nurse is MOST concerned if which finding is observed? 1. Urine is foul smelling, and the urine specific gravity is 1.035 2. The client's 24-hour fluid intake is 3,000mL 3. The client's 24-hour urinary output is 4,000mL 4. The client has diarrhea and excoriation of the anal area

3. The client's 24-hour urinary output is 4,000mL - indicates surgically induced diabetes insidious; increased urine output with pale-colored urine and low specific gravity Strategy: Determine the significance of each answer choice and how it relates to a craniotomy

Which of the following would be MOST important for the rehab nurse to assess during a new client's admission? 1. The client's expectation of family members 2. The client's understanding of available support services 3. The client's personal goals for rehab 4. The client's past experiences in the hospital.

3. The client's personal goals for rehab - It is important for the nurse to understand what the client expects from the rehab program for future success.

The nurse cares for the client hospitalized with an acute asthma attack. The nurse is MOST concerned if which finding is observed? 1. The client becomes more diaphoretic 2. The client's respirations increase from 14 to 16 per minute 3. The client's pulse increases from 86 to 100 per minute 4. The client shows increasing pallor.

3. The client's pulse increases from 86 to 100 per minute - pulse increase is due to decrease in oxygenation of tissues I picked 4. The client shows increasing pallor - wrong because subjective symptom, unreliable indicator of deterioration of status Strategy: "MOST concerned" indicates a complication

The nurse prepares an older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on which of the following? 1. The healthcare provider is able to directly observe the renal pelvis 2. An IVP assesses glomerular filtration rate 3. The health care provider is able to examine the urinary tract by x-ray 4. Medication is injected into the urinary system

3. The health care provider is able to examine the urinary tract by x-ray - X-rays of entire urinary tract taken, evaluates kidney function

The nurse performs screening at the local senior citizens' facility. The nurse is MOST concerned if which finding is observed? 1. A 69-year-old client has a slightly elevated systolic blood pressure. 2. The nurse has difficulty palpating an apical pulse on a 74-year-old client. 3. The nurse auscultates an S3 ventricular gallop on a 78-year-old client. 4. An 81-year-old man has a temp of 98.2F (36.7C)

3. The nurse auscultates an S3 ventricular gallop on a 78-year-old client. - ventricular gallop is the earliest sign of HF I picked 2. The nurse has difficulty palpating an apical pulse on a 74-year-old client. - wrong because it's a usual finding for the older adult Strategy: Determine how each assessment relates to an older adult.

The nurse cares for a patient several days after an above-knee-amputation (AKA). Which of the following symptoms are characteristics of an infected residual limb wound? 1. The patient is anxious and restless. 2. There is a small amount of dark drainage on the dressing. 3. The patient complains of persistent pain at the operative site. 4. The skin is cool above the operative site.

3. The patient complains of persistent pain at the operative site. - pain is characteristic of inflammation and infection.

The nurse cares for a client admitted with a diagnosis of acute myocardial infarction. The client's wife tells the nurse that her husband has an anxiety disorder and has been self-mediating with alcohol. It is MOSt important for the nurse to assess for which of the following? 1. Depression, difficulty falling asleep, decreased concentration 2. Elevated liver enzymes, cirrhosis, deceased platelets 3. Tremors, elevated pulse, anxiety, startles easily 4. Flu-like symptoms, diarrhea, night sweats, decreased tendon reflexes

3. Tremor, elevated pulse, anxiety, startles easily - early signs of alcohol withdrawal; begin a few hours after reduction of alcohol intake and peak in 24-48 hours Strategy: Topic of question is unstated

As a part of a disaster drill, the school nurse reacts to an announcement that a "dirty" bomb exploded 4 miles away. According to the disaster plan, which of the following actions should the nurse take FIRST? 1. Move food and water to an interior area in the school 2. Contact parents to immediately pick up their children 3. Turn off the air conditioners and forced-air heating units 4. Encourage the staff and children to remain calm

3. Turn off the air conditioners and forced-air heating units - turn off all units that bring fresh air form the outside; close and lock all doors and windows; move to an inner room or basement

The nurse cares for the client admitted with a diagnosis of myocardial infarction (MI) 36 hours ago. An appropriate nursing diagnosis is "Alteration in cardiac output" related to which team? 1. Mitral valve collapse 2. Endocarditis 3. Ventricular dysrhythmias 4. Hypertensive crisis

3. Ventricular dysrhythmias - most common complication following a myocardial infarction is dysrhythmia, with ventricular types being the most serious. I picked 1. Mitral valve collapse - wrong because not the most common occurrence Strategy: Think about each answer choice

The staff members caring for clients on a large med/surg area learn that mandatory flu vaccinations are available. One week later, the nurse receives a written abstention from a staff member citing religious reasons. Which of the following actions should the nurse take FIRST? 1. Inform the staff member that he has 30 days to comply with the regulation or face suspension or termination 2. Inform the staff member in writing that immunization is required by agency policy. 3. Verbally inform the staff member that not being immunized may determine where the staff member will be allowed to work 4. Inform staff member in writing that protective gear is required when providing client care.

3. Verbally inform the staff member that not being immunized may determine where the staff member will be allowed to work - acknowledges the staff member's rights but emphasizes the clients' right to a safe environment Strategy: "FIRST" indicates priority

The nurse administers dopamine (Intropin) by continuous IV to a client. To evaluate the desired response to the medication, the nurse monitors which of the following? 1. Heart rhythm 2. Central venous pressure 3. Vial signs 4. Daily weights

3. Vital signs - dopamine is indicates for correction of hemodynamic instability as a result of shock, monitoring vital signs provides most appropriate info regarding effects of drug Strategy: Think about how each assessment relates to dopamine

The client diagnosed with peripheral artery disease (PAD) talks with the nurse. The client reports leg pain frequently when walking. The nurse should advise the client to take which action? Select all that apply. 1. Lie down with feet elevated above the heart when experiencing pain. 2. Apply a heating pad to his legs for 15 minutes before walking. 3. Walk until pain begins, then rest, and then resume walking. 4. Perform stretching exercises 20 minutes before starting to walk. 5. Start a smoking cessation program. 6. Apply cool packs before walking.

3. Walk until pain begins, then rest, and then resume walking - exercise increases collateral circulation, should be encouraged 5. Start a smoking cessation program - smoking decreases circulation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The adult granddaughter of a patient diagnosed with moderate Parkinson's disease tells the nurse about the ideas she has come up with for gifts for her grandmother's birthday in 2 weeks. The granddaughter asks the nurse which idea is best. Which of the following is the BEST gift for the nurse to support? 1. Perfume and make-up 2. Hearing aid with batteries 3. Warming tray for food 4. Quilt and soft pillow

3. Warming tray for food - warming trays can keep food hot, safe, and appealing during the slow eating process of the Parkinson's patient; eating is slow because of overall slowed body movement, tremors, difficulty chewing and swallowing, fatigue, need for rest periods; this choice directly addresses a physiologic need Strategy: "BEST" indicates that discrimination is required to answer the question

The 20-year-old primipara attends a class for women who plan to breast feed. To prepare for breast feeding, the nurse should encourage the woman to perform which implementation? 1. Apply moisturizer to the breasts every day after bathing 2. Expose the breasts to air every day for 20 minutes. 3. Wash breasts with water only 4. Massage the breasts to increase circulation twice daily.

3. Wash breasts with water only - soap avoided to prevent drying I picked 4. Massage the breasts to increase circulation twice daily. - wrong because could cause breast tissues to become tender. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The elderly adult is admitted to a medical unit with shortness of breath and is diagnosed with an upper respiratory infection (URI). The client is placed on droplet precautions. The nurse administers oral medications to the client. As the nurse leaves the room, the nurse should take which action? 1. Wash hands, remove the gown and mask, and throw the trash in a container outside of the room. 2. Remove the mask, wash hands, and throw the trash in a container inside the room. 3. Wash hands, remove the mask, and throw the trash in a container inside the room. 4. Remove the gown and gloves, wash hands, remove the mask, and throw the trash in a container inside the room.

3. Wash hands, remove the mask, and throw the trash in a container inside the room. - hands should be washed before removing mask to prevent transfer of microbes to face I picked 1. Wash hands, remove the gown and mask, and throw the trash in a container outside of the room - gown unnecessary, trash should be left inside room Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for the client diagnosed with active tuberculosis (TB). It is MOST important for the nurse to take which action? 1. Restrict visitors to immediate family only 2. Wear a gown and gloves at all times 3. Wear a mask and gloves when in direct contact with the client 4. Dispose of waste articles more frequently

3. Wear a mask and gloves when in direct contact with the client - airborne precautions required Strategy: "MOST important" indicates priority

The physician has ordered digoxin (Lanolin) 0.02 mg/kg PO in divided doses for a 4-month-old infant. When the nurse checks the sleeping child's heart rate, it is regular at 80 bpm. The nurse should take which of the following actions? 1. Stimulate sole of the infant's foot to recheck heart rate 2. Give the med as ordered and document the heart rate in the chart. 3. Withhold the med and immediately notify the physician 4. Ask another nurse to recheck the infants heart rate

3. Withhold the med and immediately notify the physician - withhold the med if rate is below 90-110 for child; excessive slowing of beats indicate digitalis toxicity I picked 1. stimulate sole of the infant's foot to recheck heart rate - wrong because medication is given according to resting heart rate; should not stimulate child Strategy: Determine the outcome of each answer

The nurse cares for a patient during a radium implant. During the removal of the implant, it is MOST important for the nurse to take which of the following actions? 1. Clean the radium implant carefully w/ a disinfectant (alcohol or bleach) using long forceps 2. Handle the radium carefully using forceps and rubber latex gloves 3. Chart the date and time of removal together w/ the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.

3. chart the date and time of removal together w/ the total of implant treatment. - important that accurate documentation be maintained on the internal radium implant.

The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section? 1. contains a lower overall dosage of medication than is given before general surgery. 2. contains lower amounts of sedatives and hypnotics than are given before general surgery. 3. contains lower amounts of narcotics than are given before general surgery. 4. contains medications similiar in type and dosages to those given before general surgery.

