NCLEX Comprehensive Study Guide

A health care providers prescription reads 1000 mL of NS to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Record your answer to the nearest whole number.

21 drops/minute Total Volume x Drop Factor/Time in Minutes = Drops per minute 1000 mL x 15/720 = 20.83333 or 21

Describe the Paget's sensorimotor stage?

- Coordination of senses with motor responses. Sensory curiosity about the world. Language used for demands and cataloging. Object permanence is developed.

A newborn weighing 3250 gm is prescribed IV digoxin 0.025 mg/kg in three divided doses over 24 hours. The medication available is 100 mcg/mL. Which amount of medication in milliliters will the nurse administer for one dose? (Round at the end of the equation. Record your answer using two decimal places.)

0.27 mL 3250 g/1000 = 3.25 kg 0.025 mg x 3.25 kg = 0.08125 mg/day 0.08125/3 = 0.027 mg/single dose 0.027 mg = 27 micrograms 100/1 = 27/x 100x = 27 x = 0.27 mL

A HCP's prescription reads morphine sulfate 8 mgs stat. The medication ampule reads morphine sulfate, 10 mg/ml. The nurse prepares how many mL to administer the correct dose?

0.8 mL 8 mgs/10 mg = 0.8

The nurse provides discharge instructions to an adult client diagnosed with infectious diarrhea. In which situation does the nurse advise the client to call a health care provider immediately? (Select all that apply.) 1. Development of dry skin. 2. Pulse rate exceeding 100 beats per minute. 3. Lower abdominal cramping. 4. Cold extremities. 5. Increased thirst.

1. Development of dry skin. 2. Pulse rate exceeding 100 beats per minute. 4. Cold extremities. 5. Increased thirst.

Due to a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which action does the nurse take next? 1. Place an identification 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 identification bracelet on each child. — This is a priority, as it aids in communication after rescue or recovery. This addresses a pertinent physical need.

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

A semi-Fowler's position - A hyphema is the presence of blood in the anterior chamber. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping hyphema away from the optical center of the cornea.

The nurse notes documentation that a child is exhibiting the inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow

Meningitis - The inability to flex the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's Sign.

A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain

Reduction of steatorrhea - Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid to reduce the amount of fatty stools (steatorrhea). A second intended effect could be improved nutritional status. - It's use could result in weight gain, but should not result in weight loss if it is ading digestion.

The nurse prepares to administer hydroxyzine to a client. For which reason does the nurse use the Z-track method when administering this medication? 1. Slows the rate of absorption. 2. Is the safest and least painful way to give the injection. 3. Reduces irritation to the subcutaneous and skin tissues. 4. Prevents the medication from seeping into the venous circulation.

3. Reduces irritation to the subcutaneous and skin tissues. - The Z-track method is a variation of the standard intramuscular technique for administering medications that are highly irritating to subcutaneous and skin tissues.

The nurse answers a call light for a client who reports pain at the intravenous (IV) access site. Upon assessment, the nurse notes the IV insertion site is pale, cool to the touch, and mildly swollen. It is most important for the nurse to take which action? 1. Slow the infusion rate and monitor the client's response. 2. Stop the infusion and notify the health care provider. 3. Remove the IV catheter and apply a pressure dressing. 4. Remove the IV catheter and place the client's arm on a pillow.

4. Remove the IV catheter and place the client's arm on a pillow. — The client is experiencing an infiltration of the IV access site. The nurse will remove the IV catheter and elevate the extremity to increase the rate of reabsorption of the fluid. Think like a nurse: An intravenous site that is painful, edematous, and cool to the touch indicates an infiltration. The catheter should be immediately removed and the extremity elevated to reduce edema and increase absorption of the fluid. Slowing the infusion rate will exacerbate the infiltration.

A HCP prescribes 3000 mL of D5W to be administered over a 24 hour period. The nurse determines that how many mLs/hr will be administered to the client?

125 mL/hr 3,000 mL/24 = 125

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the HCP. 4. Place the client in Trendelenburg's position.

Notify the HCP. - If bleeding is excessive, the cause may be laceration of the cervix or birth canal.

The nurse assesses the precordium of an adult male. Which location will the nurse place the stethoscope to auscultate the mitral valve?

The mitral valve is located in the fifth intercostal space at the left of the midclavicular line. This is also the location of the apex of the heart. The nurse will assess for S1 at this location.

A client admitted to the hospital with chest pain and a history of T2DM is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin

Metformin - Due to the use of contrast medium that may affect kidney function, which could increase risk of lactic acidosis, with Metformin in the system.

The nurse in the outpatient clinic provides care for a client diagnosed with peptic ulcer disease and gout. Which health care provider prescription does the nurse question? 1. "Colchicine 1.6 mg initially followed by 0.6 mg in one hour." 2. "Allopurinol 100 mg daily." 3. "Probenecid 250 mg twice daily." 4. "Indomethacin 50 mg four times daily."

"Indomethacin 50 mg four times daily." — Indomethacin is a nonsteroidal anti-inflammatory that is used cautiously in clients with peptic ulcer disease.

The nurse is administering an intravenous dose of methocarbamol to a client with multiple sclerosis. For which adverse effect should the nurse monitor? 1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertension

Bradycardia - Administration of methocarbamol can cause hypotension and bradycardia.

What are the symptoms of a transfusion reaction?

Symptoms: Fever, chills, urticaria, and itching - A more serious reaction can include: respiratory distress, high fever, hypotension and red urine.

The clinic is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice? 1. The nail beds 2. The skin in the sacral area 3. The skin in the abdominal area 4. The membranes in the ear canal

The nail beds - Best assesses in the sclera, nail beds, and mucous membranes

A patient with Addison's Disease is being discharged home on Prednisone. Which of the following statements by the patient warrants you to re-educate the patient? 1. "I will notify the doctor if I become sick or experience extra stress." 2. "I will take this medication as needed when symptoms present." 3. "I will take this medication at the same time every day." 4. "My daughter has bought me a Medic-Alert bracelet."

2. "I will take this medication as needed when symptoms present."

A client is brought to the emergency department with partial thickness burns to the face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids. 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.

2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present. - Client is NPO due to gastrointestinal changes from burns.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1. Respirations that are shallow. 2. Respirations that are increased in rate. 3. Respirations that are abnormally slow. 4. Respirations that are abnormally deep. 5. Respirations that cease for several seconds.

2. Respirations that are increased in rate. 4. Respirations that are abnormally deep. - Kussmaul's respirations are deep, with an increased rate, with no periods of apnea.

The nurse provides teaching for a client diagnosed with heart failure. Which client statement indicates to the nurse that teaching is effective? 1. "Low-fat cottage cheese is a good snack." 2. "I can continue using prepared salad dressings." 3. "I will increase the amount of celery I eat every day." 4. "I will continue to eat my favorite canned green peas."

3. "I will increase the amount of celery I eat every day." — Two stalks of celery contain 62 mg of sodium, making them an appropriate snack for a low-sodium diet. The nurse should encourage the client to choose fresh vegetables, which are low in sodium. Think like a nurse: The client with heart failure should be instructed to reduce sodium intake. This reduces fluid volume, improves pumping action of the heart, and prevents fluid from accumulating in the lungs and extremities. It is essential for nurses to able to recognize appropriate food choices for clients who have a restricted sodium intake. Celery has a low amount of sodium, which makes it an ideal choice for a snack.

A nurse in the pediatric clinic discusses the potential of lead exposure with the parents of preschoolers. It is important for the nurse to follow up on which statement made by a parent? 1. "I use water from the cold water tap for cooking." 2. "My child likes to finger paint." 3. "My spouse renovates old houses." 4. "My child is very good about eating regular meals."

3. "My spouse renovates old houses." - Construction and lead abatement workers may bring home lead dust that children can inhale. Homes built prior to 1950 contain lead-based paints. Homes built between 1950 and 1978 may contain lead on exterior surfaces. The parent should shower and put on clean clothing prior to coming home. Think like a nurse: The widespread use of lead, which is a toxic metal, has caused extensive environmental contamination and health problems. Children are particularly vulnerable to lead's neurotoxic effects. Even low levels of lead exposure can cause adverse neurocognitive effects, including poor academic performance and potentially irreversible behavioral problems. No amount of lead in the bloodstream is considered safe. Any exposure to lead may negatively affect neurodevelopment. To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client's understanding.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3. Give the child a teaspoon of honey. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

A client comes to the clinic reporting muscle weakness, breathlessness, and bone pain. The nurse notes that the client takes phenytoin 100 mg three times a day. When providing nutritional counseling, which food grouping best meets this client's needs? 1. Bananas, mushrooms, yams. 2. Oranges, broccoli, papayas. 3. Milk, cantaloupe, kale. 4. Soybeans, spinach, pumpkin seeds.

3. Milk, cantaloupe, kale. - Anticonvulsants can cause folate and vitamin D deficiencies. The client has symptoms reflective of anemia and bone resorption. Folate deficiency can cause anemia. Good sources of folate are green leafy vegetables, legumes, tomatoes, and various fruits such as oranges and cantaloupe. Good sources of vitamin D include fortified milk. Because vitamin D promotes calcium absorption, foods rich in this vitamin (e.g., kale) are also recommended.

The nurse provides care for a pediatric client who is 18 months of age during a wellness visit. The nurse assesses the child's growth and development. Which assessment finding causes the nurse to be concerned? 1. The child does not follow basic instructions. 2. The child does not use two-word sentences. 3. The child has difficulty with stairs. 4. The child does not speak 15 words.

4. The child does not speak 15 words. — A cause for concern for a child age 18 months is an inability to speak 15 words. Not using two-word sentences and inability to follow basic commands are a cause for concern for a child age 2 years, not 18 months. Difficulty with stairs at age 3 years (not 18 months) is a cause for concern.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening of the outer cannula. Which nursing action is required before plugging the tube? 1. Deflate the cuff on the tube 2. Place the inner cannula into the tube 3. Ensure the client is able to speak 4. Ensure the client is able to swallow

Deflate the cuff on the tube - The cuff should be deflated, otherwise ventilation cannot occur. The ability to swallow or speak is unrelated to weaning and plugging of the tube.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of IV infusion? 1. Potassium infusion. 2. NPH insulin. 3. 5% dextrose infusion. 4. Normal saline infusion.

Normal saline infusion - Rehydration is the initial step in resolving diabetic ketoacidosis. - NPH is never administered via IV and dextrose infusions are not administered until blood glucose levels decrease to an acceptable level. Potassium may be infused, but would not be an initial treatment.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action? 1. Apply normal saline drops 2. Note the time of day the test was done 3. Contact the HCP 4. Instruct the client to sleep with the head of the bed flat.

Note the time of day the test was done - IOP normal range: 10-21 mm Hg. Since IOP is slightly higher in the morning, the initial action is to check the time it was performed.

The clinic is preparing to explain the concepts of Kehlberg's Theory of Moral Development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level? 1. Peer pressure. 2. Social pressure. 3. Parent's behavior. 4. Punishment and reward.

Punishment and reward. - The child sees actions as good or bad. Options 1, 2, & 3 are not associated factors for this stage of moral development.

A client experiencing regular contractions reports "water breaking. " Which action does the nurse take first? 1. Auscultate the fetal heart rate. 2. Document the characteristics of the amniotic fluid. 3. Obtain the pH of the amniotic fluid. 4. Notify the health care provider.

1. Auscultate the fetal heart rate. CORRECT— The priority is assessment of fetal well-being. This is completed by auscultating the fetal heart rate. This heart rate should range from 120 to 160 beats per minute. A heart rate above 160 beats per minute is an early sign of fetal hypoxia. A heart rate below 110 beats per minute is a later sign of fetal hypoxia, which could be caused by prolapse of the umbilical cord.

Which of the following is not a typical sign and symptom of Cushing's Syndrome? 1. Hyperpigmentation of the skin 2. Hirsutism 3. Purplish striae 4. Moon Face

1. Hyperpigmentation of the skin

An older adult client takes dexamethasone 1.5 mg by mouth three times a day. Which client statement causes the nurse concern? 1. "I take my medication with meals." 2. "I have this little sore on my leg that won't go away." 3. "I should take a brisk walk several times a week." 4. "I avoid public places during the flu season."

2. "I have this little sore on my leg that won't go away." - Dexamethasone, a cortiosteroid, suppresses the immune response. A non-healing sore should be reported to the health care provider and further assessed. Think like a nurse: Impaired wound healing is just one dermatologic adverse reaction associated with cortiocosteroid use. Other adverse reactions include acne, allergic dermatitis, dry scaly skin, ecchymoses, petechiae, erythema, increased sweating, rash, striae, suppression of reactions to skin tests, thin fragile skin, thinning scalp hair, and urticaria. An open sore that is not healing warrants further evaluation based on the current medication prescription of dexamethasone.

The nurse instructs a client on how to collect a 24-hour urine specimen for a creatinine clearance test. Which statement by the client would cause the nurse to intervene? 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 1 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 a waste product of muscle breakdown. A client should not engage in strenuous exercise during, or just before, the test.

The nurse provides care for an African-American client diagnosed with hypertension in a cardiac unit. Which medication prescription does the nurse question for this client? 1. Hydralazine hydrochloride. 2. Atenolol. 3. Chlorothiazide. 4. Nifedipine.

2. Atenolol. Atenolol is a beta-adrenergic inhibitor (beta blocker) that slows heart rate and decreases cardiac contractility and cardiac output, thereby lowering blood pressure. Beta blockers are less effective in African Americans than they are in Caucasians and should be questioned in an African-American client with hypertension.

A nonstress test is performed on a client who is pregnant and the results of the test indicate nonreactive findings. The HCP prescribes a contraction stress test and the results are negative. How should the nurse document the finding? 1. A normal test result. 2. An abnormal test result. 3. A high risk for fetal demise. 4. The need for a cesarean section.

A normal test result. - A negative test result indicates that no late decelerations occurred in the FHR, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period.

The nurse reviews the prenatal records of pregnant clients. Which maternal factor, associated with the potential for fetal macrosomia, is appropriate for the nurse to identify? (Select all that apply.) 1. Gestational diabetes. 2. Maternal tobacco use during pregnancy. 3. Pregnancy-induced hypertension (PIH). 4. Intrauterine infection. 5. Maternal obesity.

ANSWERS: 1, 5 Explanation: 1. Gestational diabetes. — Gestational diabetes can result in macrosomia. 5. Maternal obesity. — Maternal obesity is a risk factor for macrosomia. Think like a nurse: Fetal macrosomia describes a newborn who is significantly larger than average. Regardless of gestational age, babies diagnosed with fetal macrosomia have birth weights of more than 8 pounds, 13 ounces (4000 grams). During prenatal care, the nurse screens the client for risks of macrosomia, such as diabetes mellitus, obesity, excessive weight gain during pregnancy, and previous pregnancy. The mother is informed about possible complications, labor difficulties, postpartum hemorrhage, genital tract laceration, and uterine rupture. The teach-back method is used in all client education encounters.

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? 1. Decreased absorption of digoxin. 2. Increased risk for digoxin toxicity. 3. Decreased therapeutic effect of digoxin. 4. Increased risk for side effects related to digoxin.

Increased risk for digoxin toxicity.

A HCP prescribes 1,000 mL D5W to infuse at a rate of 125 mL/hr. The nurse determines that it will take how many hours for 1 liter to infuse?

8 hrs 1000 mL/125 mL per hr = 8 hours

What are Erikon's Stages of Psychosocial Development?

- Infant to 18 months: Trust vs Mistrust - 18 months to 3 years: Autonomy vs Shame & Doubt - 3 to 5 years: Initiative vs Guilt - 5 to 13 years: Industry vs Inferiority - 13 to 21 years: Identity vs Role Confusion - 21 to 39 years: Intimacy vs Isolation - 40 to 65 years: Generativity vs Stagnation - 65 and older: Ego Integrity vs Despair

The nurse provides care to an adolescent client diagnosed with acute glomerulonephritis. The parents ask the nurse what to expect regarding management of this diagnosis. Which information does the nurse provide to the family? 1. "Your child will likely require a nephrectomy." 2. "Your child will be prescribed chemotherapy." 3. "Your child will likely require peritoneal dialysis." 4. "Your child will be prescribed diuretic therapy."

4. "Your child will be prescribed diuretic therapy." — Acute glomerulonephritis is usually treated with anti-infectives, diuretics, and antihypertensives, which will be given at home as soon as the client is stable and discharged home. Think like a nurse: Acute glomerulonephritis is often diagnosed as a complication from a streptococcus infection. This health problem affects all aspects of renal function, which control fluid balance and blood pressure. Because of this, the client will be prescribed antibiotics to treat the infection, diuretics to maintain normal body fluid balance, and antihypertensives to control blood pressure until the kidneys heal and normal function returns.

The nurse assesses a group of clients for risk of skin breakdown. The nurse identifies which client as being lowest risk for developing skin breakdown? 1. A client who is incontinent of feces. 2. A client with nutritional deficiencies. 3. A client who is confined to bed. 4. A client with mental illness.

4. A client with mental illness. — This condition does not place the individual at increased risk for skin breakdown Think like a nurse: The skin is the largest organ in the body and is prone to developing changes in texture, color, and integrity. When identifying the client most at risk for skin breakdown, the nurse should consider factors that affect skin integrity. These factors include age, nutritional status, mobility, general health condition, and cleanliness. In this scenario, the client with a mental health disorder does not have a factor that directly affects skin integrity. The nurse recognizes this client as being least at risk for experiencing skin breakdown.

The nurse provides care for a client who just returned from surgery after a right total knee replacement. It is important for the nurse to take which action? 1. Change the surgical dressing if it becomes saturated or loose. 2. Assist the client to ambulate in the room and in the hall. 3. Encourage use of the incentive spirometer three times per day. 4. Apply sequential compression devices to the lower extremities.

4. Apply sequential compression devices to the lower extremities.

The nurse assesses a newborn whose parent is unsure of the date of conception. Which assessment finding indicates to the nurse that the newborn is preterm? 1. Presence of lanugo on the upper back and shoulders. 2. Elbow creases contain vernix. 3. Breast bud tissue measures 0.5 cm in diameter. 4. Arms and legs are extended at rest.

4. Arms and legs are extended at rest. CORRECT— Normally, the full-term newborn's extremities are flexed when the newborn is at rest. The preterm newborn may demonstrate limp or flaccid extremities that are extended when at rest. Preterm newborns also may demonstrate rigid extension of extremities.

A nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is: 1. Propranolol. 2. Haloperidol. 3. Diphenhydramine. 4. Benztropine.

4. Benztropine Benztropine, trihexyphenidyl, or amantadine are ordered for treatment of Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms.

The client is treated for deep vein thrombosis with IV unfractionated heparin. Which finding most concerns the nurse? 1. Increased anxiety. 2. Decreased heart rate. 3. Increased activated partial thromboplastin time (aPTT). 4. Decreased level of consciousness.

4. Decreased level of consciousness. - A major side effect of heparin administration is bleeding. A decrease in level of consciousness indicates intracranial bleeding and represents an immediate circulatory concern. This is the highest priority.

A client with myasthenia gravis has become increasingly weaker, prompting the HCP to determine if the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered, causing which response in the patient condition to indicate cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

A temporary worsening of the condition - An edrophonium injection makes the client in cholinergic crisis temporarily worse, with an improvement of symptoms indicating myasthenic crisis

What are Paget's Stages of Cognitive Development?

- 0 to 2 years old: Sensorimotor - 2 to 7 years old: Preoperational - 7 to 11 years old: Concrete Operational - 11 years and older: Formal Operational

The nurse plans care for a client with Grave disease. The nurse intervenes when the client drinks which fluid? 1. Whole milk. 2. Beef broth. 3. Orange juice. 4. Iced tea.

4. Iced tea — Tea is a caffeinated beverage, a stimulant that would increase metabolic rate. The client with Grave disease is in danger due to an already high metabolic rate.

The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first? 1. Monitor vital signs every 15 minutes. 2. Administer bromocriptine as prescribed. 3. Administer the haloperidol as prescribed. 4. Assess the client's level of consciousness.

2. Administer bromocriptine as prescribed. - NMS is a life-threatening complication. The nurse needs to manage fluid balance, reduce client temperature, and monitor for complications. The nurse should discontinue antipsychotic medications and administer bromocriptine (a medication to counteract the effects of NMS) and dantrolene as prescribed.

The nurse provides care for a client who experienced sudden loss of central vision. The health care provider's examination reveals neovascular exudate age-related macular degeneration (ARMD). Which information is most important for the nurse to assess? 1. Allergies to medication and food. 2. Thoughts about vision loss. 3. Medications for hypertension. 4. History of smoking.

2. Thoughts about vision loss. — Because the loss of vision is permanent, it is important for the nurse to allow the client to verbalize thoughts and fears about the future and to assist the client to maximize remaining vision. This information is most important for the nurse to assess. Think like a nurse: Age-related macular degeneration (ARMD) is the leading cause of irreversible vision loss in the industrialized world, and its onset can be acute or insidious. Though peripheral visual acuity usually remains intact, clients with ARMD typically report painless, progressive blurring or central visual acuity distortion. The nurse should assess the client's level of understanding about ARMD and the potential risk for permanent vision loss. The nurse can help explain and clarify the client's understanding of the treatment plan for ARMD. The nurse should keep in mind that clients with ARMD have been shown to have an increased risk for depression and frequent falls. The nurse should screen affected clients for depression and institute fall-prevention strategies.

The nurse develops a plan of care for a client diagnosed with dementia. Which intervention is important for the nurse to include in the plan of care? 1. Reinforce the client 's distorted thought patterns. 2. Use simple, short phrases when speaking with the client. 3. Administer anti-anxiety medication. 4. Plan a regular exercise program.

2. Use simple, short phrases when speaking with the client. - Using simple, short phrases can enhance a client 's ability to process information given. Think like a nurse: When planning communication with a client diagnosed with dementia, the nurse needs to understand the client's limitations. The client with dementia may not be able to process large amounts of information. The best approach is to use short statements with simple words to enhance this client's comprehension, and to understand that information may need to be presented more than one time. Regular conversation may cause the client to become more confused and exacerbate the symptoms.

The nurse manager on the oncology unit makes rounds during the day shift. Which observation by the manager requires an immediate intervention? 1. Wearing gloves, the nurse firmly seals all four edges of the sterile gauze dressing at an IV catheter insertion site with tape. 2. Using a marking pen, the nurse labels an IV fluid bag with the date and time the IV was initiated and the nurse's initials. 3. The nurse secures aluminum foil around a hanging IV solution of nitroprusside. 4. The nurse wears a cap, mask, gown, and gloves when initiating a peripherally inserted central catheter (PICC) line.

2. Using a marking pen, the nurse labels an IV fluid bag with the date and time the IV was initiated and the nurse's initials. — A marking pen should not be used to label an IV bag, especially directly on the plastic IV bag. Ink can penetrate the plastic and diffuse into the solution, posing a risk to the client. Labeling should be done on a label or tape using a regular pen and then placed on the IV bag. Think like a nurse: The nurse needs to understand the reason for institutional policies, procedures, and protocols; understanding promotes compliance. As a professional, nurses also need to keep abreast of best practices, which can change with research. Ink should not be placed directly onto the intravenous infusion bag since the chemicals within the ink can be absorbed by the plastic and inadvertently contaminate the solution. A time tape should be placed along the mL markings of the solution bag where the nurse can document the expected infusion amount and time.

Cefuroxime sodium, 1g in 50 mL NS, is to be administered over 30 minutes. The drop factor is 15 gtt/1 mL. The nurse sets the flow rate at how many drops/minute.

25 drops/minute Total Volume x Drop Factor/Time in Minutes = Drops per minute 50 mL x 15 gtt/30 minutes = 25 drops/min

Which client is at risk for the development of a potassium level of 5.5 mEq/L? 1. The client with colitis. 2. The client with Cushing's Syndrome. 3. The client who has been overusing laxatives. 4. The client who has sustained a traumatic burn.

4. The client who has sustained a traumatic burn. - At risk for hyperkalemia: cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, metabolic/respiratory acidosis. - At risk for hypokalemia: Client with Cushing's Syndrome, colitis, and/or a client who has been overusing laxatives.

The nurse teaches a group of adolescent parents about infant nutrition and feeding. Which point does the nurse include in the teaching? 1. Sweeten foods with honey, not sugar. 2. Introduce fruit juice at age 4 months. 3. Avoid use of no-spill cups that require sucking. 4. Introduce strained, pureed, or mashed meats at 6 months of age.

3. Avoid use of no-spill cups that require sucking. - The use of no-spill cups that requiring sucking is not recommended because they do not encourage the infant to learn to drink from a cup. Additionally, they allow juice or milk to be in constant contact with the teeth, increasing the risk for dental caries. Think like a nurse: Nutrition and feeding guidelines change over time, requiring the nurse to remain current on published evidence. Additionally, recommendations from health care providers differ based on personal experience and interpretation of guidelines. For example, one health care provider may suggest starting foods at 4 months while another may suggest waiting until 6 months of age. Parents should also be taught to watch their child for readiness cues related to food and use of eating and drinking equipment.