3. contains lower amounts of narcotics than are given before general surgery. - decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant. I picked 4. contains medications similiar in type and dosages to those given before general surgery. Wrong because dosages of narcotics are reduced Strategy: Think about the action of the medications

The nurse instructs a client about how to use crutches. Which of the following observations indicates to the nurse that teaching is successful? 1. The client bears weight under the arm in the axillary area 2. The crutches are placed about 18-20 inches in front of the body with each step 3. The weight of the body is transferred to the hands and the arms 4. The client wears leather-soled shoes

3. the weight of the body is transferred to the hands and the arms - arms should be bent at a 35 degree angle, eight should be placed on hands and arms Strategy: "Teaching is successful" indicates correct info

The nurse administers carbamazepine (Tegretol) to a client for trigeminal neuralgia (tic douloureux). The nurse knows that the therapuetic effect of this medication is to 1. relieve accompanying depression 2. reduce the possibility of grand mal seizures 3. relieve the agonizing pain 4. provide sedation effects

3. relive the agonizing pain - agonizing pain of tic douloureux may result in severe depression and suicide; Tegretol inhibits nerve impulses and reduces the pain of the condition Strategy: Think about each answer

The neonatal nurse instructs the family of a newborn about an apnea monitor. The nurse is MOST concerned if a family member makes which statement? 1. "We will be able to leave our baby for brief periods of time." 2. "We plan to sleep by our baby's crib." 3. "We can remove the monitor during our baby's bath." 4. "A family member will closely watch the monitor all the time."

4. "A family member will closely watch the monitor all the time." - indicates a feeling that monitor may not let them know if their infant stops breathing Strategy: "MOST concerned" indicates that you are looking for an incorrect statement.

A pregnant woman tells the nurse in the prenatal clinic that she received a push-pull toy as a present for her unborn child. She asks the nurse when this toy would be appropriate for her child. Which of the following responses by the nurse is BEST? 1. "A push-pull toy is good for a 3-6-month-old infant." 2. "A push-pull toy is good for a 10-12-month-old infant." 3. "A push-pull toy is good for a 12-15-month-old infant." 4. "A push-pull toy is good for an 18-21-month-old infant."

4. "A push-pull toy is good for an 18-21 month-old infant" - able to walk and begin to coordinate movements Strategy: Think about each answer

The nurse performs discharge teaching for a client who had coronary artery bypass graft (CABG). The nurse knows that teaching a successful if the client states which of the following? 1. "I may have a moderate amount of bloody drainage from the incision after I go home." 2. "I will have an elevated temperature and excessive fatigue for about one month." 3. "I will have moderate pain and tenderness of the incision sites for 2-4 weeks after the surgery." 4. "After I go home, I may see some swelling in the leg used for the donor graft."

4. "After I go home, I may see some swelling in the leg used for the donor graft." - edema increases at home because client is usually more active I picked 3. "I will have moderate pain and tenderness of the incision sites for 2-4 weeks after the surgery." - wrong because minimal incisional pain and tenderness may occur for 6-12 weeks after surgery Strategy: "Teaching is successful" indicates correct information

A father brings his 15-month-old son to the well-baby clinic for a routine checkup. The father confides to the nurse that he is concerned that his son still crawls and does not walk. Which response, if made by the nurse to the father, is BEST? 1. "I will refer you to the pediatric specialist if he doesn't start walking soon." 2. "Have you noticed any signs of paralysis or weakness in your son?" 3. "Try standing him on his feet several times a day." 4. "Children frequently set their own pace for development."

4. "Children frequently set their own pace for development." - children are individuals Strategy: "BEST" indicates priority

The nurse prepares a client for a barium enema. It is MOST important for the nurse to include which of the following instructions? 1. "Your stool will be light-colored for 2 to 3 days after the test." 2. "Once the test is over and you go to the toilet, you will be able to resume normal activities." 3. "The x-ray table will be tilted so you can assume various positions." 4. "During the test, it is crucial that you take slow, deep breaths through your mouth."

4. "During the test, it is crucial that you take slow, deep breaths through your mouth." - for test to be successful, client must retain barium; as barium is introduced, client may have the urge to defecate; slow, deep breathing will help ease the discomfort Strategy: "MOST important" indicates priority

The nurse observes that two staff members have been in frequent conflict for the last several weeks. The nurse decides to schedule a meeting with both staff members after observing them argue while putting a client back to bed. When meeting with the staff members, which of the following strategies by the nurse is MOST appropriate? 1. "One ground rule guiding this discussion is no negative comments are allowed." 2. "One of you will speak first, and the other person will refrain from commenting until the first person is done." 3. "I am here to listen. My expectation is for the two of you to work this out." 4. "Each of you will summarize what you hear the other person saying. The other person will then validate the summary."

4. "Each of you will summarize what you hear the other person saying. The other person will then validate the summary." - enhances communication; each party is actively listening and hears the other person's perspective Strategy: "MOST appropriate" indicates discrimination is required to answer the question

A family member of the client who has sustained an electrical burn states, "I don't understand why my sibling has been here a week. The burn does not look that bad." Which response by the nurse is BEST? 1. "Electrical burns are more prone to infection." 2. "Electrical burns are always much worse than they look on the outside." 3. "Cardiac monitoring is important because electrical burns affect cardiac function." 4. "Electrical burns can be deceptive because underlying tissue is also damaged."

4. "Electrical burns can be deceptive because underlying tissue is also damaged." - electrical burn injuries are typically more injurious to underlying tissue, such as nerve and vascular tissue, which require complex and timely treatment. I picked 3. "Cardiac monitoring is important because electrical burns affect cardiac function." - wrong because is true in the immediate post-burn phase, not a week later. Strategy: Determine which statement correctly states the facts.

The nurse leads a family therapy session for the family of an adolescent diagnosed with depression. During the first session, the teen's mother dominates the discussion. Which of the following responses by the nurse is MOST appropriate? 1. "Please let some of the other family members speak." 2. "You appear to be frustrated about dealing with your teen." 3. "You and I will speak privately after the session is over." 4. "How do the rest of you feel about what your Mother is saying."

4. "How do the rest of you feel about what your Mother is saying." - allow each member of group to offer feedback about the effect the mother's monopoly of the session has on each person. Strategy: Remember therapeutic communication

The nurse in the pediatric clinic receives a phone call from a mother who says, "My 10y/o has a nosebleed that won't stop bleeding even though I have applied pressure." Which of the following responses by the nurse is MOST important? 1. "Place pressure on the nose using an ice-cold washcloth." 2. "How much bleeding has occurred?" 3. "Instruct your child not to blow his nose." 4. "How long have you applied pressure?"

4. "How long have you applied pressure?" - assess before implementing; initially, should apply direct pressure for 5-10 minutes continuously; if this is ineffective, may require treatment with silver nitrate applicator and Gelfoam I picked 1. "Place pressure on the nose using an ice-cold washcloth." - wrong because it is appropriate action; nurse needs to first complete assessment Strategy: "MOST important" indicates priority

The nurse from the medical unit is floated to the psychiatric unit. During medication administration, a patient yells at the nurse, "You are a terrorist with poison pills!" Which of the following responses by the nurse is BEST? 1. "I am not a terrorist" 2. "Is it your feeling that I am trying to poison you?" 3. "This is your medication, which you have to take now." 4. "I am a nurse from another unit in this hospital."

4. "I am a nurse from another unit in this hospital" - reality orientation; addresses patient's concern without reinforcing delusion Strategy: "BEST" indicates discrimination is required to answer the question

The nurse in the community mental health center talks individually with a patient who is diagnosed with generalized anxiety disorder and who has been attending center programs for 4 months. Which of the following statements, if made by the patient to the nurse, BEST indicates that the anxiety is resolving? 1. "I have stopped biting my nails and picking at my skin." 2. "When things get to be too much, I go into my room." 3. "I still get anxious, but it does not last as long." 4. "I am sleeping 7 hours a night and my dreams are calm"

4. "I am sleeping 7 hours a night and my dreams are calm" - CORRECT—indicates major resolution of anxiety as the sleeping and dreaming both reflect and affect body, mind, and spirit and are not conscious processes; in anxious states, insomniac symptoms of disturbed sleep pattern, sleep deprivation, fatigue are common; intrusive thoughts, worrying, fear, and/or replaying traumatic events contribute to difficulty falling asleep and/or staying asleep

The client is diagnosed with myasthenia graves. The nurse instructs the client about the disease. Which statement, if made by the client to the nurse, indicates the need for further teaching? 1. "I should not drink alcoholic beverages." 2. "I should not go places that are crowded." 3. "I should try to stay calm." 4. "I should use my hot tub daily."

4. "I should use my hot tub daily." - should avoid heat (sauna, hot tubs, sunbathing) Strategy: "Need for further teaching" indicates you are looking for an incorrect statement

A client comes to the outpatient clinic for evaluation of a possible basal cell carcinoma of the nose. The nurse should consider which of the following client statements significant? 1. "I am a meet cutter at the local packing plant." 2. "My hobby is raising Great Danes." 3. "My parents came from Sicily." 4. "I spend weekends sailing with my family."

4. "I spend weekends sailing with my family." - exposure to sun increases risk of skin cancer; use sunscreen with SPF (solar protection factor) to block harmful rays (especially important for children); reapply sunscreen after swimming or prolonged time in sun; use lip balm with sunscreen protection; yeah client to examine skin surfaces monthly Strategy: Think about the client's words

The nurse conducts a class at a senior citizen center on the changes associated with aging. The nurse is MOST concerned if the client makes which statement? 1. "I seem to get colds more often now than I did years ago." 2. "I'm about an inch shorter now than I was when I was working." 3. "I don't mind cooking, but eating doesn't appeal to me much anymore." 4. "I've been sleeping with fewer blankets over me lately."

4. "I've been sleeping with fewer blankets over me lately." - usually becomes intolerant to cold Strategy: "MOST concerned" indicates something wrong. Think about the answer choices and how each relates to aging

The nurse prepares for discharge a client with newly diagnosed diabetes. The client is on a regimen of regular and NPH insulin. Which of the following statements, if made by the client to the nurse, indicates that teaching is successful? 1. "I will take the bottles out of the refrigerator and shake them thoroughly before I withdraw the medication." 2. "I will stick with the same types and sources of insulin, but I will stock up whatever insulin syringes I can find on sale." 3. "If I see that the injection site becomes red, itchy, and swollen, I will contact the physician immediately." 4. "I will put tape with a '1' on it on the regular insulin bottle and tape with a '2' on it on the NPH insulin bottle."

4. "I will put tape with a '1' on it on the regular insulin bottle and tape with a '2' on it on the NPH insulin bottle." - if insulins are to be mixed, the regular or short-acting insulin should be withdrawn first and then the NPH or intermediate-acting; "1" and "2" will remind of the order in which the insulins should be withdrawn Strategy: Determine the outcome of each answer. Is it desired?

During administration of oral medication to an elderly, confused client, the client states, "These pills look funny. They belong to the lady down the hall." Which is the BEST response by the nurse? 1. "Your health care provider has ordered new medication for you. They will help you get well." 2. "Remember yesterday when I brought your medication? They look the same." 3. "I'll explain why you are receiving these medications." 4. "I'll be back after I check your medication again."

4. "I'll be back after I check your mediation again." - even confused client should have his/her medication rechecked when there is any possibility of an error; always observe the six rights of medication administration Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

A staff member working in the newborn nursery reports to the nurse that even though they do not feel bad, they have had loose stools for the last couple of days. Which response by the nurse is BEST? 1. "Make sure you wash your hands after going to the bathroom." 2. "Are you drinking plenty of fluids?" 3. "Describe to me how you are feeling." 4. "I'm going to reassign you to the orthopedics."

4. "I'm going to reassign you to the orthopedics." - Restrict from care of newborn, infants, or immunocompromised clients Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No Determine the outcome of each implementation

The nurse cares for patients in labor and delivery. A primipara woman asks the nurse when she is going to deliver. The chart reveals at 0800 the client's cervix is 5 cm dilated, 100% effaced, and the head is at +1 station. The client is having regular contractions and labor has progressed without incident. Which of the following responses by the nurse is MOST appropriate? 1. "Every labor is different. It is impossible to predict when you will deliver." 2. "Because you are a first-time mom, your progress should be a 1-1.2 cm per hour and up to 3 hours of pushing" 3. "You are making nice progress in your labor. It should be within the next few hours." 4. "If your labor continues to progress as it has, you might deliver between 2 and 4 pm."

4. "If your labor continues to progress as it has, you might deliver between 2 and 4 pm" - answers the client's question; can't predict exact time of delivery but can speculate based on Friedman's labor curve Strategy: "MOST appropriate" indicates discrimination is required to answer the question

The nurse in the outpatient clinic cares for a client diagnosed with peptic ulcer disease (PUD) and gout. Which of the following orders, if written by the physician, should the nurse question? 1. "Colchicine (Colsalide) 1mg q 2 hours until cumulative dose of 8mg achieved." 2. "Allopurinol (Aloprim) 100 mg daily" 3. "Probenecid (Benemid) 250 mg BID." 4. "Indomethacin (Indocin) 50 mg QID."

4. "Indomethacin (Indocin) 50 mg QID" - nonsteroidal anti-inflammatory; use cautiously in clients with peptic ulcer disease Strategy: Think about the side effects of each drug

The health care provider prescribes estrogen daily for the middle-aged woman. Which statement, if made by the client to the nurse, indicates further teaching is necessary? 1. "There may be a change in my libido because of this med." 2. "I may have a change in my weight while taking this med." 3. "I may have some difficulty wearing my contact lenses because of this med." 4. "It is unnecessary for me to perform routine self-breast exams while I am taking this med." 5. "I am glad I do not have to stop smoking."

4. "It is unnecessary for me to perform routine self-breast exams while I am taking this med." - should continue to perform monthly self-breast exams 5. "I am glad I do not have to stop smoking." - smoking and this med will increase risk of CV complications. Client should be encouraged to stop smoking I also picked 3. - wrong because it will cause dryness of eyes Strategy: "Further teaching is necessary" indicates the wrong info

A patient is admitted to the psychiatric unit with a diagnosis of schizophrenia. The patient verbalizes to the nurse, "Someone wants to kill me tonight." Which of the following responses by the nurse is BEST? 1. "No one wants to kill you." 2. "Why do you think that?" 3. "Someone does not know you have been admitted." 4. "It must feel frightening to think someone is trying to kill you."

4. "It must feel frightening to think someone is trying to kill you." - focus on the feelings the delusions generate; avoid arguing about the content of the delusion; once a patient describes the delusion, do not dwell on it. Strategy: Remember therapeutic communication

The home care nurse visits a client receiving enteral feeding through a gastrostomy tube. The client's wife says that the client has been having frequent loose stools. The nurse is MOST concerned if the wife states which of the following? 1. "I give him 300 ml of formula in 45 minutes." 2. "The formula is warmed in a basin of hot water." 3. "I use a new bag and tubing every day." 4. "It's so easy to give liquid medicine through the tube."

4. "It's so easy to give liquid medicine through the tube." - liquid medication may contain sorbitol; if client has allergy to sorbitol, will cause diarrhea; nurse should further assess Strategy: "MOST concerned" indicates something is wrong

The nurse in the pediatric clinic makes a follow-up call to the mother of a school-aged child diagnosed the previous day with rubella (German measles). Which statement by the mother should the nurse respond to FIRST? 1. "My sister-in-law is coming to visit next week. She just found out that she is pregnant." 2. "I have heard measles can cause serious complications. I do not know how to protect my child." 3. "My child is so upset about missing the class trip. It is my fault for not having my child immunized." 4. "My child feels very warm. I am going to give my child some aspirin to decrease the fever."

4. "My child feels very warm. I am going to give my child some aspirin to decrease the fever." - can cause Reye's syndrome; acetaminophen is effective in reducing fever and is the preferred antipyretic for children. Strategy: "FIRST" indicates priority

Which statement by the client indicates to the nurse that the client has an accurate understanding of the cause of anxiety? 1. "When I get overly tired from working too hard, I begin to have severe headaches and nausea." 2. "I'm losing my mind. I can't think straight." 3. "My chest pounds and I can't catch my breath. I must be having a heart attack." 4. "Now that my mother has died, I've been thinking a lot about the way she abused me. I feel very tense and sick."

4. "Now that my mother has died, I've been thinking a lot about the way she abused me. I feel very tense and sick." - anxiety is often expressed as physical symptoms and can be triggered by situations in adult life that reawaken feelings of anger or anxiety unresolved from childhood Strategy: Think about what the words mean

The nurse visits the client at home receiving carbidopa-levodopa. Which statement, if made by the nursing assistive personnel to the nurse, indicates that the medication is effective? 1. "The client's weight increased by 2 lb" 2. "The client is getting over an upper respiratory infection" 3. "There is an increase in the fine motor tremors." 4. "The client seems to be more ambulatory."

4. "The client seems to be more ambulatory" - is no cure for these symptoms, but carbidopa-levodopa (Sinement) does reduce the rigidity and tremors, which facilitates mobility for the client. I picked 1. "The client's weight increased by 2 lb" - wrong because not result of the medication Strategy: Determine how each answer choice relates to Sinemet.

While the 2-day-old infant is in surgery for repair of spina bifida, the infant parent expresses concern to the nurse because the health care provider said the infant would be confined to a wheelchair. Which statement, if made by the nurse, is BEST? 1. "Physical therapy can restore the function to affected muscles." 2. "Orthopedic devices will allow your child to strengthen lower extremity muscles." 3. "Corrective surgery will return function to the affected muscles." 4. "The corrective surgery will not change your child's physical disability."

4. "The corrective surgery will not change your child's physical disability." - spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele. Strategy: Determine the outcome of each answer choice.

The parents bring their 18-month-old into the ED. The nurse notes that the child is having difficulty breathing and appears to be wheezing on inspiration. It is MOST important for the nurse to ask the parents which of the following questions? 1. "Is your child's immunization schedule current?" 2. "Do you or the child's brothers or sisters have a history of asthma?" 3. "What toy does your child like playing with the most?" 4. "Was your child eating a hot dog immediately before developing breathing problems?"

4. "Was your child eating a hot dog immediately before developing breathing problems?" - toddlers are in danger of aspirating large pieces of meat and hot dogs, as well as nuts, dried beans, chewing gum; if children offered hot dogs, cut into small, irregular shapes I picked 2. "Do you or the child's brothers or sisters have a history of asthma?" - wrong because wheezing usually occurs with expiration Strategy: "MOST important" indicates priority

The middle of the evening shift on the inpatient psychiatric unit is unusually hectic, with a large census, high acuity level, three admissions in two hours, and a fourth admission on the way. The unit secretary goes down to the emergency department to get some needed paperwork for one patient. When she gets back to the unit, she angrily and repeatedly exclaims about the ongoing rudeness of the emergency department staff, including their not providing the necessary documents. She states, "I am going home!" and starts to go toward the coatroom. What is the BEST response by the charge nurse? 1. "Take a deep breath. Give it some thought and let me know what you decide." 2. "You must stay here and do your job. If you leave, that will be insubordination." 3. "Calm down. Overreacting does not do you or anyone else any good." 4. "We are not the ones who were rude to you. Do not leave us, because we need you."

4. "We are not the ones who were rude to you. Do not leave us, because we need you." - priority is getting through the immediate situation on the unit; points out reality; conveys genuineness, empathy, and positive regard, factors that help people to grow; accepts secretary's judgment and does not set up conflict by disagreeing or challenging by choice of words Strategy: "BEST" indicates that discrimination is required to answer the questions

A middle-aged woman is brought to the ED by family. The patient reports to the nurse that yesterday morning her legs were tingling. She also states that when she got out of bed, her lower legs felt unusually weak. Now it seems that the weakness is progressing upward. The patient states, "I'm scared. I can't imagine what is wrong with me. I have always been in good health." Which of the following statements by the patient is MOSt important for the nurse to pursue during the assessment process? 1. "My grandfather had polio when he was young." 2. "I have been a vegetarian for several months now." 3. "Things have been stressful at work lately." 4. "We have been in the final preparations for a trip overseas."