The nurse provides care for a client who requires neurological checks every 2 hours. The nurse identifies which components as part of the Glasgow Coma Scale (GCS)? (Select all that apply.) 1. Eye-opening response — partially. 2. Best motor response — unsteady gait. 3. Best verbal response — confused. 4. Eye-opening response — none. 5. Best verbal response — incomprehensible sounds. 6. Best motor response — localizes pain.

3. Best verbal response — confused. 4. Eye-opening response — none. 5. Best verbal response — incomprehensible sounds. 6. Best motor response — localizes pain.

The nurse prepares to assess a client. In which location will the nurse palpate the client's femoral pulse?

Between the ischium (of the pelvis) and the femor

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem? 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation

Peripheral neuritis

A client with severe acne is seen in the clinic where the HCP prescribes isotretinoin. The nurse reviews the client's medication record and would contact the HCP if the client is also taking which medication? 1. Digoxin 2. Phenytoin 3. Vitamin A 4. Furosemide

Vitamin A - Isotretinoin is a metabolite of Vitamin A and can produce generalized intensification of isotretinoin toxicity.

In monitoring a client's response to disease-modifying antirheumatic drugs, which assessment findings would the nurse consider acceptable responses? Select all that apply. 1. Control of symptoms during periods of emotional stress 2. Normal WBC, platelet and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection 6. A low-grade temperature upon rising in the morning that remains throughout the day

1. Control of symptoms during periods of emotional stress 2. Normal WBC, platelet and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy

The nurse is completing a time tape for a 1000 mL IV bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500 mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the tape?

375 mL EXPLANATION: 1000 mL/8 hours = 125 mL/hr 500 mL - 125 mL/hr (1 hour later) = 375 mL

The community health nurse provides care to an older adult client who recently developed decreased hearing acuity. The client's family is concerned because the client insists on taking evening walks alone. Which recommendation by the nurse is most appropriate? 1. "It's best for you to walk in the morning." 2. "Consider visiting an audiologist." 3. "You'll need to find a walking partner." 4. "Carry a cell phone with you at all times."

2. "Consider visiting an audiologist." — Primary concerns for the older adult client include optimizing health and wellness to preserve autonomy and independence. Visiting an audiologist is the most appropriate recommendation, as the audiologist may prescribe hearing aids, which would enhance the client's autonomy and independence. Think like a nurse: The community health nurse should think, "What could I recommend that would help address the client's hearing loss and the family's concerns regarding the client's safety?" An audiologist can help assess the client's hearing loss and recommend possible solutions. Insisting that the client walk with a partner diminishes the client's independence. A client with hearing loss may not hear approaching people or vehicles, increasing the risk for client harm. This risk remains present regardless of the time of day. Carrying a cellphone enables the client to call for help should a problem arise, but it does not protect the client from harm.

The nurse analyzes the lab results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? 1. Platelet count 2. Hematocrit. 3. Hemoglobin level. 4. Partial thromboplastin time.

Partial thromboplastin time. - Platelet count and H&H will be normal, but clotting time (aPTT) will be abnormal.

A client who uses NSAIDs has been taking Misoprostol. The nurse determines that the Misoprostol is having the intended therapeutic effect if which finding is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased WBC count

Relief of epigastric pain - Since clients who use NSAIDs are prone to gastric mucosal injury, Misoprostol is prescribed as a gastric protectant. Diarrhea can be a side effect, but is not an intended effect.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities. 2. Addiction of the arms at the shoulder. 3. Rigid extension and pronation of the arms and legs. 4. Abnormal flexion of the upper extremities and extension and addiction of the lower extremities.

Rigid extension and pronation of the arms and legs. https://youtu.be/jfj7vEmfmH4

The HCP prescribes exenatide for a client with T1DM who takes insulin. The nurse should plan to take which most appropriate intervention? 1. Withhold the medication and call the HCP, questioning the prescription for the client. 2. Administer the medication within 60 minutes before the morning and evening meal. 3. Monitor the client for gastrointestinal side effects after administering the medication. 4. Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

Withhold the medication and call the HCP, questioning the prescription for the client. - Exenatide is an incretin used for T2DM only.

A client is prescribed cephalexin 250 mg by mouth every 12 hours. The medication is available in 500 mg/tablet. Which number of tablets will the nurse administer to the client? (Round at the end of the equation. Record your answer using one decimal place.)

0.5 tablets 500/1 = 250/x 500x = 250 x = 0.5 tablets

The nurse provides care to an older adult client. Which age-related change causes the nurse to carefully monitor the client's fluid and electrolyte balance? 1. Hyponatremia. 2. Hyperkalemia. 3. Increased plasma oncotic pressures. 4. Decreased insensible fluid loss.

1. Hyponatremia. - An increase in antidiuretic hormone and atrial natriuretic peptide, and a decrease in renin and aldosterone, lead to decreased sodium reabsorption and increased water retention by the kidneys, which can cause low sodium or hyponatremia.

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which finding indicate the presence of a side effect with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance

1. Insomnia 2. Weight loss 5. Mild heat intolerance - Bradycardia and constipation are S/S of hypothyroidism, not side effects of the medication.

The nurse is monitoring a client who was diagnosed with Type 1 DM and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps

1. Tremors 3. Irritability 4. Nervousness - Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more characteristic of hyperglycemia and options 2 & 6 are unrelated to hypoglycemia.

A HCP prescription reads Phenytoin 0.2g orally twice daily. The medication label states that each capsule is 100 mg. The nurse prepares how many capsule(s) to administer one dose.

2 capsules Desired x capsule(s)/available = capsule(s)/dose 200 mg x 1 capsule/100 mg = 2 capsules

A healthcare provider's prescription reads Clindamycin Phosphate 0.3g in 50 mL NS to be administered IV over 30 minutes. The medication label Clindamycin Phosphate 900 mg in 6 mL. The nurse administers how many mL of the medication to administer the correct dose?

2 mL Desired x mL/Available = mL/dose 300 mg x 6mL/900 = 2 mL

Which of the following patients are at risk for developing Cushing's Syndrome? 1. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. 2. A patient taking glucocorticoids for several weeks. 3. A patient with a tuberculosis infection. 4. A patient who is post-opt from an adrenalectomy.

2. A patient taking glucocorticoids for several weeks. A patient taking glucocorticoids for several weeks. Remember that CUSHING'S DISEASE is caused by the pituitary gland producing too much ACTH which in turn increases cortisol. Cushing's SYNDROME is caused by medication therapy of glucocorticoids. An adrenalectomy is a treatment for Cushing's Disease (so this is not the answer in this case) and TB is a risk factor for developing ADDISON'S Disease.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and PACO2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 1.3 mEq/L 4. Phosphorus level of 3.0 mg/dL

2. Potassium level of 3.0 mEq/L (Normal 3.5-5 mEq/L) - The potassium levels are the only abnormal lab value among the answers, indicating hypokalemia. Additionally, hypokalemia is a side effect of respiratory alkalosis.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum

3 days postpartum

The nurse is reading a healthcare providers (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL/day." The nurse makes a notation that inselible fluid loss occurs through which type of excretion? 1. Urinary output. 2. Wound drainage. 3. Integumentary output. 4. The gastrointestinal tract.

3. Integumentary output. - Insensible loss: seen through the skin and lungs - Sensible loss: urination, wound drainage, and gastrointestinal tract losses.

The nurse finds a school-age client having a tonic-clonic seizure. Which action will the nurse take first? 1. Call for help. 2. Place a padded tongue blade between the teeth. 3. Place a pillow under the head. 4. Straddle the legs and hold the arms.

3. Place a pillow under the head. — The client needs to be protected from injury. Depending upon where the client is located, placing a pillow under the head would prevent head trauma.

A nurse teaches a client who is being discharged home. The client has a T-tube after an open cholecystectomy. Which statement made by the client requires clarification by the nurse? 1. "The T-tube allows the bile to flow into my intestines. " 2. "I will measure and record the amount of drainage twice a day. " 3. "I will be careful to protect the skin around the T-tube site. " 4. "My T-tube should drain about 3 cups of bile per day. "

4. "My T-tube should drain about 3 cups of bile per day. " - The expected daily output from T-tubes is approximately 400 mL, or a little more than 1-1.5 cups. More than 3 cups, or 800 mL, per day is too much and requires the attention of the health care provider. The client needs to have this information reviewed.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1. U waves. 2. Widened T waves. 3. Prominent U wave. 4. Prolonged QT interval. 5. Prolonged ST segment.

4. Prolonged QT interval. 5. Prolonged ST segment. - A shortened ST segment and widener T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH 7.12, PaCO2 90 mm Hg, and HCO3- 22 mEq/L. The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation. 2. Respiratory acidosis with compensation. 3. Metabolic acidosis without compensation. 4. Respiratory acidosis without compensation.

4. Respiratory acidosis without compensation. - The pH is below normal limits, indicating acidosis and the PaCO2 is elevated, indicating an respiratory issue. Given the pH is outside of the normal range and the HCO3- is within normal limits (not elevated) the condition is not compensated.

The nurse is caring for a client following a craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I: Olfactory 2. Cranial nerve IV: Trochlear 3. Cranial nerve III: Oculomotor 4. Cranial nerve VIII: Facial Nerve

Cranial nerve VIII: Facial Nerve - An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (Cranial Nerve VIII) enters the internal auditory canal.

The nurse is planning to administer hydrochlorothiazide to a client. The nurse should monitor for which adverse effects related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Increased risk of osteoporosis 3. Hypokalemia, hyperglycemia, sulfa allergy 4. Hyperkalemia, hypoglycemia, penicillin allergy

Hypokalemia, hyperglycemia, sulfa allergy - Clients are at risk for hypokalemia, hypercalcemia, hyperlipidemia, and hyperuricemia (excess uric acid in the blood). In addition, hydrochlorothiazide is a sulfa-based medication.

The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify? 1. Leg exercises 2. Early ambulation 3. Irrigating the nasogastric tube 4. Coughing and deep-breathing exercises

Irrigating the nasogastric tube - A nurse should never irrigate or reposition the gastric tube unless prescribed by the HCP. - Options 1, 2, & 4 are appropriate.

A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings? 1) pH 7.25, PCO2 50 2) pH 7.35, PCO2 40 3) pH 7.50, PCO2 52 4) pH 7.52, PCO2 28

pH 7.25, PCO2 50 - Note the opposite reaction of pH and PCO2, indicating a respiratory issue. With a low pH the condition is acidotic.

A nurse with postpartum care experience is reassigned to a medical-surgical care area. Which client will the charge nurse assign to the postpartum care nurse? 1. Client with facial trauma after a motor vehicle crash. 2. Client with heat stroke. 3. Client having a systemic reaction to latex. 4. Client with progressive systemic sclerosis who is experiencing Raynaud phenomenon.

Client with progressive systemic sclerosis who is experiencing Raynaud phenomenon. — Progressive systemic sclerosis is a chronic connective tissue disease that causes inflammation, fibrosis, and sclerosis of the skin and vital organs. This is a stable client who can be assigned the nurse with postpartum care experience.

A client with trigeminal neuralgia tells the nurse that they take acetaminophen daily for relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? 1. Sodium level: 140 mEq/L 2. Platelet count: 400,000 mm 3. Prothrombin time: 12 seconds 4. Direct bilirubin level: 2 mg/dL

Direct bilirubin level: 2 mg/dL - Normal direct bilirubin level: 0.1-0.3 mg/dL. In adults, overdose of acetaminophen causes liver damage.

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which intervention is most appropriate? 1. Clamp the T-tube 2. Irrigate the T-tube 3. Document the findings 4. Notify the HCP

Document the findings - Following a cholecystectomy drainage from the T-tube is initially bloody and then turns greenish-brown. The amount of expected drainage will range from 500-1000 mL/day.

A client diagnosed with viral hepatitis is complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is less severe. 4. Eat less often, preferably only 3 large meals/day.

Eat a good supper when anorexia is less severe - Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet, as fat may be tolerated poorly due to decreased bile production. Small, frequent meals are preferable and may even prevent nausea, with a better appetite in the morning. An adequate fluid intake of 2500-3000 mL/day that includes juices is also important.

The clinic nurse reviews the record of an infant and notes that the HCP has documented a diagnosis of suspected Hirschsprung's Disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? 1. Diarrhea 2. Projectile vomiting 3. Regurgitation of feedings 4. Foul-smelling ribbon-like stools

Foul-smelling ribbon-like stools - Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul smelling is a clinical manifestation of this disorder.

The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood discharge teaching? 1. I should keep the insulin in the cabinet during the day only 2. I know I have to keep my insulin in the refrigerator at all times 3. I can store the open insulin bottle in the kitchen cabinet for 1 month 4. The best place for my insulin is on the window sill, but in the cupboard is just as good

I can store the open insulin bottle in the kitchen cabinet for 1 month - An insulin vial in current use can be kept at room temperature for 1 month without significant loss of activity.

The nurse is caring for a client following enucleation and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? 1. Document the finding 2. Continue to monitor the drainage 3. Notify the HCP 4. Mark the drainage on the dressing and monitor for any increase in bleeding

Notify the HCP - Presence of bright red drainage indicates hemorrhage, thus must be reported to HCP

A client who is HIV+ has had a tuberculin skin test (TST). The nurse notes a 7mm area of induration at the site of the skin test and interprets the result as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Need for repeat testing

Positive - HIV+ patients are considered to be positive for TST with an area of induration larger than 5mmm vs the 10mm minimum for non HIV+ patients.

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is an anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses. 2. Brisk bleeding from the site. 3. Decreasing edema formation. 4. Formation of granulation tissue.

Return of distal pulses. - Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn.

A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? 1. The medication will help dilate the eye to prevent pressure from occurring 2. The medication will relax the muscles of the eyes and prevent blurred vision 3. The medication causes the pupil to constrict and will lower the pressure in the eye 4. The medication will help block the responses sent to the muscles of the eye.

The medication causes the pupil to constrict and will lower the pressure in the eye - Miotics cause pupillary constriction, used to treat glaucoma, to lower the IOP, thereby increasing blood flow to the retina, decreasing retinal damage and loss of vision.

The nurse observes children playing at a community picnic. Which situation is the most important for the nurse to intervene? 1. School-aged child picking at a scab located on the knee. 2. Preschooler running with a lollipop in the mouth. 3. Toddler lying on the ground kicking and screaming with the parents close by. 4. Infant lying on the back, head to the right side with the left arm and leg bent.

1. School-aged child picking at a scab located on the knee. INCORRECT - Picking at a scab can cause infection and delayed wound healing, but this is not a priority for the nurse to intervene. 2. Preschooler running with a lollipop in the mouth. CORRECT - The child running with a lollipop can fall, puncture the oral cavity, and possibly obstruct the airway. The nurse should intervene. 3. Toddler lying on the ground kicking and screaming with the parents close by. INCORRECT - The toddler kicking and screaming is experiencing a tantrum. Ignoring this behavior is the best approach. 4. Infant lying on the back, head to the right side with the left arm and leg bent. INCORRECT - The infant lying with the head to the right and the left and arm and leg bent describes the tonic neck reflex. There is no need for intervention by the nurse.

A HCP prescribes heparin sodium, 1300 units/hr by continuous IV infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many mL/hr to deliver 1300 units/hr? Record your answer to the nearest whole number.

16 mL/hr Known amount of medication in solution/total volume of diluent = amount of medication per mm 20,000 units/250 mL = 80 units/mL Doses per hour desired/concentration per mL = infusion rate 1300 units/80 units per mL = 16.25 or 16 mL/hr

The nurse performs an assessment of a 2-year-old client. The nurse expects which findings? (Select all that apply.) 1. The child jumps with both feet. 2. The child kicks a ball without falling. 3. The child rides a tricycle unassisted. 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. 4. The child builds a block tower of six blocks. 5. The child uses two-to-three-word phrases.

A nurse performs developmental age assessments on several pediatric clients. The nurse determines that which finding is priority for further assessment? 1. The 6-month-old who sits alone to play. 2. The 3-month-old who has a strong grasp reflex. 3. The 13-month-old who cannot place cereal in mouth. 4. The 10-month-old who cannot pull to stand up.

3. The 13-month-old who cannot place cereal in mouth. - Bringing objects to the mouth usually occurs between 4 and 6 months, with finger eating occurring between 10 and 12 months. The ability to grasp cereal between the thumb and index finger should occur around 9 months. This child is experiencing a developmental delay that requires assessment. Think like a nurse: A 13-month-old who cannot place cereal in mouth indicates a potential developmental delay. The nurse should perform developmental screening to determine if intensive testing and assessment is warranted. When developmental delay is suspected, frequent surveillance is required. Also important to note is when a child loses a developmental milestone. For example, the child who previously could sit without support and now cannot will require full evaluation since it may indicate a neurological problem.

The nursing student is presenting at a clinical conference and discusses the cause of B-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these? 1. A child of Mexican decent. 2. A child of Mediterranean decent. 3. A child whose intake of iron is extremely poor. 4. A breast fed child of a mother with chronic anemia.

A child of Mediterranean decent. - B-thalassemia is an autosomal recessive disorder characterized by the reduced production of 1 of the globin chains in the synthesis of hemoglobin. This disorder is found primarily in individuals in Mediterranean decent, but both parents must be carriers to produce an off-spring with the disorder.

The nurse provides care for a client who had an above the knee amputation. Which intervention reduces phantom limb sensation? 1. A low dose of an opioid. 2. Mirror therapy. 3. Psychotherapy. 4. A low dose of a sedative.

2. Mirror therapy. — The mirror is thought to provide visual information to the brain, replacing sensory feedback expected from the missing limb.

The client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1. I don't believe this is true. 2. The guards aren't out to kill you. 3. Do you feel afraid that people are trying to hurt you? 4. What makes you think the guards were sent to hurt you?

3. Do you feel afraid that people are trying to hurt you? - It is most therapeutic for the nurse to empathize with the client's experience

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are are still intact and she is at a -2 station. The HCP prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix. 2. Decreased number of contractions. 3. Increased efficiency of contractions. 4. The need for increased maternal blood pressure monitoring. 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord.

3. Increased efficiency of contractions. 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord. - There is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

The nurse in the emergency department (ED) is notified that multiple workers in a local plant have been exposed to radioactive materials and will be arriving shortly. Which action does the nurse take first? 1. Set up decontamination stations outside of the emergency department. 2. Locate the nuclear exposure immediate reaction kit. 3. Notify the Director of Nursing of the incident. 4. Obtain official verification that the incident has occurred.

3. Notify the Director of Nursing of the incident. - While preparing for decontamination may be required, the priority is to notify the hospital administration in order to initiate the disaster plan.

An older adult client asks the nurse to explain therapeutic massage since the health care provider recommended it as treatment. Which response by the nurse is appropriate? 1. "It decreases fluid retention." 2. "It helps to resolve blood clots in legs." 3. "It decreases hypertension." 4. "It improves circulation and muscle tone."

4. "It improves circulation and muscle tone." - Therapeutic massage will help improve circulation and muscle tone, particularly in older clients.

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with the medication? 1. Insomnia 2. Constipation 3. Hypotension 4. Bronchospasm

Bronchospasm - Side Effects: bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritis N/D, and myalgia.

The nurse is administrating a cleansing enema to a client with a fecal impaction. Before administrating the enema, the nurse should place the client in which position? 1. Left Sim's position. 2. Right Sim's position. 3. On the left side of the body, with the head of the bed elevated 45 degrees. 4. On the right side of the body, with the head of the bed elevated 45 degrees.

Left Sim's position. - The client should be placed in this position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed should not be elevated.

What are the signs of a delayed transfusion reaction?

S/S: Fever, mild jaundice, and a decreased hematocrit level

What are the symptoms of septicemia?

Signs include: chills, fever, vomiting, diarrhea, hypotension, and the development of shock.

A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function test 4. WBC count

WBC count - A client taking clozapine may experience agranulocytosis which is monitored by reviewing the results of WBC count. Treatment is interrupted if WBC count drops below 3000 mm, since agranulocytosis can be fatal if left untreated.

A client being hemodialyzed becomes short of breath and complains of chest pain. The client is tachycardic, pale and anxious, causing the nurse to suspect an air embolism. What are the priority nursing actions? Select all that apply. 1. Administer oxygen to the client. 2. Continue dialysis at a slower rate after checking the lines for air. 3. Notify the HCP and rapid response team. 4. Stop dialysis and turn the client on their left side with their head lower than their feet. 5. Bolus the client with 500 mL of normal saline to break up the air embolism.

1. Administer oxygen to the client. 3. Notify the HCP and rapid response team. 4. Stop dialysis and turn the client on their left side with their head lower than their feet.

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L 2. 3.8 mEq/L 3. 4.2 mEq/L 4. 4.8 mEq/L

3.2 mEq/L - Normal range: 3.5 -5.0 mEq/L Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias.

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid iron supplement. Which instruction should the nurse tell the parents? 1. Administer the iron at mealtimes. 2. Administer the iron through a straw. 3. Mix the iron with cereal to administer. 4. Add the iron to formula for easy administration.

Administer the iron through a straw - A straw or medicine dropper should be used to administer the iron supplement at the back of the mouth because iron stains the teeth. The client should brush their teeth after administration. - Iron supplements should be take in between meals, since food inhibits the absorption of iron and iron needs an acidic environment for absorption.

A client has begin therapy with theophyllne. The nurse should plan to teach the client to limit the intake of which items while taking this medication? 1. Coffee, cola, and chocolate. 2. Oyster, lobster and shrimp. 3. Melons, oranges, and pineapple. 4. Cottage cheese, cream cheese, and dairy creamers.

Coffee, cola, and chocolate - A patient taking theophyllne should limit the intake of xanthine containing foods.

The nurse provides care to a client diagnosed with a negative nitrogen balance. Which dietary selection is most appropriate for the nurse to recommend to the client? 1. Rice cereal. 2. Celery. 3. Green peas. 4. Salmon.

Salmon - Fish, including salmon, is a complete protein, also called a high-quality protein. Fish contains all of the essential amino acids in sufficient quantity to support growth and maintain nitrogen balance. A negative nitrogen balance indicates tissue destruction.

A client receiving a transfusion of packed red blood cells begins to vomit. The clients blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The clients temperature is 100.8 F orally from a baseline of 99.2 F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload. 4. Delayed transfusion reaction

Septicemia - Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include: chills, fever, vomiting, diarrhea, hypotension, and the development of shock.

The nurse admits a client diagnosed with bipolar disorder. Which assessment requires immediate attention by the nurse? 1. The client has not eaten breakfast, lunch, or dinner. 2. The client has been pacing the hallway for 15 minutes. 3. The client is wearing a loose dress without undergarments. 4. The client makes statements about being rich and powerful.

1. The client has not eaten breakfast, lunch, or dinner. - This is a physical vs. psychological need. Because of the client's poor judgment, dehydration and poor nutrition put the patient at risk for injury.

Gentamicin sulfate, 80 mg in 100 mL, NS, is to be administered over 30 minutes. The drop factor is 10 gtt/1 mL. The nurse sets the flow rate at how many drops/minute. Record your answer to the nearest whole number.

33 drops/minute Total Volume x Drop Factor/Time in Minutes = drops per minute 100 mL x 10 gtt/30 = 33.33 or 33 drops/min

The nurse provides care for a client who is scheduled to receive spinal anesthesia. It is most important for the nurse to take which action when providing care to this client? 1. Ensure that the client is adequately hydrated before the procedure. 2. Assess for allergies to iodine. 3. Ensure that the client does not eat for 12 hours before the procedure. 4. Determine the specific gravity of the client's urine.

1. Ensure that the client is adequately hydrated before the procedure. - This addresses the circulatory concern of hypotension. Spinal anesthesia is associated with hypotension. Adequate fluid hydration is key to prevent hypotension and hypotension-related injury.

When providing care for a client diagnosed with primary adrenocortical insufficiency, which laboratory findings does the nurse expect? 1. Sodium 148 mEq/L (148 mmol/L), glucose 110 mg/dL (6.1 mmol/L), potassium 3.7 mEq/L (3.7 mmol/L). 2. Sodium 130 mEq/L (130 mmol/L), glucose 50 mg/dL (2.8 mmol/L), potassium 5.3 mEq/L (5.3 mmol/L). 3. Sodium 160 mEq/L (160 mmol/L), glucose 45 mg/dL (2.5 mmol/L), potassium 5.5 mEq/L (5.5 mmol/L). 4. Sodium 140 mEq/L (140 mmol/L), glucose 90 mg/dL (5 mmol/L), potassium 3.9 mEq/L (3.9 mmol/L).