4. "We have been in the final preparations for a trip overseas." - needs immediate further investigation; immunizations may have been given in preparation for this trip, depending on where the couple was to travel; trauma, surgery, acute illness, or immunizations often precede the onset of the neuralgic symptoms of Guillain-Barre syndrome; symptom onset in Guillain-Barré is usually abrupt and can progress rapidly; symptoms usually, but not always, progress in an ascending direction; it is seen as an emergency condition and the patient is placed in intensive care unit; most immediate concern is potential respiratory compromise from respiratory muscle weakness; examples of immunizations that may be given for travelers are DPT, yellow fever, typhoid, plague, meningococcal pneumonia, hepatitis A, cholera, BCG for tuberculosis immunity; what is given depends on whether the travel is to a country where the disease is endemic

The mental health nurse gives a seminar on acute grief reaction to volunteers of a mobile disaster unit. Which of the following statements, if made by one of the volunteers to the nurse, indicates the need for further teaching? 1. "We can expect people to react in different ways based on their cultural background." 2. "If we come upon a lone survivor, we should stay with the person until help arrives." 3. "We can expect that someone might accuse us of causing the death." 4. "We should not allow a survivor to assist us in our duties."

4. "We should not allow a survivor to assist us in our duties." - if survivor able to assist, activity can help relieve acute discomfort Strategy: "Need for further teaching" indicates incorrect information

The young adult comes to the outpatient clinic reporting vaginal itching. Which recommendation, if given to the client by the nurse, is appropriate? Select all that apply. 1. "Supplement your diet with yogurt and dairy products." 2. "Douche with an over-the-counter preparation." 3. "Wash the area with soap and water several times a day." 4. "Wear underwear that is lined with a cotton crotch." 5. "Refrain from sexual intercourse for a week after starting treatment." 6. "You should take your medication until is it all gone."

4. "Wear underwear that is lined with a cotton crotch." - more absorbent; allows for better circulation of air to body; dampness aggravates itching 5. "Refrain from sexual intercourse for a week after starting treatment. - decreases complication such as PID 6. "You should take your med until it is all gone." - completion of all meds decreases risk of re-infection Strategy: All answers choices are implementations. Determine the outcome of each answer. Is it desired?

The client is diagnosed with otosclerosis and is admitted for a stapedectomy. It is MOST important for the nurse to ask which question? 1. "Have you noticed fluid draining from your left ear?" 2. "Have you had problems hearing for your entire life?" 3. "Did you require speech therapy when you were a child?" 4. "When did you notice that your hearing was impaired?"

4. "When did you notice that your hearing was impaired?" - otosclerosis occurs gradually over many years; often client is not aware of it until the impairment is significant Strategy: Determine how each answer relates to otosclerosis

The parents of a 4y/o girl bring their child to the ED. The parents state that the child has been complaining of abdominal pain, is nauseated and vomiting, and refuses to eat. The nurse knows it is flu season. It is MOST important for the nurse to ask the parents which of the following questions? 1. "Did your child have the flu shot this year?" 2. "What new foods has your child been eating lately?" 3. "How long has your child been feeling like this?" 4. "Which came first: the pain, or the nausea and vomiting?"

4. "Which came first: the pain, or the nausea and vomiting?" - the sequence of symptoms is the most reliable information from the history when assessing for possible appendicitis; the clinical symptoms with acute appendicitis are similar to those of many other medical conditions; in acute appendicitis, the pain usually comes prior to nausea and vomiting; nausea and vomiting that come before pain frequently indicates gastroenteritis. Strategy: "MOST important" indicates that discrimination is required to answer the question

The client on suicide precautions asks for a razor to shave her legs. When the nurse tells the client that she must remain with the client, the client responds, "Don't you trust me?" Which response by the nurse is BEST? 1. "It is against hospital policy to allow clients on suicide precautions to have razors unsupervised." 2. "I trust you, but your health care provider said a nurse has to watch you if you want to shave your legs." 3. "Wouldn't you rather wait until you are feeling better before you try to shave your legs?" 4. "You have been having thoughts about wanting to hurt yourself recently, so I'll stay with you."

4. "You have been having thoughts about wanting to hurt yourself recently, so I'll stay with you." - provides client with factual information in a caring manner I picked 1. "It is against hospital policy to allow clients on suicide precautions to have razors unsupervised." - true statement but not the most therapeutic Strategy: Remember therapeutic communication

The client has surgery for cancer of the colon, and a colostomy is established. Before discharge, the client tells the nurse that swimming will no longer be allowed. Which response by the nurse is correct? 1. "You should begin looking for other areas of interest." 2. "You will have to wear a watertight dressing over the stoma." 3. "You cannot go into water that covers the stoma area." 4. "You may resume all previous activities."

4. "You may resume all previous activities." - all activities that the client participated in before the colostomy may be resumed after appropriate healing of the stoma or incisions Strategy: Determine the outcome of each answer choice. Is it desired?

The nurse on postpartum prepares four clients for discharge. It is MOST important for the nurse to refer which client on home care? 1. A 15y/o who vaginally delivered a 7-lb male 2 days ago 2. An 18y/o multipara who delivered a 9-lb female by cesarean section 2 days ago 3. A 20y/o multipara who delivered 1 day ago and is complaining of cramping 4. A 22y/o who delivered by cesarean section and is complaining of burning on urination

4. A 22y/o who delivered by cesarean section and is complaining of burning on urination - unstable client, indicates UTI; requires follow-up Strategy: Eliminate the most stable clients

The nurse teaches the mother of an infant about how to care for her infant following repair of a cleft lip. It is MOST important for the nurse to include which of the following instructions? 1. "Feed the infant with a newborn nipple while holding him in the recumbent position." 2. "Clean the suture site with a cotton-tipped swab soaked in Betadine." 3. "Place the infant in the prone position after feeding." 4. "Feed the infant with a rubber-tipped syringe and bubble frequently."

4. "feed the infant with a rubber-tipped syringe and bubble frequently." Strategy: Determine the outcome of each answer. Is it desired?

The nurse leads a parenting class for a group of expectant mothers. The nurse should advise that the breast-feeding mother should increase her daily caloric intake by how many calories? 1. 200 2. 300 3. 400 4. 500

4. 500 - Milk production requires an increase of 500 calories/day

The nurse cares for a client admitted w/ a diagnosis of CVA and facial paralysis. Nursing care should be planned to prevent which of the following complications? 1. Inability to talk 2. Loss of gag reflex 3. Inability to open the affected eye 4. Corneal abrasion

4. Corneal abrasion - Client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect eye.

The nurse reviews records and determine which of the following clients is at highest risk for developing pneumonia? 1. A 15y/o client diagnosed with cystic fibrosis. 2. A 36y/o client who has smoked for 18 years. 3. A 57y/o client diagnosed with hypertension 4. A 78 y/o client diagnosed with colon cancer.

4. A 78y/o client diagnosed with colon cancer - advancing age and immunosuppressed status are risk factors I picked 1. A 15y/o client diagnosed with cystic fibrosis - wrong because risk factors for pneumonia include advanced age, underlying lung disease, bedridden, and post; has one risk factor Strategy: Think about each answer

The nurse cares for children at summer camp. Which of the following children presenting at the infirmary should the camp nurse see FIRST? 1. A child diagnosed with hemophilia who is complaining of a headache and has slurred speech. 2. A child diagnosed with type 1 diabetes who is nervous, pale, and sweating. 3. A child diagnosed with asthma who is complaining of a sore throat and restlessness. 4. a child diagnosed with leukemia was stung by a bee and is complaining of feeling hot and itchy all over.

4. A child diagnosed with leukemia was stung by a bee and is complaining of feeling hot and itchy all over. - probable sign of anaphylactic reaction, which can proceed quickly to loss of consciousness, angioedema, bronchiolar constriction, pulmonary edema. I picked 3. A child diagnosed with asthma who is complaining of a sore throat and restlessness - wrong because potential problem; inflammation contributes to airways becoming more reactive; colds and infections can precipitate and/or aggravate asthmatic exacerbations; restlessness can indicate anxiety, respiratory difficulty, boredom, etc Strategy: Remember the ABCs

The nurse cares for clients on the med/surg floor. Because of a staffing shortage, an RN has been reassigned from postpartum. Which of the following clients should the nurse give to the reassigned nurse? 1. A client admitted with facial trauma after an auto accident 2. A client diagnosed with a heart stroke 3. A client having a systemic reaction to latex 4. A client with progressive systemic sclerosis experiencing Raynaud's phenomenon

4. A client with progressive systemic sclerosis experiencing Raynaud's phenomenon - chronic connective tissue disease that caused inflammation, fibrosis, and sclerosis of the skin and vital organs; stable client who can be assigned to the reassigned RN Strategy: Assign stable client with expected outcomes

The nurse in the outpatient clinic plans care for the older client with left-sided weakness due to a stroke. The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to increase which implementation? 1. Calcium in the daily diet 2 Vitamin D in the daily diet 3. Time of exposure to sunlight 4. Activities that involve weight bearing

4. Activities that involve weight bearing - weight bearing and exercise primary ways to develop high-density bones, decrease bone reabsorption and stimulate bone formation; would also help maintain mobility with left-sided weakness I picked 1. Calcium in the daily diet - wrong because diet should have adequate calcium, should increase intake in middle age to protect against skeletal demineralization; not most important Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired?

A client diagnosed w/ biopolar disorder is in a manic phase w/ combative behavior. Which of the following is the INITIAL priority nursing action? 1. Provide adequate hygiene and nutrition 2. Decrease environmental stimuli 3. Slowly involve client in unit activities 4. Admin and monitor sedative and mood-stabilizing meds

4. Admin and monitor sedative and mood-stabilizing meds - is the most important to gain control w/ a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention w/ both sedative meds and mood-stabilizing agents.