2. Sodium 130 mEq/L (130 mmol/L), glucose 50 mg/dL (2.8 mmol/L), potassium 5.3 mEq/L (5.3 mmol/L). — Hyponatremia, hypoglycemia, and hyperkalemia are expected findings in this client.

The arterial blood gas (ABG) results of a client with diabetic ketoacidosis (DKA) are pH 7.2, PaCO2 35 mm Hg, HCO3 17 mEq/L, and PaO2 89 mm Hg. Which health care provider prescription requires the nurse to intervene? 1. Apply oxygen per nasal cannula at 2 L per minute. 2. Assess capillary glucose level every hour. 3. Give sodium bicarbonate, per prescription. 4. Repeat arterial blood gas (ABG) readings in 2 hours.

3. Give sodium bicarbonate, per prescription. - Sodium bicarbonate is only given if the pH is 6.9 or lower.

The nurse finds a visitor slumped to the floor of a client's room during visiting hours at the hospital. Which action does the nurse take initially? 1. Start rescue breathing and chest compressions. 2. Call for help. 3. Shake the visitor and shout, "Are you all right?" 4. Listen for breath sounds.

3. Shake the visitor and shout, "Are you all right?" — The nurse should assess for unconsciousness. Then call for help. Think like a nurse: The nurse is trained to perform emergency care whenever or wherever it is necessary. The situation requires the nurse to determine the person's level of consciousness. This can be determined by gently shaking the individual and asking, "Are you alright?" Depending on the person's response, additional steps in resuscitation may be required, such a calling for help and initiating cardiopulmonary resuscitation (CPR).

The nurse is administrating fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back of the legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

Urine output

The nurse provides care for a client diagnosed with moderate flail chest. Which interventions will the nurse anticipate including on the care plan? (Select all that apply.) 1. Monitor client 's vital signs. 2. Maintain closed-chest drainage system. 3. Administer pain medication. 4. Maintain mechanical ventilation. 5. Monitor arterial blood gases (ABGs).

1. Monitor client 's vital signs. 2. Maintain closed-chest drainage system. 3. Administer pain medication. 4. Maintain mechanical ventilation. 5. Monitor arterial blood gases (ABGs).

Kohlberg's Six Stages of Moral Development

1. Obedience and Punishment (Infancy) 2. Self Interest (Pre-school) 3. Conformity and Interpersonal Accord (School Age) 4. Authority & Social Order (School Age) 5. Social Contract (Teens) 6. Universal Principals (Adulthood)

A client is admitted to the emergency department (ED) with respiratory compromise. Which assessment finding does the nurse document as indicative of a pneumothorax? 1. Rapid respirations. 2. Deep, rapid respirations. 3. Respiratory depression. 4. Periods of hyperpnea alternating with periods of apnea.

1. Rapid respirations. CORRECT— This describes tachypnea, a symptom of pneumothorax. Think like a nurse: The nurse must be able differentiate a pneumothorax from other respiratory issues. Since the client is exhibiting symptoms of a pneumothorax, the nurse should anticipate care to support the client's altered respiratory function. The nurse should immediately notify the health care provider, assess the client's vital signs, administer supplemental oxygen, and prepare the client for an immediate, or STAT, chest x-ray. The client will likely be very anxious, so it is important for the nurse to provide emotional support and encourage relaxation techniques.

The nurse provides care for a postpartum mother who has stopped breastfeeding her newborn. The client reports painful swollen breasts. Which nursing intervention does the nurse include in the client's plan of care? 1. Wear a snug-fitting supportive bra. 2. Have the client massage the breasts gently. 3. Place warm compresses on the breasts. 4. Expel some breast milk.

1. Wear a snug-fitting supportive bra. - To relieve the discomfort of breast engorgement, the mother can take mild analgesics such as ibuprofen, wear a supportive bra, and apply ice packs or cabbage leaves to the breasts.

The school nurse assesses four school-age clients. Which client's parents will be contacted to pick up the child from school? 1. Child with a red rash on the cheeks that makes the face look like it has been slapped. 2. Child with a fever reporting headache, malaise, anorexia, and an earache when chewing. 3. Child with allergies whose conjunctiva are inflamed with swollen eyelids and watery drainage. 4. Child with clusters of small, erythematous, intensely pruritic papules in the antecubital space.

2. Child with a fever reporting headache, malaise, anorexia, and an earache when chewing. - The child with a fever, headache malaise, anorexia, and ear pain with chewing indicates probable mumps. The child is most communicable immediately before and after the swelling begins. Think like a nurse: The child with the communicable disease needs to go home. Symptoms of mumps include fever, headache, malaise, anorexia, and ear pain. The period of time when the disease is most communicable is before and immediately after the swelling begins. The other children with infections are not contagious.

The nurse teaches a client with DM about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom(s) develop? Select all that apply 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2. Shakiness 3. Palpitations 5. Lightheadedness - Shakiness, palpitations and lightheadedness are all signs of hypoglycemia, where polyuria, blurred vision and fruity breath odor are S/S of hyperglycemia.

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which S/S are associated with this diagnosis? Select all that apply 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face

3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face - Tremors and weight loss are signs of hyperthyroidism

The nurse provides care to a client with suspected cholelithiasis. Which information in the client's health history indicates a risk for this disease process? (Select all that apply.) 1. African American ethnicity. 2. Body mass index of 21. 3. Given birth to 3 children. 4. Being 50 years of age. 5. Fasting for religious reasons.

3. Given birth to 3 children. 4. Being 50 years of age. 5. Fasting for religious reasons - A Native American or U.S. Southwestern Hispanic ethnicity and obesity places a client at risk for cholelithiasis, not African American ethnicity.

The nurse plans care for an older adult client with pernicious anemia who lives at home. Which goal is the most important for the client? 1. Obtain household help during recuperative period. 2. Increase dietary intake of green leafy vegetables. 3. Receive monthly vitamin B-12 injections. 4. Begin a program of moderate exercise.

3. Receive monthly vitamin B-12 injections. - Pernicious anemia is caused by failure to absorb vitamin B-12 because of a deficiency of intrinsic factor from the gastric mucosa. For the client with pernicious anemia, vitamin B-12 is given on a monthly basis. Without it, death may occur within 1 to 3 years.

The nurse completes post-operative teaching for a client scheduled for a total abdominal hysterectomy. Which statement by the client indicates to the nurse the need for further teaching? 1. "I will call the health care provider if I have a temperature greater than 100.0°F (37.7°C)." 2. "I will use sanitary pads until the bleeding stops and will call about increased bleeding." 3. "I will report any problems with urination to my nurse as soon as possible." 4. "I will avoid any activity for the first 24 to 48 hours after my surgery."

4. "I will avoid any activity for the first 24 to 48 hours after my surgery." — The client performs early ambulation to prevent thromboembolism. Also, the client uses techniques such as cough and deep breathing or incentive spirometry, as well as avoids heavy lifting or strenuous activity.

A client with DM has had a right, below-knee amputation. Given the client's history of DM, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of he would edges

Separation of he would edges - Clients with DM are more prone to infection and delayed wound healing.

The nurse assesses a group of clients for risk of developing psoriasis. The nurse identifies which client as being low risk for developing psoriasis? 1. A young adult African American. 2. A client with a family history of the condition. 3. A client reporting prolonged emotional stress. 4. An older adult experiencing menopause.

1. A young adult African American. — The incidence of psoriasis is lower among darker-skinned races. Think like a nurse: The nurse should mentally review the pathophysiologic process of psoriasis along with the etiology and risk factors prior to identifying the client most at risk for the development of the disorder. The reasons for the development of psoriasis vary from being a genetic disorder to being an autoimmune reaction. The one factor that is linked to the development of the disorder is skin color. Psoriasis is more likely to occur in lighter-skinned clients of European descent than in dark-skinned clients. Regardless of the reason, psoriasis has periods of latency and exacerbation that have been linked to stress and hormone imbalances.

A client just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. 1. Administer stool softeners as prescribed. 2. Instruct the client to limit fluid intake to avoid urinary retention. 3. Encourage a high-fiber diet to promote bowel movements without straining. 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed. 5. Help the client to a Folwer's position to place pressure on the rectal area and decreasing bleeding.

1. Administer stool softeners as prescribed. 3. Encourage a high-fiber diet to promote bowel movements without straining. 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.

The nurse provides care for the client diagnosed with chronic gastritis. The nurse intervenes if the LPN/LVN administers which medications to this client? (Select all that apply.) 1. Celecoxib. 2. Sucralfate. 3. Clarithromycin. 4. Naproxen. 5. Pantoprazole.

1. Celecoxib - Use of nonsteroidal anti-inflammatory medications (NSAIDs) is a potential cause of gastritis. Since celecoxib is an NSAID, the nurse needs to intervene if the LPN/LVN attempts to administer this medication. 4. Naproxen Use of nonsteroidal anti-inflammatory medications (NSAIDs) is a potential cause of gastritis. Since naproxen is an NSAID, the nurse needs to intervene if the LPN/LVN attempts to administer this medication.

The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. 1. Checks the expiration date. 2. Inspects for the presence of clots. 3. Checks the blood group and type. 4. Checks the blood identification number. 5. Hangs the blood within the specified time frame per agency policy.

1. Checks the expiration date. 5. Hangs the blood within the specified time frame per agency policy. - A nurse would also inspect for the presence of clots, check the blood group and type, and check the blood identification number, but these are not directly related to the deterioration of the blood cells.

A client who has been diagnosed with hyperthyroidism is being monitored for which S/S indicating a complication of this disorder? Select all that apply 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia

1. Fever 2. Nausea 4. Tremors 5. Confusion - Lethargy and bradycardia are signs of hypothyroidism

A client arrives at the emergency department following a burn injury that occurred in the basement at home and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client. 1. 100% oxygen via an aerosal mask. 2. 6L oxygen via nasal cannula. 3. 15 L oxygen via nasal cannula. 4. 100% oxygen via a tight fitting non-rebreather face mask.

100% oxygen via a tight fitting non-rebreather face mask.

A client is prescribed aminophylline PO. Which client statement concerns the nurse? 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."

2. "I am taking propranolol." — Co-administration of propranolol and aminophylline should be avoided, as propranolol may decrease the body's ability to metabolize the aminophylline and lead to toxicity. The nurse holds the aminophylline and notify the health care provider.

The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1. Seizures 2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias 5. Hepatotoxicity

2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias - Aminoglycoside are administered to inhibit the growth of bacteria. - Adverse effects: confusion, ototoxicty, renal toxicity, gastrointestinal irritation, palpitations or dysrhythmias, blood pressure changes and hypersensitivity reactions.

An infant is scheduled for surgery to repair a congenital heart defect. The infant's parent begins to cry and says, "I'm a terrible parent!" Which response by the nurse is best? 1. "Do you think that you caused the heart defect?" 2. "Would you like a hug?" 3. "I will be back to check on you." 4. "This is a difficult time for you."

4. "This is a difficult time for you." — This open-ended statement reflects the emotion that the parent is expressing and encourages further communication.

The triage nurse prioritizes clients to be evaluated in the emergency department. Which client does the nurse assess first? 1. A 3-year old with a fever, an earache, and vomiting since yesterday. 2. A 5-year old reporting leg and arm pain after falling from a treehouse. 3. A 21-year old at 8 weeks' gestation reporting unilateral abdominal pain. 4. A 40-year old who reports nausea, general anxiety, and is diaphoretic.

4. A 40-year old who reports nausea, general anxiety, and is diaphoretic. - Even though not complaining of chest pain, these symptoms should be treated as a potential MI. A cardiac workup should be performed immediately. Think like a nurse: Nausea, general anxiety, and diaphoresis are non-specific manifestations of myocardial ischemia. The nurse should immediately consider obtaining a 12-lead ECG and cardiac markers. In addition to frequent vital signs monitoring, the nurse should also obtain baseline electrolyte panel and CBC, screen client for possible fibrinolytic therapy, establish an IV access, and implement the protocol for acute coronary syndrome (ACS). The nurse should also anticipate a portable chest X-ray for the client.

Addison's Disease is: 1. Increased secretion of cortisol 2. Increased secretion of aldosterone and cortisol 3. Decreased secretion of cortisol 4. Decreased secretion of aldosterone and cortisol

4. Decreased secretion of aldosterone and cortisol

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the client's HCP? 1. A decreased dosage of Levothyroxine 2. An increased dosage of Levothyroxine 3. A decreased dosage of warfarin sodium 4. An increased dose of warfarin sodium

A decreased dosage of warfarin sodium - Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors, as a result, the effects of warfarin are enhanced.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? 1. A defect in the cochlea. 2. A defect in cranial nerve VIII. 3. A physical obstruction to the transmission of sound waves. 4. A defect in the sensory fibers that lead to the cerebral cortex.

A physical obstruction to the transmission of sound waves. - A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex.

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication? 1. Should always be taken with foods or antacids. 2. Should be double-dosed if 1 dose is forgotten. 3. Causes orange discoloration of sweat, tears, urine and feces. 4. May be discontinued immediately if symptoms are gone in 3 months.

Causes orange discoloration of sweat, tears, urine and feces - And with stain soft contact lenses permanently.

A client with a urinary tract infection is receiving ciproflaxin by the IV route. The nurse appropriately administers the medication by performing which action? 1. Infusing slowly over 60 minutes 2. Infusing in a light-protective bag 3. Infusing only through a central line 4. Infusing rapidly as a direct IV push medication

Infusing slowly over 60 minutes - Ciproflaxin is prescribed for treatment of mild, moderate, severe, and complicated infections of the urinary tract, lower respiratory tract, and skin/skin stricture. The medication is administered slowly over 60 minutes to minimize discomfort and vein irritation.

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? 1. Platelet count 2. Neutrophil count 3. Liver function test 4. Complete blood count

Liver function test - Zafirlukast is used with caution in clients with impaired hepatic function.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL. Which dietary selection does the nurse suggest to the client? 1. Roast pork 2. Cheese omelet 3. Pasta with sauce 4. Tuna fish sandwich

Pasta with sauce - Normal reference level: 10-80 mcg/dL. Since the liver breaks down protein, which results in the formation of ammonia, so food high in protein should be avoided, leaving pasta with sauce as the best choice.

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? 1. Avoiding infection. 2. Taking in adequate fluids. 3. Preventing and recognizing hypoglycemia. 4. Preventing and recognizing hyperglycemia

Preventing and recognizing hyperglycemia - Normal A1C range 4-6%.

The nurse is reviewing the lab results for a child scheduled for a tonsillectomy. The nurse determines that which lab value is the most significant to review? 1. Creatinine level 2. Prothrombin time 3. Sedimentation rate 4. Blood urea nitrogen level

Prothrombin time - Since the tonsils are so vascular, postoperative bleeding is a concern, and prothrombin time, partial thromboplastin time, platelet count, H&H, WBC, and urinalysis are performed preoperatively.

The nurse is assigned to care for a group of clients. On review of the clients medical record, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with a ileostomy. 2. A client with heart failure. 3. A client on long-term cotricosteroid therapy. 4. A client receiving frequent wound irrigation.

1. A client with a ileostomy. - Causes: vomiting, diarrhea, conditions that cause increased respirations or decreased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of ileostomy or colostomy. - Fluid volume excess: a client with heart failure, a client on long-term cotricosteroid therapy, a client receiving frequent wound irrigation.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. 1. Broth 2. Coffee 3. Gelatin 4. Pudding 5. Vegetable juice 6. Pureed vegetables

1. Broth 2. Coffee 3. Gelatin - A clear liquid diet consists of foods that are relatively transparent to light, are clear and liquid at room and body temperature. Such liquids include: water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular/decaffeinated coffee or tea.

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs participants that tuberculosis is considered a diagnosis of which signs and symptoms are present? Select all that apply. 1. Dyspnea 2. Headache 3. Night sweats 4. A bloody, productive cough 5. A cough with expectoration of mucoid sputum

1. Dyspnea 3. Night sweats 4. A bloody, productive cough 5. A cough with expectoration of mucoid sputum

A client with acute kidney injury has a serum potassium level of 7.0 mEq/L. The nurse should plan which actions as a priority? Select all that apply 1. Place the client on a cardiac monitor 2. Notify the HCP 3. Put the client on NPO except for ice chips 4. Review the client's medication list to determine if any contain or retain potassium 5. Allow an extra 500 mL of IV fluid intake to dilute the electrolyte concentration

1. Place the client on a cardiac monitor 2. Notify the HCP 4. Review the client's medication list to determine if any contain or retain potassium - Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium levels significantly

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/min. The ECG monitor displays tachycardia, with a HR of 120 bpm. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? 1) A decreased pH and an increased CO2 2) An increased pH and a decreased CO2 3) A decreased pH and a decreased HCO3- 4) An increased pH with an increased HCO3-

4) An increased pH with an increased HCO3- - Representing metabolic alkalosis

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? 1. Is disoriented to person, place and time 2. Affect is flat, with periods of emotional lability 3. Cannot recall what was eaten for breakfast 4. Demonstrates the inability to add or subtract and does not know who is the president of the US

Affect is flat, with periods of emotional lability - The limbic system is responsible for feelings (affect) and emotions.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins to cough, frothy, pink-finger sputum. Which finding would the nurse anticipate when auscultating the client's breath sound? 1. Stridor 2. Crackles 3. Scattered rhonchi 4. Diminished breath sounds

Crackles - The S/S described are indicative of pulmonary edema and the accumulated fluid would produce a crackles sound.

A client receives isoniazid, rifampin, ethambutol, and pyrazinamide. Which statement made by the client most concerns the nurse? 1. "I seem to be becoming color blind. I can't see green." 2. "My urine and sweat are a reddish-orange color." 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 optic neuritis, with reduced visual acuity. The decreased ability to see green is a possible initial sign. Limiting progressive damage to the optic nerve is the priority for this client.

In the scenario above, what medication do you expect the patient to be started on? 1. IV Solu-Cortef 2. PO Prednisone 3. PO Declomycin 4. IV Insulin

1. IV Solu-Cortef The patient needs cortisol immediately because they are experiencing Addisonian Crisis. IV Solu-Cortef is the best option because it is intravenous and a glucocorticoid. The patient is unconscious and can not take oral medications, therefore Prednisone is not the best option and all the other options are incorrect.

The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which findings would the nurse expect to note in assessment of this client? Select all that apply. 1. A low arterial PCO2 level 2. A hyperventilated chest noted on x-ray 3. Decreased O2 saturation with mild exercise 4. A widened diaphragm noted on the x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

2. A hyperventilated chest noted on x-ray 3. Decreased O2 saturation with mild exercise - COPD clinical manifestations: hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and use of accessory muscles of respiration. Chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function test with demonstrate decreased vital capacity.

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that a melanoma has what characteristics? Select all that apply 1. Lesion is painful to the touch. 2. Lesion is highly metastatic. 3. Lesion is a nevus that has changes in color. 4. Skin under the lesion is reddened and warm to the touch. 5. Lesions occur in the body area exposed to outdoor sunlight.

2. Lesion is highly metastatic. 3. Lesion is a nevus that has changes in color.

A client is diagnosed with a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply 1. Flatulence 2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation 6. Lactose intolerance

2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation

The nurse is caring for a client with heart failure who is receiving high doses of diuretic. On assessment the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches. 2. Decreased urinary output. 3. Hyperactive bowel sounds. 4. Increased specific gravity of their urine.

3. Hyperactive bowel sounds. - Hyponatremia: muscle weakness, increased urinary output, and decreased specific gravity of urine. - Hypernatremia: muscle twitches, decreased urinary output, and increased urine specific gravity.

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? 1. Bile stained fecal emesis. 2. The passage of current jelly-like stools. 3. Failure to pass meconium stool in the first 24 hours after birth. 4. Sausage-shaped mass palpated in the upper, right abdominal quadrant.

Failure to pass meconium stool in the first 24 hours after birth. - Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum.

The nurse is caring for a client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, pulse, respirations and decreasing blood pressure 2. Increasing temperature, blood pressure and decreasing pulse and respirations 3. Decreasing temperature, pulse, blood pressure and increasing respirations 4. Decreasing temperature and respirations, increasing pulse and blood pressure.

Increasing temperature, blood pressure and decreasing pulse and respirations - A changed in vital signs may be a late sign of increased intracranial pressure

An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. COPD

Iron deficiency anemia - The normal hemoglobin level for an adult female is 12-16 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration, heart failure and COPD may increase the hemoglobin levels.

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which, best position at this time? 1. Prone 2. On the stomach 3. Left-lateral position 4. Right lateral position

Left-lateral position - The infant should not be placed on the side of the repair or prone, to prevent rubbing of the repair site, thus the patient should be placed lateral to the repair or supine and upright to prevent airway obstruction.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? 1. Roll the bottle of solution gently. 2. Obtain a different bottle of solution. 3. Shake the bottle of solution vigorously. 4. Run the bottle of solution under warm water.

Obtain a different bottle of solution. - The nurse should not hang a fat emulsion if the emulsion has separated into layers of fat globules or accumulated into froth.

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which S/S of duodenal ulcer? 1. Weight loss 2. N/V 3. Pain relieved by food intake 4. Pain radiating down the right arm

Pain relieved by food intake - The clients generally describe the pain as a burning, heavy, sharp, or hunger pain that often localized in the mid-epigastric area. The remaining symptoms are representative of a gastric ulcer.

A client with a history of gastrointestinal bleeding has a platlet count of 300,000. The nurse should take which action after seeing the lab results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client's medical record.

Place the normal report in the client's medical record. - A normal platlet count ranges from 150,000- 400,000 mm

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1. Back 2. Axilla 3. Eyelids 4. Soles of the feet 5. Palms of the hands

1. Back 4. Soles of the feet 5. Palms of the hands - Absorption of corticosteroids can be absorbed higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, and genitalia). The nurse should avoid areas of high absorption for regions of lower absorption, such as the back, palms and soles of the feet.

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

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

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply 1. Fever 2. Positive Cullen's Sign 3. Complaints of indigestion 4. Palpable mass in the left upper quadrant 5. Pain in the right upper quadrant after a fatty meal 6. Vague lower right quadrant abdominal discomfort

1. Fever 3. Complaints of indigestion 5. Pain in the right upper quadrant after a fatty meal - The severe right upper quadrant pain radiates to the right scapula or shoulder, or experience epigastric pain after a fatty or high-volume meal. - S/S: Fever, dehydration, indigestion, belching, flatulence, and N/V. - Cullen's Sign is associated with pancreatitis.

The nurse reading an electrocardiogram (EKG) rhythm strip determines that there are 8 QRS complexes in 30 large squares for a 6-second strip. Which heart rate does the nurse calculate? 1. 60 bpm. 2. 70 bpm. 3. 80 bpm. 4. 120 bpm.

3. 80 bpm. - Thirty large squares on the EKG paper represent 6 seconds. The nurse will multiply the number of QRS complexes found in 30 large squares by 10 (8 × 10 = 80 beats per minute). Think like a nurse: Nurses who work regularly with clients who are on telemetry will be provided education about monitoring and interpreting telemetry readings. There are different ways to calculate the heart rate from a rhythm strip. The paper is made up of a series of repeating boxes. The larger boxes are made up of 25 smaller boxes. To estimate the rhythm, a 6-second or 10-second strip is required. The number of boxes between the peaks of two QRS complexes are counted and then multiplied by the appropriate number, based upon the length of the rhythm strip. The number from this calculation is the client's heart rate.

A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply 1. Peritoneal dialysis 2. Analysis of the urinary stone 3. IV opioid analgesics 4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy

4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy - Hydronephrosis develops when the stone has blocked the ureter and urine backs up, dilates and damages the kidney. Urolithiasis is the formation of the stones.

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with the syndrome? 1. Hypertension 2. Generalized edema. 3. Increased urinary output. 4. Frank, bright red blood in the urine.

Generalized edema - Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Urine output will be lower and may be more concentrated; dark or frothy.

The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way? 1. With food 2. At lunchtime 3. On an empty stomach 4. At bedtime with a snack

On an empty stomach - On an empty stomach, before breakfast to ensure absorption.

The nurse is preparing to change the PN solution bag and tubing. The clients central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? 1. Breathe normally 2. Turn their head to the right 3. Exhale slowly and evenly 4. Take a deep breath, hold it and bear down

Take a deep breath, hold it and bear down - Valsalva maneuvers are necessary during tubing changes to avoid air embolisms.

The nurse assesses a client recently diagnosed with essential hypertension. Which client statement concerns the nurse? 1. "I consume three cocktails every night." 2. "I take vitamin B and C and mineral supplements daily." 3. "I eat one orange and one banana every day." 4. "I jog 2 miles three times per week."