The nurse knows which of the following would have the greatest impact on an elderly client's ability to complete activities of daily living (ADLs)? 1. Perseveration 2. Aphasia 3. Mnemonic disturbance 4. Apraxia

4. Apraxia - Apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly.

The nurse assess a newborn just delivered by a mother who received no prenatal care and was unsure when she became pregnant. Which of the following assessments indicates to the nurse that the infant is pre-term? 1. Lanugo noted on upper back and shoulders 2. Elbow creases contain vernix 3. Nipple bud measures 0.5cm 4. Arms and legs extended at rest

4. Arms and legs extended at rest - extremities are flexed in a term infant at rest; in preterm infant, extremities are in extension Strategy: Think about each answer

For the past 3 days, an 8-year-old child has come to the school nurse's office complaining of "stomachaches." The school nurse notes that the abdominal pain subside when the child overhears the nurse contact the child's parent at work. It is MOST important for the nurse to take which of the following actions? 1. Ask the child what the child eats for breakfast and dinner 2. Ask the child to describe life at home 3. Report this event to social services 4. Ask the parents how the child behaves prior to school

4. Ask the parents how the child behaves prior to school - needs to validate anxiety, especially separation anxiety; chid may be worrying about parents and is relieved when nurse talks to the parent Strategy: "MOST important" indicates discrimination is required to answer the question

The nurse cares for clients on the psychiatric unit. A client beings to pace and continuously wrings his hands, and the nurse notes that the client's voice is becoming increasingly louder and angrier. Which of the following actions should the nurse take FIRST? 1. Utilize an organized team to place the client in seclusion 2. Leave the client alone in his room 3. Redirect the client to a quiet activity 4. Assist the client to express feelings of anger and frustration

4. Assist the client to express feelings of anger and frustration - help client to verbalize feelings; avoid disagreeing with or threatening patient; remove threatening objects or people Strategy: "FIRST" indicates priority

The 20-year-old, gravida 1, para 0 woman comes to the clinic for her first routine prenatal exam. During the physical assessment, the client informs the nurse that she is unsure of the date of her last menstrual period. Which assessments would best assist the nurse in determining her expected date of confinement (EDC)? 1. The presence of Hegar's sign 2. A positive pregnancy test 3. The presence of quickening 4. Auscultation of the fetal heartbeat

4. Auscultation of the fetal heartbeat - fetal heartbeat can be heard at 12 weeks; is a positive sign of pregnancy Strategy: Determine how each answer choice relates to determining the EDC

The nurse cares for a client following a right adrenalectomy. During the immediate postoperative period, it is MOST important for the nurse to observe for which finding? 1. Fluid and electrolyte imbalance 2. Temp fluctuation 3. Resp atelectasis 4. B/P alteration

4. B/P alteration - decrease in blood pressure may indicate shock Strategy: Remember the ABCs

The school nurse attends a class outing with a group of sixth-graders. One of the children falls from a tree, and the nurse suspects that the child's leg is broken. Which of the following actions should the nurse take FIRST? 1. Contact the child's parent 2. Instruct the child not to move 3. Send a teacher to obtain padded splints 4. Bandage the child's legs together

4. Bandage the child's legs together - priority is to prevent further injury to the leg; adequate splinting includes splinting the join above and below the fracture; uninjured leg can be used as a splint I picked 2. Instruct the child not to move - wrong because it is important to prevent movement that may cause further injury to the leg; priority is splinting the leg Strategy: "FIRST" indicates priority

A client w/ clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOSt appropriate nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV meds 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing 3. Restart the IV and continue the previous med schedule 4. Call the physician and recommend the IV meds be changed to PO.

4. Call the physician and recommend the IV meds be changed to PO. - before a new IV is started on this client, physician should be called and PO meds recommended.

The nurse cares for clients in a drug rehab facility. Which of the following complications of IV drug abuse is the nurse MOST likely to observe? 1. Jaundice 2. Rash 3. Bruising 4. Cellulitis

4. Cellulitis - Most narcotic addicts do not inject sterile purified material w/ aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus.

The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day post-op tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions? 1. Direct the LPN/LVN to obtain the child's vital signs 2. Ask the mother if the child's sutures are still intact 3. Tell the nursing assistant to take the child for a walk 4. Check to see when the child last received pain med

4. Check to see when the child last received pain med - young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observed

The nurse cares for clients in the medical clinic. A nursing assessment of a client w/ a hiatal hernia is MOST likely to reveal which of the following? 1. A bulge in the LRQ 2. Pain at the umbilicus radiating down into the groin 3. A burning sensation in the midepigastric area each day before lunch 4. Complaints of awakening at night w/ heartburn

4. Complaints of awakening at night w/ heartburn -classic symptoms of hiatal hernia associated w/ reflux

The nurse cares for clients on the neurology. What is the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil? 1. Reassess in 5 minutes 2. Check the client's visual acuity 3. Lower the head of the client's bed 4. Contact the physician.

4. Contact the physician. - implementation; fixed and dilated pupil represents a neurological emergency. I picked 2. Check the client's visual acuity Wrong because assessment; has symptoms of increased intracranial pressure (ICP) Strategy: Answers are a mix of assessments and implementations. Is this situation that requires assessment or validation? No. Determine the outcome of the implementations.

The client is treated for the deep venous thromboembolism with IV unfractionated heparin. The nurse is concerned if which findings is observed? 1. Increased anxiety 2. Decreased heart rate 3. Increased activated partial thromboplastin time (aPTT) 4. Decreased level of consciousness 5. Client takes Ginkgo for memory 6. Small pinpoint red marks are noted on the client's arms

4. Decreased level of consciousness - major side effect is bleeding; decrease in level of consciousness indicates intracranial bleeding 5. Client takes Ginkgo for memory - Ginkgo is a herbal supplement that can extend clotting times 6. Small pinpoint red marks are noted on the client's arms - Petechiae is of concern in a client on heparin I also picked 3. Increased activated partial thromboplastin time (aPTT) - wrong because desired response to therapy Strategy: "MOST concerned' indicates a complication

The nurse in the outpatient clinic receives a phone call from a young adult who says that her friend has overdosed. Which of the following actions should the nurse take FIRST? 1. Ask if the client has any vomiting or diarrhea 2. Instruct the friend to call the Poison Control Center 3. Find out what the client took 4. Determine if the client is responsive

4. Determine if the client is responsive - ask friend if client conscious, if there are breathing difficulties, and what the respiratory rate is; contact 911 I picked 2. Instruct the friend to call the Poison Control Center - nurse should complete assessment before implementation; don't pass the buck Strategy: "FIRST" indicates priority

On assessment of a patient admitted for dehydration, the nurse notes the patient appears restless and complains of difficulty breathing. The nurse notes bibasilar crackles on auscultation of the patient's lungs. Which of the following interventions should the nurse perform FIRST? 1. Place the patient on 2 liters oxygen per nasal cannula 2. Decrease the IV flow rate and administer Lasix as ordered 3. Stop the infusion and notify the physician 4. Elevate the head of the bed and stop the infusion

4. Elevate the head of the bed and stop the infusion - signs and symptoms suggest fluid overload; elevate the head of the bed maximizes respirations while stopping the infusion prevents further overload and progressive complications Strategy: "FIRST" indicates priority

The nurse determines that a client brought in to the urgent care center may be in shock. It is MOST important for the nurse to place the client in which position? 1. Trendelenburg position 2. Elevate the head of the bed 45 degrees 3. On the left side 4. Elevate the lower extremities

4. Elevate the lower extremities - improves circulation to the brain and vital organs without increasing workload or impairing respiratory effort I picked 1. Trendelenburg position - wrong because it will cause pressure on the thoracic cavity by the abdominal organs increases cardiac workload and respiratory effort Strategy: "MOST important indicates discrimination is required to answer the question

A woman returns to her room following a pyelogram using Pantopaque, an oil-based dye. It is MOST important for the nurse to take which of the following actions? 1. Apply ice packs to the puncture site 2. Ambulate the patient 3. Monitor for seizures 4. Encourage oral fluids

4. Encourage oral fluids* - need to replace fluid lost with removal of oil-based dye; offer oral analgesics for headache Strategy: Determine the outcome of each answer. Is it desired?

The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST? 1. Raise the head of the bed so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor. 2. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk toward your toes. 3. Reach over to the left side rail with your right hand, pull your body onto its left side, bend your upper leg so the foot is on the bed, and push down to elevate your trunk. 4. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress.

4. Focus on using your arms, the left elbow as a pivot with the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress. - maintains spinal alignment and prevents injury; relatively easy to accomplish Strategy: "BEST" indicates discrimination is required to answer the question

An elderly client recently immobilized is ordered to begin passive range-of-motion (ROM) exercises. What should the nurse understand about ROM before initiating this order? 1. Passive ROM exercises increase muscle strength 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort. 4. A sufficient ROM assists the elderly to carry out activities of daily living (ADLs)

4. Full ROM may not be needed or accomplished w/o discomfort for an elderly client; emphasis should be on ROMs that support ADLs.

Because of budgetary constraints, the head nurse on a large med/surg unit is required to redesign the nursing position on the second shift. The nurse plans to meet with the staff to discuss the required changes. Which of the following actions by the head nurse is MOST appropriate? 1. Inform the staff that they will redesign the positions with input as needed from the head nurse. 2. Ask the staff nurses for input; redesign the positions and forward it to the supervisor 3. Direct the nurses to redesign the position according to agency guidelines 4. Gather data from the staff nurses, redesign the positions, ask the nurses to review final draft, and submit the proposal to the supervisor

4. Gather data from the staff nurses, redesign the positions, ask the nurses to review final draft, and submit the proposal to the supervisor - should use the expertise of all staff members Strategy: Determine the outcome of each answer. Is it appropriate?

A client is scheduled for surgery in 10 days for removal of a pilotidal cyst. The nurse notes the client is diagnosed with adrenal insufficiency and has been taking prednisone 5 mg PO bid. The nurse expects the physician to take which of the following actions? 1. Continue the med as prescribed before surgery 2. Discontinue the med before surgery 3. Reduce the dosage of med before surgery 4. Increase the dosage of med before surgery

4. Increase the dosage of med before surgery - surgery increase the demand for corticosteroids; nurse should monitor vital signs and blood sugar, and check for infection and bleeding Strategy: Determine the outcome of each answer

A client is admitted to the hospital with a diagnosis of acute myocardial infarction. The client's husband tells the nurse his wife has been drinking heavily for the past 4 years. The nurse should observe for which of the following symptoms? 1. Insomnia, hyperactivity, and decreased appetite 2. Lack of energy, withdrawn, and sense of failure 3. Watery eyes, cramps, tremors 4. Hyper-alert, startles easily, and anorexia

4. Hyper-alert, startles easily, and anorexia - symptoms of early withdrawal from alcohol; other symptoms include increased pulse, anxiety, tremors, insomnia, hallucinations Strategy: Think about the answers

When doing an admission assessment for the client diagnosed with herpes zoster (shingles), it is important for the nurse to determine which finding? 1. When the client developed this allergic reaction and how long it has lasted 2. If the client has eaten any new foods within the past 24 hours 3. If the client has a history of fever blisters or canker sores 4. If the client comes in contact with anyone with chickenpox

4. If the client comes in contact with anyone with chickenpox - close relationship between the virus that causes herpes zoster (shingles) and chickenpox virus Strategy: Determine how each assessment relates to herpes zoster

When teaching a patient with chronic renal failure about dietary management, the nurse should recommend which of the following? 1. Increase intake of chicken and fish 2. Drink 2 to 3 liters of water each day 3. Use salt substitutes rather than salt 4. Increase intake of pasta and breads

4. Increase intake of pasta and breads - increasing carbohydrates intake helps patient to maintain energy requirements I picked 1. Increase intake of chicken and fish - wrong because body unable to store excess proteins; proteins break down into wastes that cannot be excreted by the compromised kidneys Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? Read the answers carefully. What does the word "increase" in answer #1 mean?

A client is scheduled for orthopedic surgery in two weeks. The nurse notes that the client has been taking carbamazepine (Tegretol) 100 mg BID PO for two years. The nurse expects the physician to take which of the following actions? 1. Instruct the client to withhold the med to the morning of surgery 2. Gradually discontinue the med 24-48 hours before surgery 3. Increase the dosage of the med before surgery 4. Inform the anesthetist

4. Inform the anesthetist - anticonvulsant med is needed to prevent seizure acitivity; amount of anesthetic may need to be reduced because client is on anticonvulsant I picked 2. Gradually discontinue the med 24-48 hours before surgery - wrong because anticonvulsant med is needed to prevent seizure activity Strategy: Determine the outcome of each answer. Is it desired?

The nurse on the surgical unit receives a call from the operating room to administer preoperative medication to a client scheduled for surgery. After administering the preoperative medication, the nurse discovers that the client has not signed the informed consent for the surgery. Which of the following actions should the nurse take NEXT? 1. Notify the physician 2. Ask the client to sign the form 3. Transfer the client to the operating room 4. Inform the nursing supervisor

4. Inform the nursing supervisor - nurse should follow chain of command; risks and benefits of the procedure must be explained by the person performing the procedure Strategy: "NEXT" indicates priority

The nurse cares for the client diagnosed with Cushing's syndrome. Which nursing action is the priority? 1. Implement measures to prevent skin breakdown. 2. Plan measures to prevent infections. 3. Teach the client signs and symptoms of hyperglycemia. 4. Instigate measures to prevent fluid overload.

4. Instigate measures to prevent fluid overload. - respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention I picked 2. Plan measures to prevent infections. wrong because clients are susceptible to skin breakdown and infections Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for a client immediately after an abdominal aortic aneurysm repair. Vital signs are B/P 100/70, pulse 120, respirations 24, urine output 75 ml during the past three hours. Which action is a PRIORITY for this client? 1. Weigh the client 2. Obtain an EKG 3. Decrease the rate of IV fluids, and start nasal oxygen 4. Maintain bedrest, and evaluate for a decrease in CVP readings

4. Maintain bedrest, and evaluate for a decrease in CVP readings - client is at increased risk for development of hypovolemic shock, vital signs and urine output correlate with the early signs of shock; the nurse should compare the CVP with previous readings Strategy: Determine what the problem is in the stem (shock). Determine how each answer relates to shock

The middle-aged adult is seen in the emergency department for reports of severe right-flank pain. The client is 20 pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi 4 years ago. Which action, if performed by the nurse, is MOST important? 1. Ensure that the client has nothing to eat or drink 2. Obtain a "clean-catch" urine specimen for analysis 3. Provide warm packs to relieve discomfort 4. Measure and strain the client's urine

4. Measure and strain the client's urine - will document passage of stone and allow composition to be analyzed I picked 2. Obtain a "clean-catch" urine specimen for analysis - not most important, used to identify infection Strategy: "MOST important" indicates discrimination is required to answer the question.

The nurse cares for a client receiving carbidopa/levodopa (Sinement). Which of the following statements, if made by the client's wife to the nurse, indicates the medication is effective? 1. "My husband has gained 2 pounds in the last month" 2. "My husband gets fewer upper respiratory infections" 3. "My husband's tremors have disappeared." 4. "My husband is better able to ambulate."

4. My husband is better able to ambulate" - reduces rigidity and bradykinesis and facilities client's mobility I picked 3. "My husband's tremors have disappeared." - wrong because medication is not a cure and tremors do not disappear Strategy: Think about the answers

The nurse knows which of the following mood-altering drugs is most often associated w/ an increased risk for HIV infection related to IV drug use? 1. Benzodiazepines 2. Marijuana 3. Barbiturates 4. Narcotics

4. Narcotics - Narcotics are most often used IV

The nurse in the ED cares for a client diagnosed with a heroin overdose. The nurse administers naloxone (Narcan) to the client. The nurse anticipates which of the following responses? 1. Decreased pulse and pallor 2. Decreased urinary output and hypotension 3 Lethargy and stupor 4. Nausea and vomiting

4. Nausea and vomiting - will cause signs and symptoms of opioid withdrawal: nausea, vomiting, restlessness, abdominal cramping Strategy: Think about each answer

The nurse cares for a client who has had an above-knee-amputation (AKA) w/ an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions? 1. Assess drainage from Penrose drain 2. Observe dressing for signs of excessive bleeding 3. Elevate the stump for no less than 40 hours 4. Provide cast care on the affected extremity

4. Provide cast care on the affected extremity - cast applied to provide uniform compression, prevent pain and contractures. I picked 1 wrong because drains not usually used with amputations

The nurse assists with the insertion of a central venous catheter. During the insertions, the nurse notes that the tip of the monitor device brushes the underside of the sterile field. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Wipe the tip with alcohol before connecting to the system 2. Notify the physician of the occurrence 3. Back-flush the catheter for several seconds before connecting 4. Obtain a new monitor device and prepare for a second attempt

4. Obtain a new monitor device and prepare for a second attempt - if equipment becomes contaminated during sterile procedure, obtain new equipment; the edge of the field is considered contaminated Strategy: Determine the outcome of each answer

After an anesthesiologist administers an epidural to a woman in labor, which nursing action has the highest priority? 1. Decrease IV fluids 2. Assess the fetal heart monitor 3. Place the mother on her right side 4. Obtain the blood pressure

4. Obtain the blood pressure - assessment; side effect of an epidural is hypotension from the vasodilation that occurs I picked 2. Assess the fetal heart monitor - wrong; assessment- may be done as ongoing management but is not a priority Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? yes. Is there an appropriate assessment? Yes

The nurse instructs a patient receiving phenelzine sulfate (Nardil). The nurse determines teaching is effective if the patient selects which dinner menu? 1. Liver with onions. 2. Dried fish and tea. 3. Pizza with pepperoni. 4. Omelet with broccoli.

4. Omelet with broccoli - does not contain tyramine; other foods containing train include aged cheese, beer, red wine, yogurt Strategy: Determine the outcome of each answer

The client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The client's vital signs are B/P 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which order? 1. Theophylline 0.7 mg/kg/h IV 2. Tetracycline hydrochloride 250 mg IM qd 3. Ipratropium bromide inhaler 2 inhalations qid 4. Propranolol hydrochloride 40 mg PO bid 5. IV of Normal Saline at 200mL per hour

4. Propranolol hydrochloride 40 mg PO bid - beta blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilation resulting in increased bronchoconstriction 5. IV of Normal Saline at 200mL per hour - This rate of IV fluid will increase the risk of fluid volume overload Strategy: Select the incorrect order. Think about the action of each implementation

The client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The clients vital signs are B/P 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which order? 1. Theophylline 0.7 mg/kg/h IV 2. Tetracycline hydrochloride 250 mg IM qd 3. Ipratropium bromide inhaler 2 inhalations qid 4. Propranolol hydrochloride 40 mg PO bid

4. Propranolol hydrochloride 40 mg PO bid - beta-blocker that blocks beta adrenergic impulses to the bronchial tweet that causes bronchodilation resulting in increased bronchoconstriction Strategy: Select the incorrect medication. Think about the action of each drug

A 75y/o man is admitted with altered mental status and a urinary tract infection. The physician writes an order for use of a Posey vest restraint. Which of the following actions by the nurse is BEST? 1. Perform some of the patient's care so he doesn't feel that the restraint is a punishment. 2. Ask the physician to change the order to wrist restraints to allow the patient some movement in bed. 3. Explain the use of the restraints to the patient and ask for permission to apply it. 4. Reevaluate the need for the restraint every 4 hours.

4. Reevaluate the need for the restraint every 4 hours. - nurse should assess for and document need for continue use of restraints; order for restraint is time-limited to 4 hours. Strategy: The answer choices are a mix of assessments and implementations. Is validation required? Yes

he nurse cares for clients at the student health clinic. Which signs and symptoms should cause the nurse to suspect cocaine abuse in the college student? Select all that apply. 1. Frequent sneezing. 2. Paranoia. 3. Fatigue. 4. Reports of insomnia. 5. Rhinorrhea. 6. Tachycardia.

4. Reports of insomnia. - cocaine stimulates with current users insomnia occurs 5. Rhinorrhea. - associated with cocaine use by inhalation; nose is most common route for administration 6. Tachycardia. - cardiac stimulant I also picked 1. Frequent sneezing - if snorted, most common method of use, decreased stimulation of the nares occurs Strategy: Determine how each answer choice relates to current cocaine use

The nurse in the clinic formulates a teaching plan for a client with open-angle glaucoma. The nurse should include which of the following in the teaching plan? 1. Limit eye movements 2. Wear protective eyewear in sunlight 3. Instill mydriatic eye drops every four hours 4. Return to the clinic for periodic tonometer readings

4. Return to the clinic for periodic tonometer readings - implementation; 1-2 times a year; normal IOP is 10-21 mm Hg; symptoms of glaucoma include cloudy; blurry vision, or loss of vision, artificial lights appear to have rainbows or halos around them, decreased peripheral vision, pain, headache, nausea, vomiting Strategy: Determine the outcome of each answer

A 5-month-old boy is brought to the clinic by his parents for a routine visit. Which of the following observations would require an intervention by the nurse? 1. The child cries when he sees the nurse 2. The infant has gained 8 pounds since birth 3. The infant cannot sit without some support 4. The child abducts his extremities and fans his fingers when he hears a noise.