1. "I consume three cocktails every night." - Excessive alcohol consumption is a risk factor for hypertension. Think like a nurse: The nurse evaluates each client behavior to identify risks for hypertension. If indicated, assist the client in identifying food alternatives that are low in sodium. If the client does not participate in an exercise regimen, assist the client in finding an exercise that he or she enjoys to foster regularity. If needed, help the client identify community resources that can aid the client in smoking cessation and/or alcohol reduction. Also, teach the client how to monitor blood pressure in the home setting. Be empathetic and nonjudgmental if the client expresses frustration regarding the lifestyle changes necessary to lower blood pressure.

An adolescent client calls the clinic to report a missed dose of a norethindrone-ethinyl estradiol pill yesterday and the day before. Which instruction does the nurse provide? 1. "Use another method of birth control for the remainder of your cycle." 2. "Take two pills now and another pill in 4 hours." 3. "Take a home pregnancy test." 4. "Take one pill now and continue with the regular schedule."

1. "Use another method of birth control for the remainder of your cycle." — The client should be instructed to use another method of birth control for the remainder of the cycle if a birth control pill is missed 2 days in a row. In addition, instruct the client to take two tablets a day for the next 2 days, and then continue on the regular dosing schedule.

A healthcare provider's prescription reads to administer an IV dose of 400,000 units of Penicillin G Benzathine. The label on the 10 mL ampule sent from the pharmacy reads Penicillin G Benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Record your answer using one decimal place

1.3 mL Desired x mL/Available = mL/dose 400,000 x 1 mL/300,000 = 1.33 or 1.3 mL

During a well-child checkup, the nurse evaluates the reflexes of a client who is 6 months of age. Which finding is of concern to the nurse when observed? 1. Presence of a positive Babinski reflex. 2. Extrusion reflex when feeding. 3. Ability to grasp objects voluntarily. 4. Ability to roll from abdomen to back at will.

2. Extrusion reflex when feeding. — The extrusion reflex disappears between 3 and 4 months of age. An infant uses this movement of the tongue as a normal reflex when anything touches the lips. It helps with sucking from a breast or bottle. A positive Babinski reflex disappears at approximately 1 year of age. The nurse would expect to observe it at 6 months. Grasping objects and rolling from the abdomen to the back are normal occurrences at this age.

The nurse instructs a group of parents about age-appropriate toys for toddlers. Which toys will the nurse recommend that toddlers use? (Select all that apply.) 1. Educational computer programs. 2. Play clothes for dress-up. 3. Pounding board. 4. Cloth picture books. 5. Tricycle. 6. Skates.

ANSWERS: 3, 4 EXPLANATION: 3. Pounding board. - A pounding board is an appropriate toy for the toddler, as it promotes physical activity. 4. Cloth picture books. - Cloth picture books are an appropriate toy for toddlers, as they stimulate mental development and creativity. Think like a nurse: Toddlers typically engage in parallel play alongside another child. The short attention span of the toddler creates a need to frequently change toys and types of play. The nurse should encourage an environment that offers the toddler many opportunities for exploration. However, ensuring a safe environment is the top priority. Toddlers do not need expensive toys. Regular household items (e.g. plastic bowls and cups) can make the most enjoyable toys. Toddlers are egocentric, which limits their ability to share.

The maternity nurse is providing instructions to a new mother regarding the psychological development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure? 1. Allow the newborn infant to signal a need. 2. Anticipate all needs of the newborn infant. 3. Attend to the newborn infant immediately when crying. 4. Avoid the newborn infant during the first 10 minutes of crying.

Allow the newborn infant to signal a need. - If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to the mistrust of others.

A client in sinus bradycardia with a heart rate of 45 BPM complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1. Administer digoxin 2. Defibrillate the client 3. Continue to monitor the client 4. Prepare for transcutaneous pacing

Prepare for transcutaneous pacing - Sinus bradycardia (HR less than 60 BPM) becomes a concern when the client becomes symptomatic, such as hypotension and dizziness as signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus increase perfusion.

A client is prescribed digoxin 0.425 mg IV. The available medication supply is digoxin 500 mcg/2 mL. Calculate the amount of medication the nurse will administer to deliver one dose of medication to the client. (Round at the end of the equation. Record your answer using one decimal place.)

1.7 mL Dimensional Analysis: x mL = 2mL/500mcg x 1000mcg/1mg x 0.425mg/1 x mL = 2 x 1000 x 0.425/500 x 1 x 1 x mL = 850/500 x = 1.7 mL

The nurse provides care for the client receiving intravenous normal saline (NS) solution at 100 mL/hr. Throughout the day, the client drinks 12 oz of water and 8 oz of milk. The client voids 1100 mL and has 380 mL liquid stool. Calculate and record the client's net 24-hour intake in mL. (Record your answer rounding to the nearest whole number.)

1520 mL 12 oz = 360 mL 8 oz = 240 mL (1100 mL x 24 + 360 mL + 240 mL) - (1100 mL = 380 mL) = 1520 mL

The nurse in the emergency department assesses an older adult client. The client's family member states that the client has glaucoma, is hard of hearing, and has been experiencing abdominal pain for the past 24 hours. Which action by the nurse is the most appropriate? 1. Assess the intensity of the client's pain using a numeric rating scale. 2. Ask if the client wears hearing aids. 3. Administer the prescribed pain medication to the client. 4. Determine when the client last saw a health care provider.

2. Ask if the client wears hearing aids. — Tools used for rating pain are ineffective if a client cannot hear what is being asked or see the pain rating scale. First ask if the client wears hearing aids and determine if they are in place.

The nurse in the outpatient clinic is assessing the outcome of the Mantoux test in a client who is HIV positive. The nurse observes a 5 mm area of erythema on the forearm where the test was administered. Which action does the nurse take first? 1. Place a mask on the client. 2. Prepare the client for a chest x-ray. 3. Assess and measure any induration present. 4. Notify the health care provider.

3. Assess and measure any induration present. — The area of induration is used to determine if the test is positive or negative. For clients who are immunocompromised, an area of induration that is 5 mm or greater is considered positive.

The nurse assists the health care provider in performing a paracentesis. Which position does the nurse assist the client to assume for the procedure? 1. Right-lying. 2. Left-lying 3. Supine 4. Upright.

4. Upright. - The upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

The nurse should tell the client, who is taking levothyroxine, to notify the HCP if which problems occur? 1. Fatigue 2. Tremors 3. Cold intolerance 4. Excessively dry skin

Tremors - Excessive doses of levothyroxine can produce S/S of hyperthyroidism, which include: tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, extreme heat intolerance, and sweating. - The remaining options are signs of hypothyroidism.

The nurse observes prominent U waves on a client's electrocardiogram (ECG) rhythm strip. Based on this abnormality, for which condition will the nurse assess the client? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Hypercalcemia.

1. Hypokalemia CORRECT— Prominent U waves on a client's ECG strip signal hypokalemia, an abnormally low serum potassium level. 2. Hyperkalemia INCORRECT - Hyperkalemia, an abnormally high serum potassium level, causes P-wave flattening, QRS complex widening, and peaking of the T waves. 3. Hypocalcemia INCORRECT - The QT interval and ST segment may be prolonged with hypocalcemia, an abnormally low calcium level. Torsades de pointe, a lethal ventricular arrhythmia, also may occur with hypocalcemia. 4. Hypercalcemia. INCORRECT - Shortening of the QT interval and ST segment may occur with hypercalcemia, an abnormally high serum calcium level.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at lest every 2 hours. 5. Ensuring that the client has a bowel movement at least once a week.

1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 4. Turning and repositioning the client at lest every 2 hours. - Straight catheterization should be done every 4-6 hours. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli.

A client reports falling at home several times over the last 6 months because of difficulty walking and the presence of a pill-rolling tremor. Which prescription does the nurse expect for this client? (Select all that apply.) 1. Prescription for β-interferon. 2. Referral for physical therapy. 3. Appointment for an MRI. 4. Referral to hospice care. 5. Prescription for carbidopa/levodopa.

2. Referral for physical therapy. - A physical therapy referral is appropriate to teach safe ambulation and determine the need for assistive devices. 3. Appointment for an MRI. - An MRI is appropriate to diagnose this client's health problem and rule out other causes for the symptoms. 5. Prescription for carbidopa/levodopa. - The client's symptoms describe Parkinson disease. Carbidopa/levodopa is a first-line medication for this health problem.

Phenazopyridine is prescribed for a client with urinary tract infection. The nurse evaluates that the medication is effective based on which observation? 1. Urine is clear amber 2. Urination is not painful 3. Urge incontinence is not present 4. A reddish-orange discoloration of the urine is present

Urination is not painful - Phenazopyridine is a urinary analgesic, effective when it eliminates pain and burning with urination, but does eliminate the bacteria causing the infection, so it would not make the urine clear amber. - The medication will cause a reddish-orange discoloration of the urine, which is a side effect of the medication, not a desired effect.

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply 1. The child has symptoms of a cold. 2. The child had a previous anaphylactic reaction to the vaccine. 3. The mother reports that the child is having intermittent episodes of diarrhea. 4. The mother reports that the child has not had an appetite and has been fussy. 5. The child has a disorder that caused a severely deficient immune system. 6. The mother reports that the child has recently been exposed to an infectious disease.

2. The child had a previous anaphylactic reaction to the vaccine. 5. The child has a disorder that caused a severely deficient immune system.

A toddler is prescribed phenobarbital 120 mg by mouth. The vial contains 160 mg of the medication in 5 mL. Which amount of medication in milliliters will the nurse administer to the client? (Record your answer using one decimal place. Do not round.)

3.7 mL RATIO/PROPORTION: 160 mg/ 5mL = 120 mg/ x mL 160x/160 = 600/160 x = 3.75 or 3.7 ALTERNATE: 160/120 = 1.3333 5 mL/1.33333 = 3.75 or 3.7

The nurse is monitoring a postpartum client who received epidural anesthesia during delivery for the presence of vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs. 2. Signs of heavy bruising. 3. Complaints of intense pain. 4. Complaints of a tearing sensation.

Changes in vital signs. - Changes in vitals signs indicate hypovolemia and may be the first sign of a vulvar hematoma before bruising and in absence of pain/tearing, given the patient is anesthetized.

Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? 1. Ensure that the client does not have diabetes. 2. Determine whether the client has an allergy to eggs. 3. Add regular insulin to the fat emulsion, using aseptic technique. 4. Contact the HCP to have a central line inserted for fat emulsion infusion.

Determine whether the client has an allergy to eggs. - Egg yolk is a component of the solution, which provides emulsification.

A client gives the home health nurse a bottle of clomipramine. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of insomnia 2. Complaints of hunger and fatigue 3. A pulse rate less than 60 BPM 4. Frequent hand washing with hot, soapy water

Frequent hand washing with hot, soapy water - Clomipramine is a tricyclic antidepressent used to treat OCD. Sedation sometimes occurs, but insomnia is seldom a side effect. Weight gain and tachycardia are side and adverse effects.

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder? 1. Myxedema 2. Kidney Disease 3. Hypothyroidism 4. Diabetes Mellitus

Kidney Disease - Colchicine is used in caution in older clients, debilitated clients, and clients with cardiac, kidney, or gastrointestinal disease.

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? 1. Ambulate following a meal 2. Eat high-carbohydrate foods. 3. Limit the fluids taken with meals. 4. Sit in a high Fowler's position during meals.

Limit the fluids taken with meals - The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low Fowler's position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. - Early manifestation usually occurs within 30 minutes of eating and include: vertigo, tachycardia, syncope, sweating, pallor palpitations, and the desire to lie down.

The nurse is receiving a surgeon's prescription sheet for a post operative client that states that the client must be NPO after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous Sulfate 3. Cyclobenzaprine 4. Conjugated Estrogen

Prednisone - With prolonged use, corticosteroids cause adrenal atrophy. Given that corticosteroids help reduce stress, they should not be limited before or during surgery, with levels potentially being decreased during surgery and given parentterally. - The three remaining medication can be held. Ferrous sulfate is an oral iron preparation, Cyclobenzaprine is a skeletal muscle relaxant, and Conjugated Estrogen is an estrogen used for hormone replacement in postmenopausal women.

The nurse provides care for a client diagnosed with pneumonia. The client has a history of type 2 diabetes. The client is an older adult and is malnourished. For which type of shock does the nurse monitor the client? 1. Anaphylactic 2. Cardiogenic 3. Septic 4. Neurogenic

Septic - Older adults with chronic diseases who are malnourished or debilitated are at great risk for septic shock. Think like a nurse: The nurse will apply knowledge of anatomy and physiology regarding the normal function of the respiratory system. Next, using knowledge of pathophysiology, the nurse will consider the impact pneumonia has on respiratory function. The nurse knows that pneumonia can lead to sepsis and septic shock in vulnerable clients, such as the client in this scenario. Once sepsis is identified, the nurse anticipates giving antibiotics (after all appropriate cultures are collected), monitoring the client's hemodynamic status, and implementing the sepsis bundle (e.g., lactic acid monitoring, fluid replacement, and vasopressor).

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly and the tube has been flushed with 15 mL of air to clear the secretions. Before removing the tube, the nurse should make which statement to the client? 1. Take a deep breath when I tell you and hold it while I remove the tube 2. Take a deep breath when I tell you and bear down while I remove the tube 3. Take a deep breath when I tell you and slowly exhale while I remove the tube 4. Take a deep breath when I tell you and breathe normally while I remove the tube

Take a deep breath when I tell you and hold it while I remove the tube - The tube is withdrawn slowly over 3-6 seconds (coiled around the nurse's hand during removal). Bearing down may inhibit the removal of the tube. Breathing normally can result in aspiration of gastric secretions during inhalation.

The client with AIDS and Pneumocystis jiroveci has been receiving pentamidine. The client develops a temperature of 101 F. The nurse continues to assess the client, knowing that this sign most likely indicates which condition? 1. That the dose of the medication is too low 2. That the client is experiencing toxic effects of the medication 3. That the client has developed inadequacy of thermoregulation 4. That the client has developed another infection caused by leukopenic effects of the medication

That the client has developed another infection caused by leukopenic effects of the medication - Frequent adverse effects of pentamidine include leukopenia, thrombocytopenia, and anemia.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

Uterine tenderness - Acute abdominal pain is present and the abdomen feels hard and board like on palpation, as the blood penetrates the myometrium and causes uterine irritability. - A soft abdomen and painless, bright red vaginal bleeding in the second and third trimester of pregnancy are signs of placenta previa.

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? 1. Doxycycline 2. Atropine sulfate 3. Acetylsalicylic acid 4. Dilitiazem hydrochloride

Acetylsalicylic acid - Also known as aspirin, is contraindicated for GI bleeding and is potentially ototoxic.

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count

Encouraging fluids - To help flush calcium from the system and from precipitating in the renal tubules 3 L of fluid intake is required/day to produce 1.5-2 L of urine output.

A nurse is administering risperidone (Risperdal) to a client who is scheduled for discharge. Before discharge, which instruction should the nurse provide to the client? 1. Get adequate sunlight 2. Continue driving usually 3. Avoid foods rich in potassium 4. Get up slowly when changing positions

Get up slowly when changing positions - Risperidone can cause orthostatic hypotension. - Sunlight should be avoided and driving should be done with caution until the client can determine whether their level of alertness is affected.

A child is diagnosed with Reye's Syndrome. The nurse creates a nursing care plan for the child and should include which intervention? 1. Assessing hearing loss. 2. Monitoring urine output. 3. Changing body position every 2 hours. 4. Providing a quiet atmosphere with dimmed lighting.

Providing a quiet atmosphere with dimmed lighting. - Reye's Syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. Care is taken to reduce stimuli of cerebral tissue. - Changing the body position every 2 hours would not affect cerebral edema directly. The child should be positioned with the head elevated to decrease progression of cerebral edema and promote drainage of cerebrospinal fluid.

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on the administration of the medication. Which instruction should the nurse provide? 1. Take the medication at bedtime 2. Take the medication with breakfast 3. Lie down for 30 minutes after taking the medication 4. Take the medication with a full glass of water after rising in the morning

Take the medication with a full glass of water after rising in the morning - The medication needs to be taken with a full glass of water after rising in the morning 30 minutes before eating or drinking anything else, to increase absorption and prevent gastrointestinal adverse effects, especially esophageal irritation.

The nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the final height to be 30 cm. How should the nurse interpret these findings? 1. The client is measuring large for gestation age 2. The client is measuring small for gestation age 3. The client is measuring normal for gestation age 4. More evidence is needed to determine size for gestational age

The client is measuring normal for gestation age - At 16 weeks the fundal height is between the symphysis pubis and the umbilicus. - During the 2nd & 3rd trimester (18-30 weeks) fundal height in centimeters approximately equals the fetus's age in weeks +/- 2 cm - At 36 weeks the funds is at the xiphoid process

A client is prescribed 1000 mL of dextrose 5% and water with 30,000 units of heparin to infuse at 50 mL/hr. Which amount of heparin will the client receive each hour? (Do not round. Record your answer using a whole number.)

1500 units/hr 30,000 units/1,000mL = x units/50 mL x = 1500 units/hr Alternate: 1,000/50 = 20 30,000/20 = 1,500 units/hr

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

Conjunctival hyperemia - In the acute stage the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. - In the sub-acute stage cracked lips, and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations and thrombocytosis occurs.

A client who is HIV seropositive has been taking Stavudine. The nurse should monitor which most closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. GI function

Gait - Stavudine is an antiretroviral used to manage HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neurotherapy, so the nurse should monitor gait closely and ask the client about paresthesia.

The nurse is teaching a client how to mix regular insulin and NPH in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into the NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into each vial

Withdraws the NPH insulin first - Short-acting or regular insulin should be drawn first to prevent contamination of the short-acting insulin.

A pediatric client begins to cough and gasp while having a small-bore feeding tube inserted. Which action does the nurse take next? 1. Withdraw the tube allowing time for rest before reinsertion. 2. Instruct the child to take deep slow breaths. 3. Pause briefly and then continue with insertion. 4. Withdraw the tube and notify the health care provider.

1. Withdraw the tube allowing time for rest before reinsertion. - If the client begins coughing and gasping, indicating that the feeding tube is in the airway, withdraw the tube and allow time for rest before attempting reinsertion.

A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L and is complaining of anorexia. The HCP prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside the therapeutic range? 1. 0.3 ng/mL 2. 0.5 ng/mL 3. 0.8 ng/mL 4. 1.0 ng/mL

1.0 ng/mL - Digoxin therapeutic range: 0.5-0.8 ng/mL. - Based on the patient's symptoms of anorexia and hypokalemia, digoxin toxicity is a concern.

The nurse provides care for a client admitted for pre-eclampsia. The health care provider prescribes magnesium sulfate at a maintenance dose of 1.5 grams per hour. Magnesium sulfate is available in 4 grams in 100 mL 0.9% sodium chloride. The nurse adjusts the flow rate to run at how many milliliters per hour? (Round at the end of the equation. Record your answer using one decimal place.)

37.5 mL/hour RATIO/PROPORTION: 4g/100mL = 1.5 g/ x mL 4x = 150 x = 37.5 mL ALTERNATIVE: 4 g/1.5 g = 2.666667 100 mL/ 2.666667 = 37.5 mL

A client weighing 53 lb is prescribed IV atropine 0.02 mg/kg now. The medication available is 0.8 mg/mL. Which amount in milliliters will the nurse provide to the client? (Round at the end of the equation. Record your answer using one decimal place.)

ANSWER: 0.6 mL Ratio/Proportion: 53 lbs/2.2 = 24.0909 0.02 x 24.0909 = 0.4818 0.4818/0.8 = 0.60225

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. Providing a sitz bath. 2. Encouraging fluid intake. 3. Placing ice on the perineum. 4. Monitoring hemoglobin and hematocrit levels.

Encouraging fluid intake. - Clients with cystitis (infection of the bladder) should consume 3000 mL of fluid/day if not contraindicated. Sitz baths and ice would be appropriate treatments, but not the priority.

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication? 1. In 2 months 2. In 2-3 weeks 3. During the 1st week 4. During the 6th week of administration

In 2-3 weeks - No details provided

The community health nurse provides care to a newborn client who is prescribed enteral feedings through a gastrostomy tube. Which statement by the client's mother indicates a need for immediate follow up by the nurse? 1. "It takes about 25 minutes to give one feeding." 2. "I use a bottle warmer to warm the formula." 3. "I wash the syringe with soap after each time I use it." 4. "It is easy to give liquid medicine through the feeding tube."

"It is easy to give liquid medicine through the feeding tube." — Liquid medication may contain sorbitol, which can cause diarrhea. Follow up is required, as additional information is needed to determine whether or not the client's medication contains sorbitol.

The nurse is planning to teach a client with GERD about substances to avoid. Which items should the nurse include on the list? Select all that apply. 1. Coffee 2. Chocolate 3. Peppermint 4. Nonfat milk 5. Fried chicken 6. Scrambled eggs

1. Coffee 2. Chocolate 3. Peppermint 5. Fried chicken - Aggravating substances: coffee, chocolate, peppermint, fried or fatty foods, carbonated beverages and alcohol.

A HCP prescription reads levothyroxine, 150 mcg orally daily. The medication reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client.

1.5 tablets 150 mcg = 0.15 mg 0.15 mg/0.1 mg = 1.5 tablets

A client is prescribed cefuroxime 250 mg by mouth every 12 hours. The medication is available in 125 mg/tablet. Which number of tablets will the nurse administer to the client for one dose? (Do not round. Record your answer using a whole number.)

2 Tablets 125/1 = 250/x 125x = 250 x = 2

A client diagnosed with a chronic idiopathic seizure disorder, controlled with antiseizure medication, will be married in five weeks. The client is concerned about having a seizure during the ceremony. Which is the best action for the nurse to implement? 1. Ask the health care provider 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 client how to perform relaxation exercises. 4. Tell the client to make a medication and seizure chart.

4. Tell the client to make a medication and seizure chart. — A chart will help identify triggers for seizures, such as alcohol, stress, or caffeine. Seizure activity may also increase during menses.

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A urinary output of 50mL/hour 2. A coagulation time of 5 minutes 3. A heart rate that is 90 BPM and irregular 4. A BUN of 20 mg/dL

A heart rate that is 90 BPM and irregular - Pheochromocytoma is a catecholamine producing tumor usually found in the adrenal medulla (but can be found extraadrenal in the chest, bladder, abdomen and brain), which cause an excessive amount of epinephrine and norepinephrine to be released. The associated complications include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, kidney failure, dysrhythmias or dissenting aortic aneurysm. - Options 1, 2, & 4 are within normal limits.

The nurse is preparing to care for four assigned clients. Which client is at the most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago. 2. A multiparous client who delivered 6 hours ago. 3. A multiparous client who delivered a large baby after oxytocin induction. 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia.

A multiparous client who delivered a large baby after oxytocin induction. - Causes of post partum hemorrhage include uterine atony, laceration of the vagina, hematoma development in the cervix, perineum, or labia, and/or retained placenta fragment.

A client receiving IV heparin 1400 units/hour is prescribed to have the dose changed to 1200 units/hour. The concentration of heparin is 25,000 units per 500 mL normal saline. At which rate, in milliliters per hour, will the nurse adjust the infusion pump to deliver the prescribed dose of 1200 units per hour? (Do not round. Record your answer using a whole number.)

ANSWER: 24 mL/hour 500 x 1,200= 600,000 600,000/25,000= 24

The mother of an 8-year-old child tells the clinic nurse that she is concerned about her child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse should make which response? 1. You need to be concerned. 2. You need to monitor the child's behavior closely 3. At this stage, the child is developing his own personality. 4. You need to provide more praise to the child to stop this behavior.

At this stage, the child is developing his own personality. - According to Erikson, between 6-12 years of age, the child begins to move toward peers and friends and away from their parents for support. In addition to development of special interest which reflect their own developing personality.

The nurse is watching the cardiac monitor and a client's rhythm suddenly changes. There are no P waves; instead there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1. Atrial fibrillation 2. Sinus tachycardia 3. Ventricular fibrillation 4. Ventricular tachycardia

Atrial fibrillation - The atrial flutter can lead to thrombus formation

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? 1. Ensure that knots are at the pulleys 2. Check the weights to ensure they are off the floor 3. Ensure the head of the bed is kept at a 45-90 degree angle 4. Monitor the weights to ensure that they are resting on a firm surface

Check the weights to ensure they are off the floor - To achieve proper traction, weights need to be free hanging (not resting on a firm surface) with knots kept away from the pulleys. In addition, the head of the bed is usually kept low to provide counter traction.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level. 2. Clear CSF, elevated protein and decreased glucose levels. 3. Cloduy CSF, elevated protein and decreased glucose levels. 4. Cloudy CSF, decreased protein and decreased glucose levels.

Cloduy CSF, elevated protein and decreased glucose levels.

The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include a temperature of 97.2 F, pulse of 108 bpm, BP of 152/76 mm Hg, RR of 24 bpm, and O2 saturation of 95% on room air. The client denies pain. Based on this information, what initial action should the nurse take? 1. Collect a urine sample for analysis. 2. Place the client in an upright position. 3. Compare current data to baseline data. 4. Slow the rate of the blood transfusion.

Compare current data to baseline data. - Baseline vitals should be check for comparison to look for signs of circulatory overload (cough, dyspnea, chest pain, wheezing, headache, hypertension, tachycardia, bounding pulse and distended neck veins). If signs of circulatory overload are observed, the client should be placed in an upright position and the transfusion rate should be slowed. - Collection of a urine sample should only occur if a transfusion reaction is suspected

The nurse is reviewing an electrocardiogram rhythm strip with regular P waves and QRS complexes. The PR interval is 0.16 seconds and the QRS complexes measure 0.06 seconds. The overall heart rate is 64 BPM. Which action should the nurse take? 1. Check vital signs 2. Check laboratory results 3. Notify the HCP 4. Continue to monitor for any rhythm change

Continue to monitor for any rhythm change - Normal PR measurements: 0.12-0.20 secs - Normal QRS measurements: 0.04-0.10 secs - Given all signs are within normal limits, all options are eliminated except continuing to monitor the client

Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? 1. Nocturia 2. Scrotal edema 3. Occasional constipation 4. Decreased force in the stream of urine

Decreased force in the stream of urine - The stream later becomes weak and dribbling, when the client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

The nurse is providing discharge instructions to a client receiving trimethoprim-sulfamethoxazole. Which instruction should be included in the list? 1. Advise that sunscreen is not needed. 2. Drink 8 to 10 glasses of water per day. 3. If the urine turns dark brown, call the HCP immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response.

Drink 8 to 10 glasses of water per day - Trimethoprim-sulfamethoxazole should be administered with a full glass of water and the client should maintain a high fluid intake to avoid crystalluria since the medication is more soluble in alkaline urine.

The nurse should assess the male client who has a tentative diagnosis of urethritis, for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

Dysuria and penile discharge - Urethritis usually results from chlamydia and often coexists with gonorrhea, so diagnostic tests are run for both. Hematuria is not associated with urethritis and proteinuria is associated to kidney dysfunction.

The nurse is giving report to an UAP who will be caring for a client who has hand restraints. The nurse instructs the UAP to check the skin integrity of the client's restrained hands how frequently? 1. Every 2 hours. 2. Every 3 hours. 3. Every 4 hours. 4. Every 30 minutes.

Every 30 minutes - In addition, the safety device should be removed at least every 2 hours to permit muscle exercise and to promote circulation.

The nurse is evaluating the neurological signs of a client in spinal shock following a spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

Flaccid paralysis - Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity and reflex emptying of the bladder.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the HCP to prescribe? 1. Platelets 2. Granulocytes 3. Fresh-frozen plasma 4. Packed red blood cells

Fresh-frozen plasma - Fresh-frozen plasma is used for volume expansion as a result of fluid and blood loss. - Platelets are used to treat thrombocytopenia and platelet dysfunction.

The nurse collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should he nurse document in the client's chart? 1. G: 3 T: 2 P: 0 A: 0 L: 1 2. G: 2 T: 1 P: 0 A: 0 L: 1 3. G: 1 T: 1 P: 1 A: 0 L: 1 4. G: 2 T: 0 P: 0 A: 0 L: 1

G: 2 T: 1 P: 0 A: 0 L: 1 - Gravida: number of pregnancies - Term births (longer than 37 weeks) - Preterm births (before 37 weeks) - Abortions - Living children

The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parents should the nurse expect that is associated with the diagnosis? 1. I'm so glad that they didn't find any protein in his urine. 2. I noticed his urine was the color of Coca-cola lately. 3. His health care provider said his kidneys are working well. 4. The nurse who admitted my child said his blood pressure was low.

I noticed his urine was the color of Coca-cola lately. - Blood urea nitrogen, serum creatinine, and protein levels may be elevated. The patient may also experience hypertension due to fluid volume overload.

The home care nurse provides instructions regarding basic infection control to the parent of an infant with a HIV infection. Which statement if made by the parent, indicates the need for further instruction? 1. I will clean up any spills form the diaper with diluted alcohol. 2. I will wash baby bottles, nipples, and pacifiers in the dishwasher, 3. I will be sure to prepare foods that are high in calories and protein. 4. I will be sure to wash my hands carefully before and after caring for my infant.

I will clean up any spills form the diaper with diluted alcohol. - Since HIV is transmitted through blood, semen, vaginal secretions and breast milk, a bleach solution for disinfecting contaminated objects should be used. All other answers are correct.

The nurse provides instructions to a client prescribed nicotinic acid for hyperlipidemia. Which statement by the client indicates an understanding of the instructions? 1. It is not necessary to avoid the use of alcohol 2. The medication should be taken with meals to decrease flushing 3. Clay-colored stools are a common side effect and should not be of concern. 4. Ibuprofen IB take 30 minutes before the nicotinic acid should decrease the flushing

Ibuprofen IB take 30 minutes before the nicotinic acid should decrease the flushing - Aspirin or IBU should be take to reduce the risk of flushing. Alcohol should be avoided since it will enhance flushing and the medication should be taken with meals to prevent gastrointestinal upset, not flushing. Clay-colored stools are a sign of hepatic dysfunction and should reported to the HCP immediately.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? 1. Assessing for edema 2. Monitoring edema 3. Monitoring blood pressure 4. Assessing blood glucose level

Monitoring blood pressure - Side/Adverse Effects: hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate and bradycardia.

A mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. A health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. Which response by the nurse is appropriate? 1. I am so please also that everything has turned out fine. 2. Because symptoms have not developed, it is unlikely that your infant will develop HIV infection. 3. Everything looks great, but be sure to return with your infant next month for the scheduled visit. 4. Most children infected with HIV develop symptoms within the first 9 months of life, and some become asymptomatic sometime before they are 3 years old.

Most children infected with HIV develop symptoms within the first 9 months of life, and some become asymptomatic sometime before they are 3 years old.

The nurse has just administered the first dose of omalizumab to a client. Which statement by the client would alert the nurse that the client may be experiencing a life-threatening effect? 1. I have a severe headache. 2. My feet are quite swollen. 3. I am nauseated and may vomit. 4. My lips and tongue are swollen.

My lips and tongue are swollen - Anaphylactic reactions can occur with the administration of omalizumab.

What are the symptoms of hyperkalemia?

S/S: weakness, paresthesias, abdominal cramps, diarrhea, and dysrthythmias.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape experienced by the client

The death of a loved one - A situational crisis arises from external rather than internal sources, including: loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. - Option 1, 3, & 4 identify adventitious crisis or crisis of disaster, is not part of everyday life, and is unplanned or accidental.

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? 1. Provide less frequent, larger feedings. 2. Burp the infant less frequently during feedings. 3. Thin the feedings by adding water to the formula. 4. Thicken the feedings by adding rice cereal to the formula.

Thicken the feedings by adding rice cereal to the formula - Small, more frequent feedings with frequent burning are prescribed, along with feedings thickened with rice cereal to reduce episodes of emesis. If feedings are thickened, cross-cutting of the nipple may be required.

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1. Bradycardia 2. Ventricular dysrhythmias 3. Rising diastolic blood pressure 4. Falling central venous pressure

Ventricular dysrhythmias - Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure become apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

A HCP prescribes lab studies for an infant of a woman positive for HIV. The nurse anticipates that which lab study will be prescribed for the infant? 1. Chest x-ray 2. Western blot 3. CD4+ cell count 4. p24 antigen assay

p24 antigen assay - Or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ count indicates how well the immune system is working. A chest x-ray evaluates the presence of the other manifestations of HIV infection such as pneumonia.

An external insulin pump is prescribed for a client with diabetes mellitus and the client asks the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: 1. It is timed to release programmed doses of short-duration (regular) or NPH insulin into the bloodstream at specific intervals 2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels 3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas, which in turn releases the insulin into the bloodstream 4. It administers a small continuous dose of short-acting (regular) insulin subcutaneously. The client can self-administer a bolus with an additional dose from the pump before each meal

It administers a small continuous dose of short-acting (regular) insulin subcutaneously. The client can self-administer a bolus with an additional dose from the pump before each meal.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The clients activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? 1. Discontinue the heparin infusion. 2. Increase the rate of the heparin infusion. 3. Decrease the rate of the heparin infusion. 4. Leaving the rate of the heparin infusion as is.

Leaving the rate of the heparin infusion as is. - The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (42-52.5 seconds) and 2.5 (70-87.5 seconds) times normal. Thus, the clients value should be between 42 and 87.5 seconds

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? 1. Measure abdominal growth 2. Irrigate the nasogastric tube 3. Continue to monitor the drainage 4. Notify the HCP

Continue to monitor the drainage - Following a gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged and then is yellow or clear.

Carbidopa-levodopa is prescribed for the client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication, which would include which client experience? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

Impaired voluntary movements - Dyskinesia and impaired voluntary movements may occur with high doses of Carbidopa-levodopa. - Other frequent side effects: nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia.

The nurse is preparing a plan of care for a client with DM who has hyperglycemia. The nurse places priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients

Inadequate fluid volume - An increased blood glucose level will cause the kidneys to excrete the glucose in the urine, accompanied by fluid and electrolytes, causing an osmotic diuresis, leading to dehydration.

The nurse is describing the medication side and adverse effects to a client who is taking oxazepam. Which information should the nurse incorporate in the discussion? 1. Consume a low-fiber diet 2. Increase fluids and bulk in the diet 3. Rest if the heart begins to beat rapidly 4. Take antidiarrheal agents if diarrhea occurs

Increase fluids and bulk in the diet - Oxazepam causes constipation, so the client is instructed to increase fluid intake and bulk (high fiber) on the diet. If the heart starts to beat fast, the HCP should be contacted, because this can be a sign of overdose. In addition, diarrhea can suggest an intestinal obstruction, which also necessitates contacting the HCP.

Describe the Paget's Preoperational stage?

- Symbolic thinking. Use of proper syntax and grammar to express concepts. Imagination and intuition are strong, but complex abstract thoughts are still difficult. Conservation is developed.

A client is prescribed intravenous penicillin G potassium 1.2 million units per day in divided doses every 6 hours. The medication vial contains 300,000 units/mL. Which amount of the medication in mL will the nurse provide to the client for a single dose? (Record your answer rounding to the nearest whole number.)

1 mL 1,200,000 units/4 = 300,000 units/dose 300,000/1 = 300,000/x x = 1 mL

The nurse instructs a client receiving phenelzine sulfate 11 mg PO daily. Which statement by a client indicates to the nurse that teaching is effective? 1. "I will call my health care provider if I begin to have severe headaches." 2. "I can drink wine, but I should avoid whiskey." 3. "I know I am going to feel better in a couple of days." 4. "I can take cold medications that contain pseudoephedrine."

1. "I will call my health care provider if I begin to have severe headaches." CORRECT — Phenelzine sulfate is a monoamine oxidase inhibitor (MAOI). A hypertensive crisis may be precipitated by foods containing tyramine. A client should be taught to report problems associated with hypertension, such as a severe headache, dizziness, and fatigue.

The nurse performs discharge teaching for a client treated for cervical cancer with a cesium 137 implant. The nurse learns that the client works 40 hours per week in a factory and has a toddler and preschooler at home. Which client statement indicates that further teaching is needed? 1. "I will call the health care provider if I am still bleeding after a couple of days." 2. "I will abstain from sexual intercourse and not use tampons for 2 weeks." 3. "I cannot lift either of my children for 2 months." 4. "I will take showers for the next 2 weeks."

1. "I will call the health care provider if I am still bleeding after a couple of days." INCORRECT — This is an appropriate action. Slight to moderate vaginal bleeding is expected after discharge. The color of vaginal discharge normally begins pink, turns brown, and becomes white. The client should notify the health care provider if bleeding increases, lasts more than 48 hours, or has a foul odor. 2. "I will abstain from sexual intercourse and not use tampons for 2 weeks." CORRECT— The client can resume normal activities after discharge but is instructed to avoid sexual intercourse and tampons until a follow-up visit with the health care provider, which occurs about 6 weeks after discharge. 3. "I cannot lift either of my children for 2 months." INCORRECT — This is appropriate. The client should avoid activities that cause abdominal strain for 6 to 8 weeks. 4. "I will take showers for the next 2 weeks." INCORRECT — This is appropriate. The client should avoid baths for at least 6 weeks after discharge.

The nurse provides dietary teaching to a client with Cushing syndrome. Which client statements cause the nurse to intervene? (Select all that apply.) 1. "I will follow a low-protein diet. " 2. "I will follow a high-carbohydrate diet. " 3. "I will follow a high-potassium diet. " 4. "I will follow a low-sodium diet. " 5. "I will follow a high-calorie diet. "

1. "I will follow a low-protein diet. " 2. "I will follow a high-carbohydrate diet. " 5. "I will follow a high-calorie diet. "

The nurse counsels a client about the West Nile virus during an outbreak. Which client statement requires follow up by the nurse? 1. "I will get an immunization for the West Nile virus." 2. "I will limit my time outside between dusk and dawn." 3. "I will wear long sleeves and pants when I go outside." 4. "I will use a mosquito repellent that contains DEET."

1. "I will get an immunization for the West Nile virus." - There is no immunization for the West Nile virus infection. Think like a nurse: Depending upon the place of residence, some clients may be prone to developing diseases caused by insect bites or stings. One such illness is the West Nile virus. The nurse should recall the mode of transmission of the virus (the vector is a specific type of mosquito) and recommend actions to prevent the client from contracting the disease. The client should understand the use of DEET-based insect repellent and the importance of keeping the skin covered when in areas where the possibility of exposure is high. The nurse should also remind the client that there is no immunization against this disease so precautions must be taken at all times.

The nurse provides teaching to a client receiving ferrous sulfate 300 mg per day. Which client statement indicates that teaching is effective? 1. "I will have to eat more fresh fruits and whole-grain bread." 2. "This medication may cause fine motor tremors." 3. "My bowel movements may become light in color." 4. "I may have problems with blurred vision."

1. "I will have to eat more fresh fruits and whole-grain bread." — A side effect of ferrous sulfate is constipation. The client should increase intake of fruits, fiber, and fluids. Other side effects include gastric irritation, nausea, abdominal cramps, anorexia, vomiting, diarrhea, and dark-colored stools.

The nurse reviews circumcision site care with the parents of a newborn client. The newborn was circumcised with a clamp. Which statement by the parent to the nurse indicates that teaching is successful? 1. "I will wipe off any discharge that appears using warm water and a gentle circular motion." 2. "I will put petroleum jelly on a gauze pad and put that over the penis before I diaper him." 3. "I will be sure the diaper fits snugly, but not too tightly, and that it is changed when wet." 4. "I understand that it is normal for the first few days for the penis to look red or swollen."

1. "I will wipe off any discharge that appears using warm water and a gentle circular motion." INCORRECT - Yellowish-white exudate appears on the second day. This is part of the granulation process. Do not remove or disrupt during cleaning of the are 2. "I will put petroleum jelly on a gauze pad and put that over the penis before I diaper him." CORRECT - A small gauze pad with either petroleum jelly or medicated ointment is placed on the circumcision site as a dressing. This prevents the wound from adhering to the dressing or diaper. Dressing changes continue for 3 days after the procedure. 3. "I will be sure the diaper fits snugly, but not too tightly, and that it is changed when wet." INCORRECT - The diaper should be loosely fastened to prevent friction, rubbing, or pressure against the tender penis, but it should be changed when wet. 4. "I understand that it is normal for the first few days for the penis to look red or swollen." INCORRECT - These are signs of infection. Penile edema can cause urinary obstruction. This is reported to the health care provider immediately. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess understanding. That understanding is clear when the parents of the client state a plan to take measures to reduce friction and prevent further injury to the skin, such as using a lubricating ointment. The goal of post-circumcision care is to allow healing, which means keeping the site clean and protecting the penis from irritation.

The nurse teaches a class on birth control options to a group of clients. Which client statement indicates to the nurse that teaching was effective? (Select all that apply.) 1. "If I take an oral contraceptive, I may need to use additional measures to prevent pregnancy if I take the antibiotic rifampin." 2. "If I use a diaphragm with a spermicidal gel, I need to insert the diaphragm 1 hour before I have sexual intercourse." 3. "The copper in my intrauterine device decreases the likelihood that sperm and ovum will unite." 4. "I will need to replace my cervical cap every 3 months." 5. "The sponge prevents sperm from entering the uterus and releases a spermicide."

1. "If I take an oral contraceptive, I may need to use additional measures to prevent pregnancy if I take the antibiotic rifampin." — Certain medications and supplements may interact with oral contraceptives, including rifampin. 3. "The copper in my intrauterine device decreases the likelihood that sperm and ovum will unite." — Non-hormonal intrauterine devices (IUDs) use copper to prevent pregnancy. The copper ions are toxic to sperm and also induce a thickening of cervical mucus, making sperm motility more difficult. 5. "The sponge prevents sperm from entering the uterus and releases a spermicide." — The sponge covers the cervix and blocks sperm from entering the uterus. It also continuously releases a spermicide that decreases sperm motility.

A client develops post-concussion syndrome caused by a head injury sustained from a fall. For which client statements will the nurse intervene? (Select all that apply.) 1. "The concussion showed up on the head computed tomography scan." 2. "I may have a persistent headache for 2 weeks or longer." 3. "I should notify the health care provider if I have repeated episodes of vomiting." 4. "I can immediately resume contact sports at school." 5. "I may have trouble remembering details from one day to the next." 6. "I have no recollection of the events surrounding the incident."

1. "The concussion showed up on the head computed tomography scan." — A concussion does not appear on a head computed tomography scan. Concussion is a clinical diagnosis based upon symptoms. 4. "I can immediately resume contact sports at school."

The nurse prepares to administer the polio vaccine by intramuscular injection to a child. The parent says "I am afraid my child will get polio from the vaccine." Which response by the nurse is best? 1. "The vaccine cannot cause polio because it contains killed virus particles." 2. "The vaccine contains weakened toxins that produce an immune response, not polio." 3. "Do not worry, your child will not get polio from the vaccine." 4. "The vaccine contains live virus, but it is weakened so it will not give your child polio."

1. "The vaccine cannot cause polio because it contains killed virus particles." - The polio vaccine administered by the intramuscular route contains inactivated (or killed) polio virus. The organism causes an immune response, but is incapable of reproducing and causing infection. Think like a nurse. Health promotion and disease prevention activities include monitoring and providing required vaccinations at the appropriate times. The use of vaccinations may cause anxiety for some parents because of a lack of knowledge of how the vaccine works and what the vaccination is intended to do. The parent who is concerned that a vaccination will cause a disease needs information about the contents of the vaccine and the expected response once the vaccine is administered. The person receiving the vaccination may also be concerned and the nurse should provide teaching prior to administering the vaccination. The nurse should maintain knowledge about the mechanism of immunity associated with various vaccines.

The nurse prepares to perform a breast examination on a 20-year-old female client. Which question is most important for the nurse to ask before beginning the examination? 1. "When was your last menstrual period?" 2. "Do you have a family history of breast cancer?" 3. "How much caffeine do you consume a day?" 4. "Have you ever had a mammography?"

1. "When was your last menstrual period?" - Breast examination is ideally done about 1 week after the onset of menses, when hormonal influences on the breasts are at a low level. Think like a nurse: A breast examination is considered a part of the physical assessment. However, before beginning this portion of the examination the nurse should mentally ask, "What is the most common event that can impact this examination?" Using knowledge of anatomy and physiology, the nurse should recognize the importance of determining when the client last had a menstrual cycle. If the breasts are assessed immediately before or during menses, the client may exhibit swelling and tenderness and experience unnecessary discomfort during the examination.

A group of clients are identified as at risk for pressure injury. For which client does the nurse initiate pressure injury prevention measures? (Select all that apply.) 1. A client in skeletal traction who is diaphoretic. 2. A client with reddened areas that blanch on both elbows. 3. A premature neonate with nasogastric feedings. 4. An infant who had surgical repair of an umbilical hernia. 5. A client who has a temperature of 103 °F (39.44 oC). 6. A client with urinary retention who self-catheterizes.

1. A client in skeletal traction who is diaphoretic. — The immobility imposed by skeletal traction combined with moist skin from diaphoresis puts this client at risk for a pressure injury. 3. A premature neonate with nasogastric feedings. — A preterm neonate does not have sufficient subcutaneous fat stores and is at risk for skin breakdown. The presence of an NG tube increases the neonate's risk, due to pressure from the tube and tape on delicate skin.

The nurse determines that which client needs vitamin B6 (pyridoxine) supplementation? 1. A client who is tuberculosis positive. 2. A client with pernicious anemia. 3. A client with chronic alcoholism. 4. A client who is 12 weeks' gestation.

1. A client who is tuberculosis positive. - The client with tuberculosis is likely to be taking isoniazid (INH), a mainstay in prevention and treatment of tuberculosis, used in combination with other antitubercular drugs if the disease is active. Vitamin B6 is given to prevent the peripheral neuropathy, dizziness, and ataxias that can occur with this drug.

The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit determines that which clients would be the most likely candidates for PN? (Select all that apply) 1. A client with extensive burns. 2. A client with cancer who is septic. 3. A client who has had an open cholecystectomy. 4. A client with sever exacerbation of Crohn's disease. 5. A client with persistent N/V from chemotherapy.

1. A client with extensive burns. 2. A client with cancer who is septic. 4. A client with sever exacerbation of Crohn's disease. 5. A client with persistent N/V from chemotherapy. - PN is indicated in clients who GI tracts are not functional or must be rested, cannot take in a diet enterally for extended periods, or have increased metabolic need. Examples of these conditions include: clients with burns, exacerbation of Crohn's disease, persistent N/V from chemotherapy, those who had extensive surgery, have multiple fractures, are septic, have advanced cancer or AIDS. - The client with an open cholecystectomy would resume a regular diet within a few days, following surgery.

The nurse is in the home of an older adult client who is being visited by grandchildren. For which observation causes the nurse to intervene? 1. An infant who plays with a rattle that is cracked. 2. A preschool-age child who goes up and down the stairs alone. 3. A young school-age child who has an imaginary playmate. 4. An adolescent who cuts meat using a table knife.

1. An infant who plays with a rattle that is cracked. — Rattles have small beads inside that can be aspirated, presenting a choking risk for the infant. All rattles or toys that make noise should be inspected to ensure that they are intact. Developmentally, a preschool-age child is able to walk the stairs alone safely. This does not require an intervention by the nurse. A young school-age child may have an imaginary playmate. This does not require an intervention by the nurse. An adolescent is able to use a table knife. This does not require an intervention by the nurse.

The nurse provides care for a client in labor. The client received meperidine 20 minutes ago. The fetal heart rate (FHR) is 106 beats/min. Which action does the nurse take next? 1. Assess FHR in relation to uterine contractions. 2. Place the client in the supine position. 3. Administer the next scheduled dose of meperidine. 4. Contact the health care provider.

1. Assess FHR in relation to uterine contractions. —This action will determine if the decreased FHR is in relation to uterine contractions or due to adverse effects of meperidine (decreased HR, decreased BP, decreased ventilations).

The nurse provides care for a client who exhibits the signs and symptoms of acute confusion and delirium. Which strategy is appropriate for the nurse to implement? 1. Keep the room organized and clean. 2. Maintain a high environmental noise level. 3. Keep lights in the room dimmed during the day. 4. Use restraints as needed for client safety.

1. Keep the room organized and clean. — A disorganized, cluttered environment increases confusion. Keeping the room well-lit during waking hours helps promote adequate sleep at night.

The nurse provides care for a newborn diagnosed with a myelomeningocele. Which actions will the nurse identify as most important when providing care to this client? 1. Monitor for elevated temperature, irritability, and lethargy. 2. Perform range-of-motion exercises to feet, ankles, and knee joints. 3. Apply lotion to healthy skin and gently massage skin.

1. Monitor for elevated temperature, irritability, and lethargy. - The newborn is at risk to develop an infection called meningitis because of the myelomeningocele sac. Change the dressing every 2 to 4 hours using aseptic technique. Monitor the temperature and the infant for signs of increased irritability and lethargy.

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in Vitamin B12 in the diet? Select all that apply. 1. Nuts 2. Corn 3. Liver 4. Apples 5. Lentils 6. Bananas

1. Nuts 3. Liver 5. Lentils - Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells, which results in an inability to absorb Vitamin B12, leading to development of pernicious anemia. - Foods rich in Vitamin B12: nuts, organ meats, dried beans, citrus fruits, green leafy vegetables, and yeast.