4. The child abducts his extremities and fans his fingers when he hears a noise - Moro reflex; is strongest during first 2 months; should disappear after 3 to 4 months Strategy: "Requires intervention" indicates a complication

The nurse cares for clients in the ED. A newly married woman is brought to the ED by her parents, who relate that their son-in-law was killed 3 days ago in the boating accident. The parents report their daughter has been uncontrollably screaming and crying since the boating accident. Which of the following actions should the nurse take FIRST? 1. Administer diazepam (Valium) 2. Ask the parents to leave the room 3. Refer the client and her parents to family therapy 4. Silently sitting with the wife maintaining eye contact

4. Silently sitting with the wife maintaining eye contact - important that nurse convey warmth, caring, and empathy with the client' nurse should structure environment so client can express feelings about her loss; allowing the sharing painful feelings while the nurse is silent and maintaining eye contact is healing and conveys concern Strategy: "FIRST" indicates priority

The nurse plans care for the elderly client with dementia. Which action is a priority for the nurse? 1. Encourage dependency with activities of daily living 2. Provide flexibility in schedules due to confusion 3. Limit reminiscing due to poor memory. 4. Speak slowly in a face-to-face position.

4. Speak slowly in a face-to-face position. - is most effective when communicating with an elderly client I picked 3. Limit reminiscing due to poor memory. - wrong because reminiscence and life reviews help client resume progression through grief process associated with disappointing life events, and increases self-esteem Strategy: The topic of the question is unstated. Read the answer choices for clues

A client requests information on nonprescription methods of birth control. In planning the client's care, the nurse knows which of the following methods is MOST effective? 1. The calendar method 2. Coitus interruptus 3. Basal body temperature evaluation 4. Symptothermal method

4. Symptothermal method - combines cervical mucus evaluation and basal body temperature evaluation; any time a method of birth control is used in combination with another, the rate of effectiveness increases Strategy: Think how each method works

A client receives theophylline (aminophylline) IV for an acute respiratory problem. Which of the following observations alerts the nurse to withhold the medication and notify the doctor? 1. Hypertension 2. Unresponsiveness 3. Polyuria 4. tachycardia

4. Tachycardia - side effects of aminophylline; levels above 20 mcg/L are considered toxic; after long-term use, clients may tolerate higher blood concentration; other side effects include hypertension, nausea, vomiting Strategy: Think about each answer and how it relates to aminophylline

When providing care for a client over the age of 65 years, the nurse knows that which of the following is the MOST reliable sign of infection? 1. Fever 2. Hypotension 3. Leukocytosis 4. Tachypnea

4. Tachypnea - tachycardia, tachypnea, and confusion may be signs of infection in elderly patients I picked 1. Fever - absent in 25 to 30% of clients Strategy: Think about each answer

The client has received cimetidine 300 mg aid for several weeks. During an office visit, the health care provider gives the client an additional prescription for aluminum hydroxide 600 mg qid. Which instructions, if given by the nurse, is BEST? 1. Take the cimetidine and aluminum hydroxide together after meals and hs for combined effect. 2. Take the aluminum hydroxide with meals and before bed, and take the cimetidine one hour after meals and before bed. 3. Take the cimetidine two hours before meals and before bed, and take the aluminum hydroxide two hours after meals and at bedtime. 4. Take the cimetidine with meals and one hour before bed, and take the aluminum two hours after meals and hs.

4. Take the cimetidine with meals and one hour before bed, and take the aluminum two hours after meals and hs. - give cimetidine with meals (causes more consistent therapeutic effect) and hs; antacids interfere with absorption; separate administration by one hour, give aluminum hydroxide one hour after meals and hs (separate administration by one hour) Strategy: All answers are implementation. Determine the outcome of each answer choice. Is it desired?

The nurse makes a follow-up visit to a client recently diagnosed with AIDS. Which activity, if performed by the client, indicates that the nurse's teaching has been effective? 1. The client uses a firm toothbrush once a day to brush teeth 2. The client eats a large lunch at noon and a small dinner at 6PM 3. The client changes the litter in the cat's litter box every day 4. The client takes docusate sodium 300 mg once a day

4. The client takes decussate sodium 300 mg once a day - bowel programs, stool softeners, and laxatives reduce intestinal stasis and bacterial overgrowth Strategy: Think about what the words mean

The nurse is contacted by a client diagnosed with a chronic idiopathic seizure disorder currently controlled with anticonvulsant medication. The client is getting married in five weeks, and she is concerned about having a seizure during the ceremony. Which of the following actions by the nurse is BEST? 1. Ask physician to increase the client's medication dosage for the wedding day. 2. Ask a nurse to attend the wedding and assist as needed. 3. Teach the bride-to-be how to perform relaxation exercises. 4. Tell the bride-to-be to make a medication and seizure chart.

4. Tell the bride-to-be to make a medication and seizure chart. - may help identify seizure triggers such as alcohol, stress, caffeine, constipation; may be increased in seizure activity during menses Strategy: "BEST" indicates discrimination is required to answer the question

The nurse evaluates care for the client diagnosed with depression. The nurse is MOST concerned if which finding is observed? 1. The LPN/LVN reinforces the client breathing and relaxation techniques. 2. The staff allows the client to verbalize thoughts when they try to sleep 3. The staff encourages the client to express feelings more clearly 4. The LPN/LVN administers flurazepam hydrochloride 15 mg hs.

4. The LPN/LVN administers flurazepam hydrochloride 15 mg hs - medication that produces dependence should be a last resort; used only if other nursing measures and antidepressant medications have not worked and the client is exhausted Strategy: "MOST' concerned" indicates an incorrect action

The nurse performs an assessment on a 40-year-old client. The nurse expects to find which of the following? 1. The client's cognitive skills are beginning to decline 2. The client has achieved a balance between work and family 3. The client's bone mass has increased 4. The client compares life's accomplishments against goals

4. The client compares life's accomplishments against goals - self-questioning occurs, reappraises the past, discards unrealistic goals, potential mid-life crisis Strategy: Think about the developmental level of a 40-year-old

The nurse cares for a client after electroconvulsive therapy (ECT). The nurse is MOST concerned if which of the following is observed? 1. The client complains of a headache 2. The client has difficulty with short- and long-term memory 3. The client appears confused 4. The client complains of a backache

4. The client complains of a backache - not an expected effect; assess severity, duration, location, and report to physician Strategy: "MOST concerned" indicates something is wrong

The nurse cares for a client admitted with malnutrition due to disorientation and confusion. The nurse determines that the client has responded positively to care when which of the following is observed? 1. The client states that he understands that he does not eat when he is confused. 2. The client correctly identifies the food groups. 3. The client states that he needs to drink more water. 4. The client feeds himself when the nurse offers cues.

4. The client feeds himself when the nurse offers cues. - a disoriented, confused client who is unable to care for himself will require cues from the nurse in order to eat; goal is for client to feed self. Strategy: Think about each answer.

The nurse questions the family of the client admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNK). The nurse should expect which info to be contained in the client's history? 1. The client with diagnosed with type 1 diabetes four years ago 2. The client has a history of 3+ ketones in his urine 3. The client is 20b overweight and smokes a pack of cigarettes a day 4. The client is 66 years old and takes propranolol (Inderal) 20 mg PO TID

4. The client is 66 years old and takes propranolol (Inderal) 20 mg PO TID - seen after 50 years old; age-related changes in thirst perception result in dehydration and decrease in urine-concentrating abilities of the kidney Strategy: think about the cause of each answer and how it relates to the situation

The nurse cares for a client diagnosed w/ type 1 diabetes complaining of decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which of the following? 1. The client's decreased vision is caused by bleeding into the inner ocular chamber of the eye. 2. The client's decreased vision is caused by gradual separation of the retina from the base of the eye 3. The client's decreased vision is caused by an increase in the size of vessels in the back of the eye. 4. The client's decreased vision is caused by gradual destruction and degeneration of the retina.

4. The client's decreased vision is caused by gradual destruction and degeneration of the retina. - Gradual destruction occurs because of deterioration of the retinal vessels.

The nurse cares for a client who began receiving epoetin alpha (Procit) 10 days ago. It is MOST important for the nurse to report which of the following to the physician? 1. The client reports walking around the block without difficulty 2. The client's B/P is 130/80 3. The client complains of flu-like symptoms 4. The client's hematocrit increases from 28 to 33%.

4. The client's hematocrit increases from 28 to 33% - likelihood of hypertension and seizures increase if hematocrit increases by more than 4 points in 2 weeks; contact physician to decrease dose Strategy: "MOST important" indicates that discrimination is required to answer the question

The nurse who is caring for patients in the outpatient clinic receives four phone calls. Which of the following calls should the nurse return FIRST? 1. A patient reports a headache that is unrelieved by medications. The patient reports taking two propoxyphene napsylate acetaminophen (Darvocent-N) and two acetaminophen (Tylenol) every 4 hours for 3 days. 2. A patient complains of left ankle pain and swelling that is reddened and warm to the touch. The patient states the redness and swelling occurred spontaneously and denies injury to the ankle. 3. The mother of a toddler calls to report that her child has a rash and a sore throat 4. The father of a toddler calls to report that his child swallowed a dime.

4. The father of a toddler calls to report that his child swallowed a dime. - nurse should immediately evaluate to determine if the toddler is having respiratory difficulty Strategy: Determine the MOST unstable patient

An infant is treated in the newborn nursery for hyperbilirubinemia using phototherapy lights. It is MOST important for the nurse to intervene in which of the following situations? 1. The mother turns off the phototherapy lights and removes the light's eye patches in preparation for feeding. 2. The mother is worried because the infant experiences frequent loose, greenish stools, and increased urine output. 3. A lab tech turns off the phototherapy to draw blood. 4. The jaundice observed around the infant's eyes has begun to disappear.

4. The jaundice observed around the infant's eyes has begun to disappear. - indicates that the eye patches are not adequately placed or are not of adequate opaqueness and are allowing light to enter; with phototherapy, eyes must be completely shielded with patches or an opaque mask in order to prevent exposure to the light, which could result in eye damage, especially of the retina.

While scheduling the administration of bromocriptine, which nursing action has the HIGHEST priority? 1. The medication should be taken once a day for 6 weeks. 2. The medication should be taken with orange juice 3. The medication should be taken in the morning and at bedtime 4. The medication should be taken with meals.

4. The medication should be taken with meals. - will decrease GI upset Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired?

The nurse makes rounds on the medical unit to assess the care given by the nursing assistants. Which of the following observations requires an intervention by the nurse? 1. The nursing assistant places the fingers of one hand on the first of a patient in order to evaluate the respirations 2. The nursing assistant prepares to take a b/p in the left arm of a patient recovering from a right mastectomy 3. The nursing assistant weighs a patient on a standing scale while the patient is balanced on crutches 4. The nursing assistant prepares to take an oral temp on a patient recovering from a rhinoplasty

4. The nursing assistant prepares to take an oral temp on a patient recovering from a rhinoplasty - rhinoplasty compromises ability of patient to breath through the nose due to the packing in both nostrils Strategy: "Requires an intervention by the nurse" indicates that something is wrong

The charge nurse of a psychogeriatric unit makes rounds on the unit. Which of the following situations requires an IMMEDIATE intervention by the nurse? 1. The dietary aide removes a full breakfast try untouched by a patient with major depression who is still in bed wearing night clothing 2. The psychiatric aide makes the bed while a patient with schizophrenia is sitting in the bedside chair shaving with a disposable razor and mirror 3. The LPN/LVN assigned to medication administration argues loudly with a bipolar patient who is refusing to take prescribed medication 4. The patient care tech please personal care items in reach of a patient with stage 2 dementia of the Alzheimer type and then leaves to fill the wash basin with water.

4. The patient care tech please personal care items in reach of a patient with stage 2 dementia of the Alzheimer type and then leaves to fill the wash basin with water. - patient at risk for choking on inedible items such as soap, lotions, caps of sample bottles, etc Strategy: Determine the MOST unstable patient

The nurse cares for clients in the outpatient psychiatric unit. The mother of a client diagnosed with antisocial personality disorder says to the nurse, "My son seems much better. He seems to be growing up and willing to accept more responsibility." Which of the following responses by the nurse is BEST? 1. The prognosis is good because there is no evidence of psychotic behavior 2. The prognosis is doubtful because psychotherapy causes regression 3. The prognosis is good because medication and psychotherapy have solved the underlying problems 4. The prognosis is doubtful because clients with antisocial personality disorder have little motivation for change

4. The prognosis is doubtful because clients with antisocial personality disorder have little motivation for change - usually move from situation to situation in an opportunistic fashion; experience problems with authority I picked 1. The prognosis is good because there is no evidence of psychotic behavior - wrong because clients with antisocial personality disorder are often manipulative, untrustworthy, and unreliable Strategy: "BEST" indicates discrimination is required to answer the question

Which of the following findings during a newborn examination requires IMMEDIATE action by the nurse? 1. The left side of the newborn's face is drooping 2. The newborn's uvula has two lobes 3. The newborn's ears are low-set bilaterally 4. The red reflex is absent in the newborn's right eye

4. The red reflex is absent in the newborn's right eye - indicates an ophthalmic emergency because light is not being transmitted to the retina, and the early suppression of optic nerve function which results from the obstruction of the light can cause blindness; notify the physician immediately I picked 1. The left side of the newborn's face is drooping - wrong because it may indicate facial paralysis from cranial nerve VII (facial nerve) which occurred during delivery. paralysis usually resolves within a few days to 3 weeks, can be permanent Strategy: "IMMEDIATE action" indicates priority

The nurse observes the psychiatric staff interact with a client exhibiting manipulative behavior. The nurse should intervene in which situation? 1. The staff discusses with the client the consequences of the manipulative behavior 2. The staff collaborates to establish limits on the manipulative behavior 3. The staff clarifies the consequences of the client's manipulative behavior 4. The staff decreases demands placed on the client that trigger the manipulative behavior.

4. The staff decrease demands placed on the client that trigger the manipulative behavior - can foster a sense of entitlement along with under functioning; establishing realistic, achievable goals and activities is necessary to build self-esteem Strategy: "The nurse would intervene" means you are looking for an incorrect response

The nurse cares for a 14-year-old 1 day after insertion of a Harrington rod. The nurse determines that the pain medication is effective if which of the following is observed? 1. The teen verbalizes the pain has decreased 2. The teen refused the pain medication 3. The teen becomes agitated with visitors in the room 4. The teen uses the incentive spirometer when requested.

4. The teen uses the incentive spirometer when requested - using the incentive spirometer indicates teen can breathe without pain; nurse can measure effectiveness of respiratory efforts; Harrington rod is inserted to fuse spine to treat scoliosis I picked 1. The teen verbalizes the pain has decreased - wrong because not measurable

The nursing team consists of an RN, two LPN/LVNs, and a nursing assistive personal (NAP). The Rn should care for which client? 1. The infant 2 days ago post-op after repair of cleft lip requiring a tube feeding 2. The preschool child 3 days post-op after surgical removal of Wilms tumor requiring a bath 3. The school-aged child diagnosed with osteomyelitis requiring a dressing change 4. The teenager with a head injury, Glasgow coma scale is 5, requiring personal care.

4. The teenager with a head injury, Glasgow coma scale is 5, requiring personal care. - Glasgow coma scale of 5 indicates coma, client requires frequent assessment. Strategy: RN care for clients who require assessment, teaching, and nursing judgment.

The ICU nurse cares for a patient diagnosed with septic shock. Which of the following observations MOST concerns the nurse? 1. The peripheral pulses are strong and bounding and there respiratory rate is 26 breaths per minute. 2. The white blood cell differential results indicate that there are predominantly band neutrophils rather than segmented neutrophils 3. The skin changes from warm, dry, and flushed to cool, clammy, and pale. 4. There is blood at a venipuncture site and around an IV catheter.

4. There is blood at a venipuncture site and around an IV catheter. - this is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem; sepsis is the most frequent cause of DIC Strategy: Think about the implications of each question

Prior to a caesarean delivery, the client is treated for abrupt placenta. The nurse cares for the client during the postpartum period. Which symptom is suggestive of disseminated intravascular coagulation (DIC)? 1. The client's vital signs are: BP 90/58, temp 101.0F (38.3C), pulse 112/min, rest 18/min 2. The client's lab results are Hgb 13 g/dL, HCT 40%, WBC 7,000/mm3 3. The client is nauseated, lethargic, and has vomited three times 4. There is oozing blood from the venipuncture site and abdominal incision.

4. There is oozing blood from the venipuncture site and abdominal incision. - DIC is an acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom. I picked 1. The client's vital signs are: BP 90/58, temp 101.0F (38.3C), pulse 112/min, rest 18/min Wrong because may indicate hemorrhage or sepsis Strategy: Determine how each answer choice relates to DIC.

The nurse discovers a visitor on the floor of the waiting room in the outpatient clinic. The elderly woman is unconscious and not breathing. Which of the following actions should the nurse take FIRST? 1. Lift the back of the woman's neck and check her airway 2. Move the lower jaw backward and push the tongue to the side 3. Turn the woman's head to one side and shake her firmly 4. Tilt the woman's head back and lift her chin.

4. Tilt the woman's head back and lift her chin* - provides for airway, place hand on forehead, applying backward pressure, place fingers of other hand under chin and lift forward Strategy: Determine the outcome of each answer

The preschooler is brought to the ED after ingesting a bottle of baby aspirin. The nurse should observe the preschooler for which signs and symptoms? 1. Nausea and vertigo 2. Epistaxis and paralysis 3. Dysrhythmia and hypoventilation 4. Tinnitus and gastric distress

4. Tinnitus and gastric distress - symptoms of overdose I picked 1. Nausea and vertigo - wrong because dizziness not seen with aspirin overdose Strategy: Think about each answer choice and how it relates to aspirin overdose

One day after a coronary artery bypass graft (CABG), the nurse discovers a client sitting in a chair. The client is cold and pale, and responds to loud verbal stimuli. Which of the following actions by the nurse is MOST appropriate? 1. Perform cardiac assessment 2. Review chart for prior sedative administration 3. Administer oxygen per nasal cannula 4. Transfer client back to bed

4. Transfer client back to bed - cold, pale client needs to be reclining in bed, hypothermia causes vasoconstriction and hypertension; hypertension causes leakage from suture lines and may cause bleeding Strategy: "MOST appropriate" indicates priority

The nurse instructs a client diagnosed with diverticulosis. The nurse determines that teaching is effective if the client selects which of the following menus? 1. Baked chicken breast with rice, and a lettuce, tomato, and cucumber salad with Italian dressing 2. Broiled cod with sliced almonds and cooked beets 3. Lean roast beef with low-fat gravy and corn on the cob 4. Tuna sandwich on whole-wheat toast with carrot sticks

4. Tuna sandwich on whole-wheat toast with carrot sticks - Tuna is nutritious and relatively low in fat; whole-wheat provides fiber that will increase bulk in stools Strategy: "Teaching is effective" indicates correct information

The nurse notes that a term client in labor is having persistent late decelerations. The nurse should notify the physician because this indicates which of the following? 1. Cord compression 2. Impending delivery 3. Fetal distress 4. Uteroplacental deficiency

4. Uteroplacental deficiency - late decelerations are correlated with uteroplacental deficiency I picked 3. Fetal distress - wrong because fetal distress is a general term indicating the fetus is in trouble; can be correlated with fetal tachycardia, bradycardia, and various decelerations and fetal heart rate patterns Strategy: Think about each answer

The nurse performs discharge teaching for a client who had a lens implant after intracapsular cataract extraction of the right eye. It is MOST important for the nurse to include which of the following instructions? 1. Rotate the right eye once daily 2. Irrigate the left eye with warm saline solution twice per day 3. Tilt head back while in a sitting position 4. Utilize dry shampoo for several weeks

4. Utilize dry shampoo for several weeks - head held in a dependent position can result in significant increased intraocular pressure Strategy: Determine the outcome of each answer. Is it desired?