Steps in the incidence of a transfusion reaction

1. Stop the transfusion 2. Change the IV tubing down to the IV site 3. Keep the IV line open with normal saline 4. Notify the HCP and blood bank 5. Stay with the client, monitoring S/S every 5 minutes 6. Prepare to administer emergency medications as prescribed 7. Obtain a urine specimen and perform laboratory studies and prescribed 8. Return the blood bag, tubing, attached labels, and transfusion record to the blood bank. 9. Document the occurrence, actions taken, and the client's response

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands 2. Puts gloves on 3. Place the drop in the conjuctival sac 4. Pull the lower lid down against the cheekbone 5. Instruct the client to squeeze the eyes shut after instilling the eye drop 6. Instruct the client to tilt the head forward, open the eyes, and look down

1. Wash hands 2. Puts gloves on 3. Place the drop in the conjuctival sac 4. Pull the lower lid down against the cheekbone

The client has had hypertension for 20 years. The nurse should assess the client for? 1. Peptic ulcer disease. 2. Renal insufficiency and failure. 3. Valvular heart disease. 4. Endocarditis.

2. Renal insufficiency and failure Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.

The nurse provides care to clients in the outpatient newborn clinic. Which message from a parent will the nurse return first? 1. Umbilical cord of a 5-day-old newborn is dry and hard to the touch. 2. The "soft spot" on the head of a 4-day-old newborn feels slightly elevated when the baby sleeps. 3. Circumcision of a 3-day-old newborn is covered with yellowish exudate. 4. A 2-day-old newborn violently extends the extremities and returns them to the previous position when the crib is bumped.

2. The "soft spot" on the head of a 4-day-old newborn feels slightly elevated when the baby sleeps. - The fontanel or the "soft spot" should feel soft and flat. Bulging or an elevation indicates an increase in intracranial pressure that needs to be immediately addressed. Think like a nurse: When faced with a situation similar to the one in this scenario, the nurse needs to determine which client requires immediate assessment, and potentially, intervention. The anterior and posterior fontanels on a newborn should feel soft and appear flat. Bulging of these areas when the child is at rest could indicate additional fluid in the cerebral tissue and increased intracranial pressure (ICP). The nurse should contact the parent of this newborn first. The other situations are expected findings and do not necessitate priority assessement.

During a flood, two ambulances arrive at an emergency substation at the same time. One contains a toddler near-drowning victim on a ventilator. The other contains an older adult client with a left-sided cerebrovascular accident (CVA) who is conscious and has a blood pressure of 220/130 mm Hg. Which client does the nurse see first? 1. The toddler because the client is on a ventilator. 2. The older adult client because the client is hypertensive. 3. The toddler because the client is a victim of the flood. 4. The older adult client because of the client's age.

2. The older adult client because the client is hypertensive. - The client's blood pressure is an obvious threat to health status and is an emergent problem. Think like a nurse: A client with hypertension and suspected stroke and a toddler near-drowning victim arrive at the emergency substation at the same time. The toddler receives mechanical ventilation. The older adult has severe hypertension and left-sided weakness. The nurse should think, "Which client's condition is life-threatening, but survivable with rapid intervention?" The toddler's airway and breathing are currently supported by mechanical ventilation. The older adult has severe hypertension and left-sided weakness. If left untreated, the older adult client could suffer life-threatening consequences.

The nurse provides care for a client diagnosed with disseminated herpes zoster. Which observation by the nurse would require intervention? 1. The health care provider wears an N-95 mask when entering the client's room. 2. The phlebotomist leaves the door open when exiting the room. 3. The client is placed in a room with negative air pressure. 4. The LPN/LVN removes the gown before leaving the client's room.

2. The phlebotomist leaves the door open when exiting the room. — Disseminated herpes zoster requires both airborne and contact precautions. The client must be placed in a negative air pressure room, which requires the door to be closed at all times. The nurse needs to intervene if the client's door is left open.

Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor? Select all that apply 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate

2. Tremors 3. Drowsiness 4. Hypotension - Side/Adverse Effects: respiratory depression, drowsiness, hypotension, constipation, urinary retention, N/V & tremors

The nurse obtains health information from a client scheduled for permanent pacemaker insertion. Which information is most important for the nurse to convey to the health care provider (HCP)? 1. Diagnosis of obsessive-compulsive disorder. 2. Uses a hearing aid in the left ear. 3. Works as a computer programmer. 4. Lives in a two-story house.

2. Uses a hearing aid in the left ear. CORRECT— The hearing aid battery may affect the placement of the pacemaker. It should not be placed under the left clavicle in this client.

A HCP prescribes 1000 mL of NS 0.9% to infuse over 8 hours. The drop factor is 15 gtt/1mL. The nurse sets the flow rate at how many drops/minute? Record your answers to the nearest whole number.

31 drops/minute Total Volume x Drop Factor/Time in Minute = drops per minute 1,000 mL x 15 gtt/480 = 31.25 or 31 drops/min

The health care provider prescribes 900 mg of cimetidine to be infused over 24 hours. How many milligrams per hour does the nurse administer to the client? (Round at the end of the equation. Record your answer using a whole number.)

38 mg/hr 900 mg/24 hrs = 37.5 (38 mg/hr)

The nurse on the psychiatric unit finds a client crying. As the nurse approaches the client, the client states, "What do you want? Go away. I hate you, and I hate myself." Which response by the nurse is appropriate? 1. "Why is it that you don't like me or you?" 2. "I will come back later when you are in a better mood." 3. "It is difficult for me to communicate with you when you talk this way." 4. "You seem to be in pain, so I will stay with you."

4. "You seem to be in pain, so I will stay with you." — This conveys support and understanding. Depressed clients are frequently angry, but the anger is displaced inwardly.

The nurse in the prenatal clinic assesses a client at 7 weeks ' gestation. The client is 5'7" (170.2 cm) tall and weighs 125 lb (56.8 kg). The client reports to the nurse concerns about gaining too much weight during the pregnancy. Which response by the nurse is appropriate? 1. "You seem to be concerned about gaining weight. It 's too early to think about that now. " 2. "You are already thin. You will not have any problems with gaining too much weight. " 3. "You don 't need to worry about your weight gain. I'm sure you 're used to eating balanced meals. " 4. "You should gain 3 to 5 pounds (1.4 to 2.3 kg) during your first trimester and eat foods rich in calcium, protein, and iron. "

4. "You should gain 3 to 5 pounds (1.4 to 2.3 kg) during your first trimester and eat foods rich in calcium, protein, and iron. " - This statement is the best response because it addresses the client's concerns while providing information. The client should gain 3 to 5 pounds (1.4 to 2.3 kg) in the first trimester, along with focusing on enhancing intake of foods rich in calcium, protein, and iron. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client 's teaching and learning needs, including literacy issues. Health literacy skills have been shown to be a stronger predictor of health status than age and educational level. The prenatal care visit is a great opportunity to educate the client on health promotion and disease prevention. For optimal comprehension and compliance, education materials should be written at a sixth-grade or lower reading level, preferably including pictures and illustrations. The nurse can have the client keep a weight diary throughout pregnancy.

The nurse reviews the lab results for a child with a suspected diagnosis of rheumatic fever, knowing that which lab result would assist in confirming the diagnosis? 1. Immunoglobulin 2. RBC count 3. WBC count 4. Anti-streptomycin O titer

Anti-streptomycin O titer

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which time? 1. Immediately before swimming 2. 5 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun

At least 30 minutes before exposure to the sun - To allow absorption into the skin

The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? 1. Restrict fluids as prescribed. 2. Care for the arteriovenous fistula. 3. Encourage foods high in potassium. 4. Administer analgesics as prescribed.

Restrict fluids as prescribed. - The patient will be on fluid restriction due to anuria.

"A nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose of 120 mg/dL, temp of 101 F, pulse of 102 bpm, respirations of 22, and blood pressure of 142/72. Which finding would be of most concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

Temperature - An elevated temperature in a T2DM client may indicate infection, which is the leading cause of hypersosmolar hyperglycemic syndrome.

A nurse prepares to administer medications to clients at 0900. In which order does the nurse administer the medications? (Please arrange in order of priority. All options must be used.) - The client receiving digoxin 0.375 mg by mouth, with a recent HR of 92 BPM - The client receiving Hydrochlorothiazide 25 mg PO daily, with a recent blood pressure of 140/84 - The client receiving Levetiracetam 1000 mg BID, PO for a seizure disorder - The client receiving metronidazole 500 mg every 8 hours, IV for C. diff

- The client receiving Levetiracetam 1000 mg BID, PO for a seizure disorder - The client receiving metronidazole 500 mg every 8 hours, IV for C. diff - The client receiving Hydrochlorothiazide 25 mg PO daily, with a recent blood pressure of 140/84 - The client receiving digoxin 0.375 mg by mouth, with a recent HR of 92 BPM Levetiracetam, like most antiseizure medication, needs to be maintained at consistent plasma levels to prevent seizures. As seizures would cause immediate harm to the client, delays in medication administration should be avoided. This is the priority medication to administer. Metronidazole, like most antibiotics, needs to be maintained at a minimum effective circulating level and therefore delays in medication administration should be avoided. Infection is a concern, but there is another medication that is more important for client immediate safety. The metronidazole is the second priority. Hydrochlorothiazide has a half-life of 6 to 15 hours. While long delays in administration should be avoided, it is not a particularly time-sensitive medication. The client's blood pressure is slightly elevated. This is the third priority. Digoxin has a half-life of 36 to 48 hours, so delays in administration are unlikely to impact the client. The heart rate is within the normal range, so this client does not require the medication immediately. This can be administered last.

The client is prescribed 1 unit of red blood cells (RBCs). The transfusion is started at 0945. At 1003, the client reports chills and back pain rated at 5 of 10. The client's skin is flushed, blood pressure is 98/66 mm Hg, and pulse rate is 108 beats/min. In which order does the nurse implement these nursing interventions? (Please arrange in order. All options must be used.) - Assess blood pressure, HR and RR - Begin 0.9% sodium chloride infusion - Call the healthcare provider - Hang a new IV infusion set - Obtain blood and urine specimens - Stop the blood transfusion

- Stop the blood transfusion - Hang a new IV infusion set - Begin 0.9% sodium chloride infusion - Call the healthcare provider - Assess blood pressure, HR and RR - Obtain blood and urine specimens - The client has signs and symptoms that suggest a hemolytic reaction. The nurse should first stop the blood transfusion to prevent worsening the client's reaction. Next, the nurse should hang a new intravenous infusion set to allow for the administration of 0.9% sodium chloride. This will provide additional hydration to promote perfusion and to flush the kidneys to reduce the risk of acute kidney injury from the hemolytic reaction. The nurse should then notify the health care provider of the reaction and assess to see whether the client's condition has improved. The nurse has a set of current vital signs in the stem of the question, so there is no need to reassess the vital signs prior to notifying the health care provider. Finally, the nurse should obtain blood and urine specimens for laboratory confirmation of the hemolytic reaction. Think like a nurse: Because a hemolytic reaction is a medical emergency, the nurse must act quickly to decrease the risk of the client progressing to cardiovascular collapse. The nurse prioritizes discontinuation of the blood transfusion, changing IV infusion set, and administration of isotonic IV fluid to promote filling of the client's dilated blood vessels and expanded intravascular space. If a standing prescription allows for administration of steroids or an antihistamine, these medications are administered next. If the client's condition worsens, notifying the rapid response team (RRT) would be the next step. Ideally, the nurse would delegate reassessment of vital signs to a nurse colleague during this period.

A newborn weighing 3675 g is prescribed IV digoxin 0.03 mg/kg in three divided doses over 24 hours. The medication available is 100 mcg/mL. How many milliliters will the nurse provide to the client at each dose? (Do not round. Record your answer using two decimal places.)

0.36 mL 3675 g/1000 = 3.675 kg 0.03 mg x 3.675 kg = 0.11025 mg/day 0.11025 mg/3 (doses) = 0.03675 mg/dose 0.03675 mg/dose = 36.75 mcg/dose 100/1 = 36.75/x 100 x = 36.75 x = 0.3675 or 0.36

A client is prescribed a subcutaneous injection of heparin 3000 units every 12 hours. The medication is in a 10 mL multiple-dose vial containing 5000 units/mL. Which amount of medication in milliliters will the nurse provide for each dose? (Round at the end of the equation. Record your answer using one decimal place.)

0.6 mL

The nurse in the outpatient clinic receives a phone call from an adolescent who states, "There is no reason to live. I am going to shoot myself." Which response by the nurse is best? 1. "Do you have access to a gun?" 2. "Why do you want to shoot yourself?" 3. "Think about how this will affect your family." 4. "Share with me what happened to you today."

1. "Do you have access to a gun?" - The nurse should first ensure the client's safety by determining if the client has a plan and the means to carry out the plan. Think like a nurse: Because the adolescent client specifically said "shoot myself," the nurse needs to immediately assess if the client has access to a firearm. This is one instance when it is appropriate and necessary to ask the client a direct "yes/no" question since it is paramount to determine the lethality of the client's statement. Ongoing assessment, communication, and interventions will depend upon the client's response.

A 45-year-old male client presents to the emergency department with acute mid-abdominal pain and acute vomiting. The health care provider wants to rule out pancreatitis. Which question does the nurse ask based on the client's differential diagnosis? 1. "How much alcohol do you drink per day?" 2. "Do you have a 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 drink per day?" — The client's symptoms indicate an acute episode of pancreatitis. Pancreatitis is associated with males ages 40 to 45 with a history of heavy drinking and females ages 50 to 55 diagnosed with biliary disease. As this is a 45-year-old male client, asking about alcohol intake will help confirm the diagnosis.

Which client is at risk for the development of a sodium level at 130 mEq/L? 1. A client taking diuretics. 2. A client with hyperaldosteronism. 3. A client with Cushing's Syndrome. 4. A client who is taking corticosteroids.

1. A client taking diuretics. - The clients with hyperaldosteronism, Cushing's Syndrome, and/or taking corticosteroids are at risk for hypernatremia.

The nurse provides care for a client with a complete heart block (CHB). The nurse questions which prescription from the health care provider? 1. Administer lidocaine 50 mg IV push for premature ventricular contractions in excess of six per minute. 2. Prepare and administer epinephrine 2 to 10 mcg/min, titrating based on response. 3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to decrease. 4. Mix and administer 10 mL of 1:5000 solution of isoproterenol in 500 mL D5W for sustained bradycardia below 30 beats/min.

1. Administer lidocaine 50 mg IV push for premature ventricular contractions in excess of six per minute. - In CHB, the atrioventricular node blocks all impulses from the sinoatrial node, so the atria and ventricles beat independently. Because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response, causing cardiac arrest.

The nurse provides care for a client after surgery. Which intervention does the nurse include in the client's plan of care? 1. Begin oral fluids when bowel sounds are present. 2. Maintain nothing by mouth status until passing flatus. 3. Insert catheter if unable to void 4 hours after surgery. 4. Insert nasogastric tube as needed every 4 hours.

1. Begin oral fluids when bowel sounds are present. - To prevent abdominal distension, do not offer oral fluids until bowel sounds are heard. Think like a nurse: After receiving anesthesia, oral intake is resumed once bowel sounds return. This means that the intestinal tract is no longer under the influence of anesthesia. It may take a while for flatus to occur if the client has been on nothing by mouth status for awhile. It may take up to 8 hours for the client to void independently after receiving anesthesia. A nasogastric tube is not inserted as needed every 4 hours. If the tube is needed, it remains in place.

The nurse provides care for a client at 29 weeks ' gestation. The nurse reviews the results of the client 's biophysical profile. Which fetal assessment parameters are included in the profile? (Select all that apply.) 1. Breathing movement. 2. Weight. 3. Muscle tone. 4. Heart rate during contractions. 5. Amniotic fluid volume.

1. Breathing movement. 3. Muscle tone. 5. Amniotic fluid volume. —The client will undergo ultrasonography to obtain four of the five biophysical profile parameters, including fetal breathing movement. The fetus should demonstrate one or more episodes of rhythmic breathing lasting 30 seconds or more within 30 min.

The nurse provides care for a client who is scheduled for a dipyridamole thallium-201 scan. Which food item does the nurse ensure that the client has avoided prior to the scan? 1. Caffeine. 2. Milk. 3. Fatty foods. 4. Sugar.

1. Caffeine - Caffeine intake up to 24 hours before the scan can interfere with the medication used in the stress test and the heart effects being measured.

The nurse is caring for a primigravida 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. When performing a cervical assessment, which finding should the nurse anticipate? 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 a primigravida, the progress of labor is cervical effacement, followed by descent and dilation. The normal progression of labor is at 1 to 1.2 cm cervical dilation per hour for a primigravida. This finding is what the nurse should anticipate when performing a cervical evaluation.

Which information will the nurse include when teaching the client about the self-management of an implantable cardioverter/defibrillator (ICD)? (Select all that apply.) 1. Continue taking antidysrhythmic medications until the health care provider directs otherwise. 2. Do not wear tight clothing or belts over the ICD generator. 3. Notify the local fire department about having an ICD. 4. Avoid activities that involve rough contact with the ICD. 5. Report symptoms such as nausea, fainting, and weakness.

1. Continue taking antidysrhythmic medications until the health care provider directs otherwise. - Even after ICD placement, the client will need to continue taking antidysrhythmics until otherwise directed by the health care provider. 2. Do not wear tight clothing or belts over the ICD generator. - Tight clothing and a belt could cause irritation to the ICD generator. 4. Avoid activities that involve rough contact with the ICD. - Rough activities, such as contact sports, may cause ICD electrodes to become dislodged. 5. Report symptoms such as nausea, fainting, and weakness. - Nausea, fainting, and weakness indicate low cardiac output and must be reported to the health care provider. Think like a nurse: After implantable cardioverter/defibrillator (ICD) implantation, the client typically is provided with a product brochure that includes key information on living with an ICD. The nurse can reinforce teaching, reminding the client to keep the incision dry for at least 4 to 5 days after insertion. The client should be informed of what signs and symptoms (e.g., redness, swelling, fever) to report to the health care provider. It is important that the client continue to take prescribed cardiac medications (e.g., antidysrhythmics) and follow up with the cardiologist for routine interrogation of the ICD. Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify client 's understanding.

The fire alarm sounds in the hospital that houses a locked inpatient psychiatric unit. The alarm code indicates that the fire is on another medical unit. Which priority action does the nurse on the psychiatric unit take? 1. Ensure that all clients are in the day room. 2. Assign a staff member to each of the unit's locked doors. 3. Explore with clients their past experiences with fire. 4. Prepare for evacuation of the unit using the stairs.

1. Ensure that all clients are in the day room. - The priority is direct client care (think RACE, even though fire is not on this unit). Psychiatric clients are usually mobile, versus confined to bed, and the unit usually has a central gathering area such as a day room. Staff should be assigned to check all rooms and direct patients to leave their rooms and go to the day room.

A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings with the interprofessional health care team focus on? Select all that apply 1. Hypotension 2. Leukocytosis 3. Hyperkalemia 4. Hypercalcemia 5. Hypernatremia

1. Hypotension 3. Hyperkalemia -Due to loss of vascular response (from lack of adrenocortical and mineralocortical -- aldosterone -- hormones). With the loss of salt and water due to low aldosterone, potassium levels also rise.

A client diagnosed with multiple myeloma experiences persistent lower back pain. In which position will the nurse place this client? 1. In bed with the head elevated 45 degrees and hips and knees moderately flexed. 2. In bed with the head elevated 60 degrees and arms resting on the overbed table. 3. In bed with the head of the bed elevated 15 degrees and legs extended. 4. In a straight-backed chair with feet resting on the floor.

1. In bed with the head elevated 45 degrees and hips and knees moderately flexed. - Flexing the knees relieves pressure on the sciatic nerve and disk. Think like a nurse. To maximize comfort and reduce pain, the client with low back pain is encouraged to sleep on the side with a pillow between the knees. The client can also sleep on the back with a pillow under the knees and a small pillow under the small of the back. The client is advised not to sleep on the stomach. During waking hours, the client is advised to sit as little as possible, and only for short periods (10 to 15 minutes).

In Cushing's Disease and Syndrome there are: 1. Increased cortisol production 2. Low potassium and glucose levels 3. Increased production of aldosterone and cortisol 4. Decreased production of cortisol and aldosterone

1. Increased cortisol production

The nurse conducts an admission assessment for an older adult client who is at risk for developing deep vein thrombosis (DVT). Which preventive measures does the nurse expect to be prescribed? (Select all that apply.) 1. Low molecular weight heparin. 2. Bed rest. 3. Leg massage. 4. Compression stockings. 5. Sequential compression devices.

1. Low molecular weight heparin CORRECT - This is utilized as an anticoagulant to prevent DVT. 2. Bed rest INCORRECT - Clients, who are able to get out of bed, need to be in a chair for meals and ambulate four to six times per day to increase circulation and to prevent thrombosis. 3. Leg massage INCORRECT - This is contraindicated in clients at risk for deep vein thrombosis. Massage can dislodge a thrombus and cause it to become a pulmonary embolus. 4. Compression stockings CORRECT - These promote effective blood flow in the deep veins of the legs to prevent thrombosis. 5. Sequential compression devices CORRECT - Air pressure in sequential compression devices squeeze leg tissues to promote blood flow towards the heart. Effective blood flow in the deep veins assists to prevent thrombosis.

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are the characteristics of this disorder? Select all that apply. 1. Nocturia 2. Incontinence 3. Enlarged prostate 4. Nocturnal emissions 5. Decreased desire for sexual intercourse

1. Nocturia 2. Incontinence 3. Enlarged prostate - All of the above should be assessed for in all male clients over 50 years of age

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. For which side/adverse effects of the medication should the nurse monitor? Select all that apply. 1. Signs of hepatitis 2. Flu-like syndrome 3. Low neutrophil count 4. Vitamin B6 deficiency 5. Ocular pain or blurred vision 6. Tingling and numbness of the fingers

1. Signs of hepatitis 2. Flu-like syndrome 3. Low neutrophil count 5. Ocular pain or blurred vision - Side/adverse effects: rash, gastrointestinal disturbances, neutropenia, red-orange colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. - Vitamin B6 efficiency and tingling and numbness of the fingers are associated with the use of isoniazid.

The nurse obtains a history from a client scheduled to undergo electroconvulsive therapy (ECT). Which finding does the nurse report to the health care provider (HCP)? 1. The client takes alendronate once a day. 2. The client reports feelings of lethargy and fatigue. 3. The client has received the therapy in the past. 4. The client walks for a half hour three times per week.

1. The client takes alendronate once a day. — Alendronate is used to treat osteoporosis. Osteoporosis places the client at risk for an injury during the contractions of muscles during the ECT procedure. This finding should be reported to the HCP.

The nurse provides care for a client diagnosed with type 1 diabetes mellitus. Which assessment findings alert the nurse to a hypoglycemic reaction? (Select all that apply.) 1. Tremors. 2. Hot, dry skin. 3. Nervousness. 4. Irritability. 5. Muscle cramps.

1. Tremors. 3. Nervousness. 4. Irritability.

The nurse is caring for a client who takes IBU for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the HCP if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide

1. Warfarin 2. Glimepiride 3. Amlodipine - NSAIDS such as IBU can amplify the effects of anticoagulants like Warfarin. Hypoglycemia may result by taking IBU with a oral hypoglycemic agent like Glimepiride. And a high risk of toxicity exists if the client is taking a calcium channel blocker such as Amlodipine.

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 1. 3 mg/dL 2. 15 mg/dL 3. 29 mg/dL 4. 35 mg/dL

15 mg/dL - A normal BUN level is 6-20 mg/dL. A value of 29 mg/dL and 35 mg/dL reflect continued dehydration. A value of 3 mg/dL reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

A client is prescribed IV aminocaproic acid 4 grams to be administered now. The label reads 250 mg/mL. Which amount in milliliters will the nurse provide to the client? (Record your answer rounding to the nearest whole number.)

16 mL Ratio/Proportion: 1g = 1000mg 250mg/1mL = 4000mg/x mL 250x = 4000 x = 16 mL

The nurse provides a client diagnosed with type 1 diabetes mellitus an insulin injection of 30 units of isophane insulin (NPH) and 10 units of regular insulin at 0700. At which time will the nurse instruct the client to observe for an insulin reaction? 1. 0700 2. 1000 3. 1300 4. 2100

2. 1000 - The onset of action for regular insulin is 30-60 minutes and it peaks in 2-3 hours. The onset of action for NPH insulin is 2-4 hours and it peaks in 6-12 hours. After lunch, the client 's blood glucose level will be elevated.

The nurse provides care for a group of clients in the hospital. Which client does the nurse see first? 1. A client who reports pain 2 hours after a liver biopsy. 2. A client with a long leg cast who reports pain after taking medication. 3. A client 2 days postpartum who reports pain during breast-feeding. 4. A young child who reports a sore throat after a tonsillectomy.

2. A client with a long leg cast who reports pain after taking medication. — Unrelieved pain for a client with a long cast may indicate compartment syndrome and should be assessed first.

A pregnant client comes into the prenatal clinic accompanied by her spouse. The spouse states they were in a car accident and his wife's abdomen hit the steering wheel. The nurse observes the woman wringing her hands and not making eye contact. The client's record shows two recently missed prenatal appointments. Which action does the nurse take? 1. Make eye contact with the client and ask about the accident. 2. Accompany the client into the restroom to obtain a urine sample. 3. Ask the husband if the wife had been drinking alcohol. 4. Escort the couple to an examining room to await the health care provider.

2. Accompany the client into the restroom to obtain a urine sample. - A useful strategy to get women away from an abuser is to claim the need to assist in obtaining a urine sample so that the nurse can further assess the client without the client feeling as fearful.

A client receiving a continuous infusion of milrinone to treat heart failure is prescribed a dose of intravenous furosemide. Which action will the nurse take next? 1. Question the health care provider about the prescription. 2. Administer the furosemide through a separate intravenous access device. 3. Monitor the client for signs of hyperkalemia. 4. Monitor the client for signs of hypermagnesemia.

2. Administer the furosemide through a separate intravenous access device. - Furosemide and milrinone are incompatible. Therefore, the nurse should administer the furosemide through a separate intravenous line to avoid precipitate formation.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PACO2 of 30 mm Hg, and HCO2 of 20 mEq/L. The nurse analyzes these results as indicating which condition? 1. Compensated metabolic acidosis 2. Compensated respiratory alkalosis 3. Uncompensated metabolic alkalosis 4. Uncompensated respiratory acidosis

2. Compensated respiratory alkalosis - In a respiratory condition, an opposite effect will be seen between the pH and the PACO2. The pH is at the high end of normal and the PACO2 is low, representing an alkalotic condition, which is compensated, given the pH is within the normal range.

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right

2. Leukocytosis with a shift to the left - Lab findings do not establish a diagnosis, but there is often an elevation of WBC count (leukocytosis) with a shift to the left (an increased number of immature WBC -- neutrophils). - Shift to the right indicates a reduced amount of young neutrophils. - Leukopenia: Low level of white blood cells

The nurse provides care to a middle-age adult client who is hospitalized following a cerebrovascular accident (CVA). Which information in the client's history does the nurse recognize as being a risk factor for experiencing a CVA? (Select all that apply.) 1. Frequent tension headaches. 2. Pheochromocytoma. 3. Routine use of ibuprofen. 4. Weight loss. 5. Diabetes mellitus.

2. Pheochromocytoma. 3. Routine use of ibuprofen. 5. Diabetes mellitus.

In Cushing's disease, the _______ is secreting too much ACTH (Adrenocorticotropic hormone) which is causing an increase in cortisol production. 1. Adrenal cortex 2. Pituitary gland 3. Thyroid gland 4. Hypothalamus

2. Pituitary gland

The nurse provides instructions to a client with low potassium levels about the foods that are high in potassium, telling the client to consume which foods? Select all that apply 1. Peas. 2. Raisins. 3. Potatoes. 4. Cantaloupe. 5. Cauliflower. 6. Strawberries.

2. Raisins. 3. Potatoes. 4. Cantaloupe. 6. Strawberries. - Foods high in potassium: avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes, - Peas and cauliflower are high in magnesium.

A client with a diagnosis of type 1 diabetes mellitus reports severe continuous pain of the right leg and foot. Which assessment finding most concerns the nurse? 1. The skin on the right lower leg appears brown and leathery. 2. The client cannot distinguish between sharp and dull pressure on the right leg. 3. The client says the right leg is more comfortable when elevated on pillows. 4. The client has 2+ edema distal to the malleolus on the right foot.

2. The client cannot distinguish between sharp and dull pressure on the right leg. — This client may be experiencing peripheral arterial occlusion. Symptoms of occlusion include pain, pulselessness, pallor, paresthesia, and paralysis. Think like a nurse: The client's symptom of continuous pain of the foot and leg could indicate arterial occlusion. The inability to discern between sharp and dull pressure is a major indicator of this health problem. The client needs to be assessed for the additional symptoms of pulselessness, pallor, and paralysis. The other signs or symptoms are indicators of chronic venous insufficiency, which does not pose a risk of immediate harm. Arterial occlusion needs to be reported immediately to the health care provider to prevent tissue damage or loss.

During the nursing assessment, the nurse learns that the client takes garlic capsules daily. After completing the history, it is most important for the nurse to follow-up on which client information? 1. The client was diagnosed with hypertension recently. 2. The client takes regular insulin for type 1 diabetes mellitus. 3. The client is chief executive officer of a real estate company. 4. The client 's father died at age 42 of a myocardial infarction.

2. The client takes regular insulin for type 1 diabetes mellitus. - Garlic supplements can have a direct hypoglycemic effect and may potentiate the action of diabetic drugs. This information should be given to the health care provider.

The home care nurse assesses a client who reports having diarrhea. Which client statement indicates a need for follow up by the nurse? 1. "I am taking an over-the-counter probiotic pill." 2. "I like to drink water that is at room temperature." 3. "I am taking azithromycin." 4. "I like waffles for breakfast."

3. "I am taking azithromycin." — Azithromycin, which is a macrolide anti-infective agent, may cause diarrhea, nausea, and abdominal pain. The client should be advised to consult a health care provider regarding management of diarrhea, which may include changing the medication regimen. Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects. The client is experiencing a side effect to the antibiotic. The client or nurse should notify the health care provider who may change the medication or ask the client to take an over-the-counter anti-diarrhea medication. Occasionally, gastrointestinal symptoms are too severe to continue the medication.

The nurse instructs a client diagnosed with chronic obstructive pulmonary disease (COPD) about how to perform pursed-lip breathing. Which statement by the client indicates to the nurse a need for further teaching? 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. " - Further teaching is necessary because the breath should never be held during pursed-lip breathing. The client is attempting to release trapped air in the lungs due to the effects of COPD.

The nurse is caring for a client with heart failure. On assessment the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin. 2. Flat neck/hand veins and decreased urinary output. 3. An increase in blood pressure and increased respirations. 4. Weakness and decreased central venous pressure (CVP).

3. An increase in blood pressure and increased respirations. - Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bouncing pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.

The nurse provides care for a client receiving a full strength tube feeding. Which complication is the nurse likely to assess in this client? 1. Vomiting. 2. Hypervolemia. 3. Diarrhea. 4. Hypokalemia.

3. Diarrhea. - Intolerance of the feeding solution or the feeding rate most often result in runny stools. Think like a nurse: Solutions for tube feedings are manufactured containing different amounts of nutrients and electrolytes. The nurse should be aware that full strength feedings have a high osmolality and may contain sorbitol, both of which will pull water into the intestine. The nurse is aware that increased water in the intestine may trigger diarrhea. To counteract and decrease the high osmolality of a full strength enteral feeding solution, the solution should be diluted with a predetermined amount of water. The strength of the enteral feeding solution may be increased as the client becomes more tolerant.

A university sponsors a trip abroad for students majoring in international law. At 0300, a student awakens the nurse to report frequency, urgency, and dysuria. Because of safety concerns, night travel is prohibited. Which action should the nurse take first? 1. Ask if the student has experienced this problem previously. 2. Obtain the student 's temperature. 3. Encourage the student to drink large volumes of fluid. 4. Insist that the police override the curfew and allow travel.

3. Encourage the student to drink large volumes of fluid. - The client's symptoms are consistent with a urinary tract infection (UTI), and fluids will help flush the system and may relieve some discomfort. A warm sitz bath may also help relieve discomfort. Antibiotics, the treatment of choice for a UTI, can be obtained after curfew. Think like a nurse

A patient with Addison's Disease should consume which of the following diets? 1. High fat and fiber 2. Low potassium and high protein 3. High protein, carbs, and adequate sodium 4. Low carbs, high protein, and increased sodium

3. High protein, carbs, and adequate sodium

The nurse reviews the electrolyte result of an assigned client and notes that the potassium level is 5.7 mEq/L. Which patterns would the nurse watch for on the cardiac monitoras a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave. 3. Tall peaked T waves. 4. Prolonged ST segment. 5. Widened QRS complexes.

3. Tall peaked T waves. 5. Widened QRS complexes. - Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. - Hypokalemia: ST depression and prominent U wave. - Hypocalcemia: prolonged ST segment

The nurse provides care for a client in acute respiratory distress. The health care provider initiates mechanical ventilation. Which parameter is most important for the nurse to assess after 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. — A client may experience hypotension from decreased cardiac output. The blood pressure is monitored closely.

The nurse provides care for a client with a history of heart failure. The health care provider writes prescriptions for the client. Which prescription does the nurse question? 1. Digoxin 0.25 mg PO in a.m. 2. Oxygen at 4 L/min per nasal cannula. 3. Verapamil 120 mg orally three times daily. 4. Furosemide 40 mg IV push now.

3. Verapamil 120 mg orally three times daily. - Verapamil is contraindicated in clients diagnosed with heart failure and in clients taking digoxin, because it can cause severe bradycardia.

he nurse provides instructions to a pregnant client who is 28 weeks' gestation. The client is prescribed a 1-hour oral glucose tolerance test (GTT). Which instruction does the nurse include in the teaching? 1. "You will be diagnosed with gestational diabetes if the blood sugar at 1 hour is greater than 140 mg/dL (7.8 mmol/L)." 2. "This test requires you to be connected to a glucose drip." 3. "This test will determine if you have gestational diabetes." 4. "You can continue to eat your normal diet prior to test day."

4. "You can continue to eat your normal diet prior to test day." - The client should continue to consume a normal diet until the day of the test. Think like a nurse: Client teaching is essential when providing care to the pregnant client. The nurse must adequate prepare the client regarding what is expected during the different stages of pregnancy along with diagnostic testing that will occur. Clients who are in the second trimester of pregnancy will be prescribed a glucose tolerance test (GTT) to assess for gestational diabetes mellitus. The nurse provides information to the client and then evaluates understanding through the teach-back method. If the nurse determines inadequate understanding of the information presented, the nurse must re-teach the material allowing the client to obtain adequate understanding.

The nurse provides care for clients on the medical-surgical unit. After receiving report, which client does the nurse assess first? 1. A client admitted 8 hours ago with viral gastroenteritis who is complaining of nausea, vomiting, and diarrhea. 2. A client 24 hours post-thyroidectomy who is complaining of a headache and pain at the incision site. 3. A client admitted 3 days ago for chronic kidney disease with a urinary output of 220 mL in 8 hours. 4. A client admitted yesterday for heart failure and digitalis toxicity with frequent premature ventricular complexes.

4. A client admitted yesterday for heart failure and digitalis toxicity with frequent premature ventricular complexes. — Premature ventricular complexes indicate potassium imbalance (hypokalemia), resulting in dysrhythmias (cardiac/circulatory problem), which can rapidly deteriorate to ventricular tachycardia or sudden death.

The nurse provides care for a client diagnosed with respiratory failure. Which nutrient does the nurse instruct the client to limit in the diet? 1. Protein. 2. Calcium. 3. Water. 4. Carbohydrates.

4. Carbohydrates. — Carbohydrates should be limited in clients with respiratory failure because metabolism of this nutrient causes increased carbon dioxide production.

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

4. Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back - Grayish-blue discoloration at the flank is known as Grey-Turner's Sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the pertoneal cavity.

The nurse provides care for a client who is in balanced suspension traction. The client reports pain in the affected extremity, and the nurse administers the prescribed pain medication. One hour later, the client tells the nurse that the pain is unrelieved. Which action should the nurse first take? 1. Contact the health care provider. 2. Turn on the client's radio. 3. Ask client to rate pain using a numeric scale. 4. Perform a neurovascular assessment.

4. Perform a neurovascular assessment. — Pain that is unrelieved by medication is a sign of acute compartment syndrome. The nurse needs to perform a neurovascular assessment before taking other action.

The nurse provides care to a client receiving sulfamethoxazole-trimethoprim (SMZ-TMP). Which observation indicates that the client is experiencing a common side effect of this medication? 1. Hypotonia. 2. Loss of hearing. 3. Hypotension. 4. Urticaria.

4. Urticaria. - A mild to moderate rash is the most common side effect of SMZ-TMP, which is a urinary tract anti-infective. Think like a nurse: The nurse is responsible for monitoring clients who are prescribed medications for both side effects and adverse reactions. While side effects are bothersome and may affect adherence, adverse reactions can be life-threatening. Adherence is particularly important for the client who is prescribed antibiotics such a sulfamethoxazole and trimethoprim (SMZ-TMP) as not completing the complete prescribed course can lead to drug resistance. The most common side effect for SMZ-TMP is a mild to moderate rash. The client should be educated regarding this information and provided with instruction on how to treat the rash if it occurs and when to notify the health care provider.

The nurse provides care for a client admitted for pre-eclampsia. The health care provider prescribes a loading dose of magnesium sulfate 4 g IV over 30 minutes. Magnesium sulfate is available in 2 g/100 mL in 0.9% sodium chloride. At how many milliliters per hour does the nurse set the infusion rate for the loading dose? (Do not round. Record your answer using a whole number.)

400 mL/hr 2g/100mL = 4g/x 2x = 400 x = 200mL in 30 minutes

The nurse provides education about influenza treatment and prevention at a local health fair. Which statement from a participant demonstrates correct understanding of oseltamivir? (Select all that apply.) 1. "I will begin taking the medication as soon as I experience flu symptoms." 2. "The capsules must be swallowed whole and never opened." 3. "If the medication upsets my stomach, I can take it with food." 4. "Children younger than 12 years should not take this medication." 5. "After I complete the medication, I will not need a yearly flu shot." 6. "I should not take this medication if I am allergic to eggs."

ANSWERS: 1, 3 EXPLANATION: 1. "I will begin taking the medication as soon as I experience flu symptoms." — To lessen the severity of influenza symptoms, influenza sufferers should take oseltamivir as soon as symptoms appear. 3. "If the medication upsets my stomach, I can take it with food." — Oseltamivir may cause stomach upset, and taking it with food should decrease this adverse effect.

The nurse provides care to a client who underwent surgical repair of a femur fracture 1 day ago. After awakening the client for assessment, the nurse realizes the client has developed slurred speech. Which nursing action is appropriate? (Select all that apply.) 1. Perform a neurological assessment. 2. Measure oxygen saturation level. 3. Administer glucose tablets as ordered. 4. Contact the health care provider. 5. Review the medication administration record. 6. Request a speech therapy consultation.

ANSWERS: 1, 2, 4, 5 EXPLANATION: 1. Perform a neurological assessment. - Slurred speech may indicate a brain injury. Further evaluation is needed to help identify additional signs and symptoms that correlate with a neurologic deficit. 2. Measure oxygen saturation level. - Hypoxia may cause slurred speech. Measurement of oxygen saturation is appropriate to obtain additional assessment data. 4. Contact the health care provider. - A significant change in the client's condition is cause for notifying the health care provider. 5. Review the medication administration record. - Because medications and medication interactions may cause neurologic changes, including slurred speech, a quick review of the medication administration record is warranted. Think like a nurse: The client is at risk for developing post-operative complications and should have a complete neurologic assessment. Oxygen saturation level should be assessed since hypoxia can cause slurred speech. The client's medical record should be reviewed to determine if any medications have slurred speech as an adverse effect. The health care provider should be contacted after completing the assessment to report the change in the client's condition. A serum glucose level should be obtained before providing glucose.

The client is admitted with extreme fatigue, shortness of breath, anxiety, and chest pressure. Which intervention does the nurse implement? (Select all that apply.) 1. Place the client on bed rest. 2. Administer supplemental oxygen. 3. Administer ketorolac for pain. 4. Assess serum troponin level. 5. Monitor intake and output.

ANSWERS: 1, 2, 4, 5 EXPLANATIONS: 1. Place the client on bed rest. — The client is experiencing the symptoms of a myocardial infarction. Bed rest decreases stress on the heart by decreasing muscle metabolism and therefore oxygen demand. 2. Administer supplemental oxygen. — In a myocardial infarction, administering oxygen is a priority action as this client is experiencing poor oxygenation to the heart muscle. 4. Assess serum troponin level. — The troponin level is sensitive to cardiac damage and can confirm that the client is having a myocardial infarction. 5. Monitor intake and output. — The nurse should monitor intake and output to assess for fluid overload. The client is at high risk to experience heart failure due to death of myocardial tissue. Think like a nurse: These symptoms suggest that the client is experiencing a myocardial infarction. The first action is to place the client on bedrest to reduce myocardial oxygen demand and apply supplemental oxygen to ensure adequate oxygenation of myocardial tissue. Monitoring intake and output is essential for early detection of fluid overload, which can occur when myocardial tissue is damaged. A troponin level is used to evaluate for myocardial tissue damage.

During the admission assessment, an older adult client exhibits poor skin turgor, dry lips, and an open sacral wound with reddened edges and malodorous drainage. The nurse observes the client has poor hygiene and a withdrawn affect. Which actions will the nurse implement? (Select all that apply.) 1. Bring the client's caregiver into the room. 2. Alert the nursing supervisor to possible elder abuse. 3. Obtain a thorough skin assessment. 4. Perform an elder mistreatment assessment. 5. Conduct a mini mental status exam.

ANSWERS: 2, 3, 4 EXPLANATION: 2. Alert the nursing supervisor to possible elder abuse. — Health care workers are mandated to report suspected mistreatment to the authorities. Follow the facility's procedure for reporting suspected abuse. 3. Obtain a thorough skin assessment. — A thorough assessment may reveal other indications of abuse. Document all findings clearly in the health care record. 4. Perform an elder mistreatment assessment. — Protocols for elder mistreatment screening should be followed. This will include documentation and photographs. Think like a nurse: The client's symptoms, hygiene, and affect could indicate elder abuse or neglect. The first action is to complete a thorough skin and elder mistreatment assessment. Based upon the findings, the nurse should notify the supervisor to report suspected elder abuse. The client should be assessed alone. Having family or a caregiver present could hinder free and honest communication from the client.

The nurse teaches staff members about developmental considerations related to bowel elimination. Which statements are appropriate for the nurse to include in the teaching? (Select all that apply.) 1. "An infant 's stool will vary depending on how the infant is fed." 2. "Bowel control is usually achieved before bladder control." 3. "Voluntary control of anal and urethral sphincters begins at about 30 months of age." 4. "Constipation in the older adult can be related to decreased gastrointestinal motility." 5. "Fecal impaction may be associated with oozing of liquid feces."

ANSWERS: 1, 2, 4, 5 Explanation: 1. "An infant 's stool will vary depending on how the infant is fed." - The formula-fed infant excretes pale yellow to light brown stools. They are firmer in consistency than those of the breastfed infant. The stools of infants fed with breastmilk are seedy, and the color and consistency of mustard with a sweet-sour smell. 2. "Bowel control is usually achieved before bladder control." - Bowel control is usually achieved before bladder control. 4. "Constipation in the older adult can be related to decreased gastrointestinal motility." - Older adults may experience slowed peristalsis related to the loss of muscle elasticity, reduced intestinal mucous secretion, or a low-fiber diet. 5. "Fecal impaction may be associated with oozing of liquid feces." - The cardinal sign of impaction is continuous oozing of liquid stool, with no normal stool. Oozing occurs as the liquid portion of feces higher in the intestines seeps around the mass. Think like a nurse: Comprehensive bowel assessment requires an understanding of normal gastrointestinal (GI) functions in various developmental stages. During the interview of clients with diarrhea or constipation, the nurse should inquire about its onset, duration, and character, as well as associated symptoms and alleviating factors. The nurse can inquire about the client 's usual bowel patterns, routines followed to promote bowel elimination, diet and fluid intake history, medication use, and medical-surgical conditions affecting the GI function.

The nurse provides care for a child receiving 40 drops of IV fluid per minute. The IV set has a drip factor of 60 drops per mL. At this rate, how many hours will take to infuse 400 mL? (Record your answer rounding to the nearest whole number.)

Answer: 10 hours If the IV set delivers 60 drops per minute, drops per minute equals mL per hour. 40 drops/min = 40 mL/hr 400mL/40 mL per hour = 10 hours

The nurse reviews a client's medication administration record. Which prescriptions are correctly questioned by the nurse? (Select all that apply.) Medication Administration Jane Doe, 7/22/1964, MRN J000376584 Allergies: meperidine, hydrocodone and ibuprofen, pantoprazole, iodine, latex, nifedipine, levofloxacin, glipizide, sulfamethoxazole and trimethoprim 1. The frequency of acetaminophen administration. 2. The administration of pantoprazole. 3. The dosage of lisinopril. 4. The administration of azithromycin. 5. The route of rivaroxaban. 6. The administration of trimethoprim- sulfamethoxazole.

Answers: 2, 6 Explanation: 2. The administration of pantoprazole. — The nurse should question administration of pantoprazole as the client has a documented allergy to this medication. 6. The administration of trimethoprim- sulfamethoxazole — The nurse should question administration of trimethoprim-sulfamethoxazole as the client has documented allergy to this medication. Think like a nurse: When evaluating a client's medication administration record, the nurse is responsible for identifying contraindicated medications, including medications that are inappropriate due to allergies, health alterations, or potential medication interactions. The nurse also evaluates medication appropriateness in terms of dosage, frequency of administration, and route of administration. Nurses are held to a high legal standard regarding medication administration. Along with identifying contraindicated medications and evaluating medication appropriateness, the nurse also must verify the Rights of Medication Administration.

The nurse answers the call light of a client reporting a severe headache 30 minutes after undergoing a lumbar puncture. Which action does the nurse take first? 1. Assess the puncture site. 2. Administer an analgesic as prescribed. 3. Assess the client's blood pressure. 4. Encourage the client to lie flat.

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 is required to determine if further intervention is indicated.

A client who has a cold is seen in the emergency department with the inability to void. Because the patient has a history of benign prostatic hyperplasia, which medication should the nurse question? 1. Diuretics 2. Antibiotics 3. Antilipemics 4. Decongestants

Decongestants - Decongestants, anticholinergics, and antidepressants lessen the voluntary ability to contract the bladder.

A client with AIDS has histoplasmosis. The nurse should assess the client for which expected finding? 1. Dyspnea 2. Headache 3. Weight gain 4. Hypothermia

Dyspnea - Histoplasmosis is an opportunistic fungal infection that can occur in clients with AIDS, beginning as a respiratory infection and can progress to disseminated infection. - S/S: fever, dyspnea, cough, and weight loss, with possible enlargement of the clients lymph nodes, liver and spleen.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. Which information would be important for the nurse to obtain during the client visit regarding the side and adverse effects of their prescribed fluoxetine? 1. Cardiovascular systems 2. GI dysfunction 3. Problems with mouth dryness 4. Problems with excessive sweating

GI dysfunction - The most common side and adverse effects of fluoxetine are central nervous system and GI dysfunction, including N/V/D and cramping.

A client has been on treatment for rheumatoid arthritis for 3 weeks and is undergoing treatment with etanercept. Which is most important for the nurse to assess? 1. The injection site for itching and edema 2. The WBC and platelet count 3. Whether the client is experiencing fatigue or joint pain 4. Whether the client is experiencing a metallic taste in the mouth and loss of appetite

The WBC and platelet count - Infection and pancytopenia are side effects of etanercept. The appearance of abnormal WBC and platelet counts can alert the nurse to a potential life-threatening infection. - Injection site itching is a common occurrence following administration. A metallic taste in the mouth and loss of appetite are not signs of adverse effects of this medication.

The home care nurse returns to the office to find four phone messages. Which message does the nurse return first? 1. The adult child of a client diagnosed with lung cancer stating that the client refuses chemotherapy today. 2. A client asking when staples can be removed from an abdominal incision. 3. A client with a colostomy reporting that the skin is raw around the stoma. 4. The spouse of a client with a cerebrovascular accident stating that the client is refusing a bath.

The adult child of a client diagnosed with lung cancer stating that the client refuses chemotherapy today — This client is at risk for experiencing physical harm and this issue is time-sensitive. The nurse should assess whether the client is experiencing side effects and should ensure that the client is informed about the risks of refusing chemotherapy.

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

The client is experiencing a pulmonary reaction requiring cessation of the medication - Nitrofurantoin can induce two kinds of pulmonary reactions: acute and sub-acute. Acute reactions (most common) manifest with dyspnea, chest pain, chill, fever, cough, and alveolar infiltrates. These symptoms resolve 2-4 days after discontinuing the medication. Subacute reactions are rare and occur during prolonged treatment, with symptoms (dyspnea, cough & malaise) usually regressing weeks to months following Nitrofurantoin withdrawal.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, red and edematous with a palpable pedal pulse, which is unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

The neurovascular status is normal because of increased blood flow through the leg - An expected outcome of aortoiliac bypass graft surgery is warmth, redness and edema in the surgical extremity due to increased blood flow.

The nurse provides care to a client 8 hours after delivery of a newborn. Which location on the diagram will the nurse expect to palpate the client's fundus?

The nurse anticipates finding the fundus at the level of the umbilicus. The fundus rises to the level of the umbilicus 6-12 hours after delivery. Beginning with day 1, the fundus descends about 1 fingerbreadth (1 cm) per day. By 14th day, the fundus has normally descended into the pelvic cavity and cannot be palpated abdominally. The descent is documented in relation to the umbilicus.

A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? 1. Elevated vanillylmandelic acid urinary levels. 2. The presence of blast cells in the bone marrow. 3. The presence of Epstein-Barr virus in the blood. 4. The presence of Reed-Sternberg cells in the lymph nodes.

The presence of Reed-Sternberg cells in the lymph nodes.

The nurse supervises care of a client in Buck traction. Which observations does the nurse determine are appropriate? (Select all that apply.) 1. The nurse removes the foam boot three times/day to inspect the skin. 2. The staff turns the client to the unaffected side. 3. The staff provides back care for the client once per shift. 4. The nurse asks the client to dorsiflex the foot on the affected leg. 5. The staff offers magazines to the client when the client reports pain. 6. The staff elevates the foot off the client 's bed.

ANSWERS: 1, 2, 4, 6 EXPLANATION: 1. The nurse removes the foam boot three times per day to inspect the skin. — It is important to observe for skin breakdown. During the inspection, a second nurse should support the extremity. 2. The staff turns the client to the unaffected side. — It is appropriate that if client has a fracture, to turn to the unaffected side and support the upper leg with pillows. 4. The nurse asks the client to dorsiflex the foot on the affected leg. TEACHER ANSWERS: 1, 2, 4, 6 EXPLANATION: — Assess function of the peroneal nerve. Weakness of dorsiflexion may indicate pressure on the nerve that must be corrected to prevent permanent damage. 6.The staff elevates the foot off the client 's bed. — Elevating the foot off the bed provides countertraction for the client. Think like a nurse: The nurse knows that care of a client in Buck traction focuses on maintaining skin integrity, protecting the affected extremity, and frequently assessing sensorimotor status of the affected limb. The nurse also understands that Buck traction is generally used for short-term treatment (48 to 72 hours) until surgery is possible. The nurse should prepare the client for surgery by utilizing informational pamphlets, videos, individualized and structured instruction, and website programs that explain procedures and specific information about the surgery.

The nurse administers a client's prescribed medications. During administration of ampicillin/sulbactam IV piggyback, the client reports throat itchiness and difficulty breathing. Which actions will the nurse implement? (Select all that apply.) 1. Auscultate the client's lungs. 2. Stop the IV piggyback infusion. 3. Give the client sips of water. 4. Lower the head of the client's bed. 5. Prepare for administration of epinephrine.

ANSWERS: 1, 2, 5 EXPLANATION: 1. Auscultate the client's lungs. - Auscultation of the client's lungs may reveal wheezes or diminished breath sounds, both of which may occur as a result of bronchoconstriction due to an allergic reaction. 2. Stop the IV piggyback infusion. - Stopping the IV antibiotic infusion is a critical intervention, as the antibiotic medication may be triggering an allergic reaction. 5. Prepare for administration of epinephrine. - Treatment of an allergic reaction may include epinephrine administration. Think like a nurse: Ampicillin is an antibiotic within the penicillin family. Penicillin allergy is one of the most common medication allergies. An itchy throat and difficulty breathing are symptoms of a drug allergy. The first action is to stop the infusion and then auscultate the client's lung sounds. The nurse should also prepare to administer epinephrine, which is used to treat acute allergic reactions.

The nurse provides care for a client diagnosed with postural hypotension. The nurse includes which intervention in the client 's plan of care? (Select all that apply.) 1. Teach the client energy conservation techniques. 2. Encourage the client to increase fluid intake. 3. Maintain the client on a low-sodium diet. 4. Encourage the client to maintain bed rest. 5. Instruct the client to rise slowly.

ANSWERS: 1, 2, 5 Think like a nurse: 1. Teach the client energy conservation techniques. CORRECT — Hypotension can cause generalized weakness. The client should implement energy conservation techniques to prevent excessive exertion and an increase in symptoms. 2. Encourage the client to increase fluid intake. CORRECT — Increased fluid intake may correct hypotension related to decreased fluid volume. 3. Maintain the client on a low-sodium diet. INCORRECT — Sodium will cause fluid retention, thereby increasing blood volume and blood pressure. 4. Encourage the client to maintain bed rest. INCORRECT — The client will need to improve exercise tolerance slowly. 5. Instruct the client to rise slowly. CORRECT — A slow rise to the standing position may prevent falls. Think like a nurse: Postural hypotension is a sudden drop in blood pressure when changing position from sitting or lying to standing. The acute drop in blood pressure can cause generalized weakness. The client should be counseled to prevent excessive exertion and pace activities. Increasing fluids will help maintain fluid balance and blood volume. Changing positions slowly helps reduce the acute effects when the blood pressure falls.

The clinic nurse assesses a client who presents with a documented history of a gastric ulcer. Current symptoms include nausea, vomiting, and diarrhea of 2 days' duration. Which client statement requires immediate intervention by the nurse? 1. "I take aspirin for headaches and arthritis pain, and antacids for this ulcer of mine." 2. "I have been drinking more fluids to keep from getting dehydrated, but I am urinating less than I thought I would." 3. "On my last visit to the health care provider, I was told I may be developing cataracts." 4. "I knew I was under a lot of stress at work, but I thought I was coping well."

"I have been drinking more fluids to keep from getting dehydrated, but I am urinating less than I thought I would." — It is particularly important to assess urine output because of the potential for fluid volume deficit and resultant shock. In the first stages of shock there is decreased urine output, even when there is normal fluid intake. It is especially important for the nurse to elicit information about fluid intake and output during the preceding 24 hours. This client has an ulcer, which might be bleeding and, in addition, the client is experiencing loss of fluid from vomiting and diarrhea. These could result in hypovolemic shock. This is an actual circulatory problem and is the highest priority.

The nurse prepares a client diagnosed with cervical cancer for the insertion of an internal radiation implant. Which client statement requires immediate follow-up by the nurse? 1. "Unless I have a bowel movement every day, I just do not feel right." 2. "I am glad this whole process is only going to last 3 days." 3. "I will get up only when I have to urinate, and then I will go right back to bed." 4. "If it were not for my children, I would not be going through all of this."

"I will get up only when I have to urinate, and then I will go right back to bed." — This is the priority concern. The client will be on strict bed rest, supine with the head of the bed elevated no more than 20 degrees. Movement is restricted and an indwelling catheter is inserted into the bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts. Severe radiation burns can result from a distended bladder or from the client attempting to go to the bathroom and void.

The nurse receives report from the previous shift on four clients. In which order will the nurse assess the clients? (Please arrange in order. All options must be used.) - A client requesting pain medication for post-surgical pain rated 7 on a 0-10 scale. - A client with Alzheimer disease who is disoriented to place, time and event. - A client who has a new prescription to insert a nasogastric (NG) tube with low, intermittent suction. - A client with a subdural hematoma who has a sudden onset of acute confusion.

- A client with a subdural hematoma who has a sudden onset of acute confusion. - A client requesting pain medication for post- surgical pain rated 7 on a 0-10 scale. - A client who has a new prescription to insert a nasogastric (NG) tube with low, intermittent suction. - A client with Alzheimer disease who is disoriented to place, time and event. - The client with a subdural hematoma experiencing a change in level of consciousness indicates potential increased intracranial pressure. The client has a new and acute symptom related to circulation, which places the client at risk for immediate harm. This client should be seen first. The client requesting pain medication for acute pain is experiencing an immediate need. This client should be seen second. There are no indications of any immediate problems, but there is a new prescription that should be carried out (NG tube insertion). The nurse can see this client third. The client is experiencing the expected symptoms of Alzheimer disease. This client has no immediate needs and can be seen last. Think like a nurse: The nurse should consider each client health problem and determine which condition is most acute. Of the clients listed, the client with a subdural hematoma experiencing changes in level of consciousness is the most acute. The change in consciousness could be caused by increasing intracranial pressure and become life-threatening. The client requesting medication for post-operative pain should be cared for next.

The nurse notes that four clients arrive for emergency care at the same time. In which order will the nurse assess the clients? (Please arrange in order. All options must be used.) - Client diagnosed with an open fracture and chest contusions from a motor vehicle crash. - Client diagnosed with COPD experiencing shortness of breath and an oxygen saturation of 88 percent - Client diagnosed with diaphoresis and feeling chest pressure. - Client diagnosed with dyspnea and swollen lips after being stung by a bee.

- Client diagnosed with dyspnea and swollen lips after being stung by a bee. - Client diagnosed with diaphoresis and feeling chest pressure. - Client diagnosed with an open fracture and chest contusions from a motor vehicle crash. - Client diagnosed with COPD experiencing shortness of breath and an oxygen saturation of 88 percent Think like a nurse: If approaching the triage of these clients with the ABCs (airway, breathing, and circulation), the client with a condition affecting the airway should be addressed first. The client with dyspnea after a bee sting is at risk for an occluded airway as a result of an anaphylactic reaction to the bee sting. The client with chest pressure should be addressed next, because of the potential for a myocardial infarction. The client with an open limb and chest contusion is at risk for bleeding and compromised oxygenation. The client diagnosed with a chronic pulmonary disease who has a low oxygen saturation level takes lowest priority, because of the chronicity of the health problem.

The nurse instructs the unlicensed assistive personnel (UAP) on the emptying of a drainage evacuator. In which order will the nurse teach the UAP to perform the required actions? (Please arrange in order. All options must be used.) - Compress the evacuator and replace the plug - Identify the client - Pour drainage into a measuring cup - Don gloves - Elevate the bed to a workable height

- Identify the client - Elevate the bed to a workable height - Don gloves - Pour drainage into a measuring cup - Compress the evacuator and replace the plug

The nurse plans care for assigned clients. In which order will the nurse prioritize the care for these clients? (Please arrange in order. All options must be used.) - Child diagnosed with sickle cell crisis reporting priapism - Child requiring observation following an acute asthma attack - Child whose temperature has risen to 103.8 degrees F (39.9 degrees C) - Infant who is vomiting and has frothy oral secretions

- Infant who is vomiting and has frothy oral secretions - Child requiring observation following an acute asthma attack - Child whose temperature has risen to 103.8 degrees F (39.9 degrees C) - Child diagnosed with sickle cell crisis reporting priapism Think like a nurse: The nurse needs to consider which client is most unstable and at greatest risk. The nurse makes this determination by using knowledge about ABCs (airway, breathing, circulation) and Maslow to set priorities. The client with frothy oral secretions is at risk for airway compromise and should receive care first. The client recovering from an acute asthma attack is still at risk for airway occlusion. The client with an elevated temperature may have an infection and is at risk for dehydration. Priapism, while uncomfortable, is not a life-threatening condition.

The nurse auscultates 40 bowel sounds in 1 minute when assessing the abdomen of a client with pain, nausea, and vomiting. Which statement will the nurse use when documenting this assessment finding? 1. "Absent bowel sounds on auscultation." 2. "Hypoactive bowel sounds heard on auscultation." 3. "Normal bowel sounds heard on auscultation." 4. "Hyperactive bowel sounds heard on auscultation."

1. "Absent bowel sounds on auscultation." INCORRECT— Absent bowel sounds mean that no sounds are heard over 3-5 minutes. 2. "Hypoactive bowel sounds heard on auscultation." INCORRECT— Hypoactive bowel sounds mean that one or two sounds are heard over 2 minutes. 3. "Normal bowel sounds heard on auscultation." INCORRECT— Normal bowel sounds mean that 5-30 sounds are heard per minute. 4. "Hyperactive bowel sounds heard on auscultation." CORRECT— Hyperactive bowel sounds mean that more than 30 sounds are heard over 1 minute. Think like a nurse: Hearing 40 bowel sounds in 1 minute upon auscultation indicates bowel hyperactivity and should be documented as such. This amount of sounds would be expected because of the client's symptoms of pain, nausea, and vomiting. Five to 30 bowel sounds is considered normal. Hearing no sounds for 3 to 5 minutes indicates absence of bowel activity.

The nurse provides care to a school-age client who is prescribed amoxicillin suspension 250 mg PO for treatment of an upper respiratory infection (URI). Prior to administering the medication, the nurse provides which information to the client? 1. "Amoxicillin is an antibiotic that will help you get well." 2. "This medicine tastes just like fresh strawberries." 3. "You can't drink anything for an hour after taking this medicine." 4. "If you don't want to drink this medicine, I can give you a shot instead."

1. "Amoxicillin is an antibiotic that will help you get well." — For the school-age client, discussion of facts is appropriate. School-age clients can process information about their treatments and benefit from participating in their plan of care. Think like a nurse: School-age clients are given facts about their care. Telling things that are false, tricking, and trying to make the client fearful of other medication options is not professional, and will cause the child to become argumentative or distrustful. The nurse is honest and describes the client's care in age-appropriate words, empowering the child to help manage his or her own well-being.

A client seeks medical attention for cramping pelvic pain and saturating five sanitary napkins over a 2 hour period. Which questions are most important for the nurse to ask the client when conducting the health history of the current issue? (Select all that apply.) 1. "Are you feeling dizzy?" 2. "When was the first day of your last period?" 3. "Are you taking ibuprofen for your pain?" 4. "When did the bleeding start?" 5. "When did you last have intercourse?" 6. "What did you eat at your last meal?"

1. "Are you feeling dizzy?" - Dizziness is an adverse effect from blood loss. Asking about dizziness helps determine the effects bleeding has on the client. 2. "When was the first day of your last period?" - Asking when the client experienced menstruation last is important to determine pregnancy potential and the possible loss of a pregnancy. 4. "When did the bleeding start?" - Asking when the bleeding started is important to gather history of this event, as it will help determine the amount of bleeding the client is experiencing. Think like a nurse: The nurse needs to assess the client to determine the potential cause for the bleeding. Questions should include when the bleeding started to determine the potential amount of blood loss and when the client's last menstrual period occurred in the event the client is experiencing a spontaneous abortion. Assessing the client for dizziness helps to determine if the blood loss is affecting total body fluid volume status.

The nurse reviews the developmental milestones for a 20-month-old client. Which statements made by the parent indicate to the nurse that the family is ready for toilet training? (Select all that apply.) 1. "Diapers are usually dry when waking up from a nap." 2. "Wearing wet or dirty diapers does not bother my child." 3. "I am looking forward to taking the next 2 weeks off." 4. "Sitting still for 2 to 3 minutes is not a problem." 5. "Bowel movements occur any time during the day." 6. "Dressing and undressing are a favorite activity."

1. "Diapers are usually dry when waking up from a nap." CORRECT - Having dry diapers after a nap indicates the ability to stay dry when asleep. This is an indication the client is ready for toilet training. 2. "Wearing wet or dirty diapers does not bother my child." INCORRECT - Tolerating a wet or dirty diaper does not indicate readiness for toilet training. A toddler indicates readiness by wanting the wet or soiled diaper to be changed immediately. 3. "I am looking forward to taking the next 2 weeks off." CORRECT - Parents have to have the time to devote to toilet training. This is an indication the family is ready for toilet training. 4. "Sitting still for 2 to 3 minutes is not a problem." INCORRECT - The client should be able to sit on the toilet for 5 to 10 minutes without getting off for toilet training to be successful. 5. "Bowel movements occur any time during the day." INCORRECT - Having regular bowel movements indicates readiness for toilet training. 6. "Dressing and undressing are a favorite activity." CORRECT - The child needs the fine motor skills to be able to pull clothing up and down for toilet training to be successful. This is an indication the client is ready for toilet training.

A client returns for a follow-up appointment after treatment for renal calculi. Which instruction is most beneficial for the nurse to teach the client to prevent a recurrence of the health problem? 1. "Drink at least 3000 mL of fluid a day." 2. "Reduce the amount of dairy products and eggs in your diet." 3. "Increase the amount of whole grains and vegetables that you eat." 4. "Avoid foods that contain tyramine, such as wine and cheese."

1. "Drink at least 3000 mL of fluid a day." — Prevention of renal calculi includes ingesting between 3000-4000 mL of fluid per day.

The health care provider prescribes ciprofloxacin for the client. Which instruction is most important for the nurse to include about this medication? 1. "Drink plenty of fluids until this medication is complete." 2. "Do not take this medication with your multivitamin." 3. "Monitor the intake of dairy products in your diet." 4. "Take every dose of this medication with a meal."

1. "Drink plenty of fluids until this medication is complete." — Increased fluid intake is essential because it prevents crystalluria and kidney stone formation. This complication can lead to surgery, hospitalization, or other medical intervention. Think like a nurse: Fluoroquinolones such as ciprofloxacin are known to cause acute renal failure due to interstitial nephritis. The crystals of this agent precipitate under alkaline urine and can lead to renal failure through intratubular precipitation. Hydration with IV fluids and further avoidance of urine alkalinization can treat the condition. The nurse should also keep in mind that taking ciprofloxacin is one of the risk factors for Clostridium difficile infection. The nurse should monitor the client for diarrhea and put the client in prophylactic isolation until proven the diarrhea is not due to C. diff.

The nurse counsels the parents of school-age children. One of the parents asks the nurse how they should teach their children about human sexuality. Which response by the nurse is best? 1. "Find out what your children know before answering their questions." 2. "Remember, your words have more influence than your actions." 3. "Avoid correct anatomic terms because they are difficult for the child to comprehend." 4. "Playing 'doctor' satisfies the child's curiosity."

1. "Find out what your children know before answering their questions." — The nurse should suggest that parents first assess their child's knowledge. Children often have misinformation about human sexuality. If the misinformation is not identified and corrected, the child will incorporate the misinformation into the parent's answer. Think like a nurse: The nurse should follow the nursing process and suggest that the parent ask what the child knows or "has heard" about human sexuality. The suggestion is for the use of assessment. Assessing the child provides the parent with a valid starting point. It is necessary to assess whether the child has been exposed to incorrect information. After the child's basic knowledge has been determined, the parent can then proceed with teaching the child about human sexuality and answering any questions.

Which post-operative recommendation by the nurse is best when assisting a client prepare for cataract surgery? 1. "Have someone do the vacuuming." 2. "Eat foods high in antioxidants." 3. "Have loperamide 2 mg available." 4. "Ask someone to sit with you for 2 days."

1. "Have someone do the vacuuming." — The client should not vacuum following cataract surgery because the jerky movements and bending at the waist can increase intraocular pressure. This is the best recommendation by the nurse to prevent postoperative complications. Think like a nurse: The client post-cataract surgery should be taught not to do any activities that may increase intraocular pressure, such as pushing or pulling on a vacuum sweeper. The client should also be encouraged to eat a high-fiber, high-fluid diet to avoid constipation. Additional teaching includes instructing the client and caregiver about prescribed eye drops to prevent infection, reduce inflammation, and control eye pressure. The client should be informed to call the provider if the client experiences vision loss, persistent pain, increased eye redness, or if the client reports light flashes or multiple new spots (floaters) in front of the eye.

The nurse assesses a 10-year-old client during a well-child visit. Which statements will the nurse expect the client to make? (Select all that apply.) 1. "I am allergic to strawberries. Whenever I eat one my lips get real big." 2. "I have a kitten. I love having an animal." 3. "This is my sword!" while holding a pen. 4. "A child in my class has hurt feelings when teased by others." 5. "I would love to have an extra eye on my hand, so I could see around corners with it!"

1. "I am allergic to strawberries. Whenever I eat one my lips get real big." CORRECT - According to Piaget's concrete operational stage, inductive logic is appropriate at this age. 2. "I have a kitten. I love having an animal." CORRECT - According to Piaget's concrete operational stage, reversibility thinking is appropriate at this age. 3. "This is my sword!" while holding a pen. INCORRECT - This is appropriate for Piaget's pre-operational stage, which occurs before the client reaches the age of 10. 4. "A child in my class has hurt feelings when teased by others." CORRECT - According to Piaget's concrete operational stage, children should be able to take on the perspective of others. 5. "I would love to have an extra eye on my hand, so I could see around corners with it!" INCORRECT - This is appropriate for Piaget's formal operational stage, which occurs before the client reaches the age of 10. Think like a nurse: Based on Piaget's stages of cognitive development, concrete operational development occurs among school-age children (7 to 11 years of age). When providing care to the school-age client during a well-child visit, the nurse expects certain behaviors based on the stage of cognitive development. During the concrete operational stage, the child learns by manipulating concrete objects, lacks the ability to think abstractly, learns that certain characteristics of objects remain constant, understands the concept of time, starts collecting items, understands relationship among objects, and can reverse thought processes.

An entertainment celebrity is admitted to a psychiatric unit with a diagnosis of major depression with psychotic features. A nurse who works on the medical-surgical unit asks the psychiatric nurse why the client was admitted. Which response by the nurse is appropriate? 1. "I cannot share that information with you." 2. "You can look at the record the next time you are on the unit. " 3. "I will tell you why, but you have to promise not to tell anyone. " 4. "I will introduce you to the client, and you can ask about the hospitalization. "

1. "I cannot share that information with you." - This statement maintains confidentiality, a legal requirement. Think like a nurse: The privacy and confidentiality of protected health information (PHI) is federally mandated by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. All members of the health care team are required to protect the client 's privacy and confidentiality. Violation of a client 's right to privacy and confidentiality may lead to serious consequences, including termination of employment. As a rule, staff members should have access only to confidential or sensitive information that is necessary to perform their jobs. This means staff should not review electronic files or paper records of clients for whom they are not assigned to provide care.

The nurse provides care for the client diagnosed with hemophilia. The nurse intervenes if the client makes which statement? (Select all that apply.) 1. "I drink two beers every day after work." 2. "I receive intramuscular pain relief injections weekly." 3. "I play golf on the weekends with my cousin." 4. "I take meloxicam daily for arthritis pain." 5. "I always wear my medical alert bracelet."

1. "I drink two beers every day after work." CORRECT— The nurse should intervene because alcohol interferes with platelet aggregation, which increases the risk for bleeding for a client diagnosed with hemophilia. 2. "I receive intramuscular pain relief injections weekly." CORRECT— The nurse should intervene because intramuscular injections place the client diagnosed with hemophilia at risk for bleeding at injection sites. 4. "I take meloxicam daily for arthritis pain." CORRECT— The nurse should intervene because meloxicam interferes with platelet aggregation, which increases the risk for bleeding for a client diagnosed with hemophilia.

The client taking phenelzine is discussing an appropriate diet with the nurse. Which client statements indicate to the nurse a need for further teaching? (Select all that apply.) 1. "I have a glass of wine with dinner." 2. "I got a great deal on vegetable soup." 3. "My grandparent makes me liver and onions every Sunday." 4. "I ordered a tray of meat and cheese for my cocktail party this weekend." 5. "My favorite breakfast is yogurt and granola." 6. "I eat at least one orange and one apple every day."

1. "I have a glass of wine with dinner." CORRECT — Phenelzine is a monoamine oxidase inhibitor (MAOI). Tyramine-containing foods are contraindicated with MAOIs, as these precipitate a hypertensive reaction. Alcohol contains a high amount of tyramine and should be avoided. 2. "I got a great deal on vegetable soup." INCORRECT— Vegetable soup is an acceptable diet option for a client taking an MAOI as it does not contain tyramine. 3. "My grandparent makes me liver and onions every Sunday." CORRECT — Organ meat, such as liver, contains a high amount of tyramine and should be avoided. 4. "I ordered a tray of meat and cheese for my cocktail party this weekend." CORRECT — Processed or cured meats, such as salami, pepperoni, or ham, contain tyramine and should be avoided. Cured cheeses and alcohol are also tyramine-rich. 5. "My favorite breakfast is yogurt and granola." CORRECT — Fermented foods like yogurt are tyramine-rich and should be avoided. 6. "I eat at least one orange and one apple every day." INCORRECT— Apples and oranges do not contain tyramine and are acceptable diet options for a client on an MAOI.

The nurse provides care for a client 24 hours after a thyroidectomy. Which client statement to the nurse requires an immediate intervention? 1. "I have been having some muscle spasms in my legs and my lips are tingling." 2. "I think I am getting a cold because I have been coughing and sneezing all night." 3. "I am still having pain around the incision." 4. "My voice is still very hoarse."

1. "I have been having some muscle spasms in my legs and my lips are tingling." — The client is at risk for hypocalcemia, which may be manifested by tetany and result in airway obstruction, respiratory arrest, cardiac dysrhythmias, and cardiac arrest. Think like a nurse: The nurse should apply knowledge of anatomy and physiology when caring for a client who has undergone surgical alteration. When the thyroid gland is removed, there is a risk of accidentally removing the smaller parathyroid glands. It is these smaller glands that control calcium balance in the body. If the parathyroids are removed or damaged, the client can experience hypocalcemia. The nurse should recognize that evidence of a low calcium level includes muscle spasms and circumoral parasthesias. The client's symptoms need to be reported immediately to the health care provider so that a serum calcium level can be obtained and appropriate treatment implemented.

A new nurse makes staff assignments for the first time. After completing assignments, the nurse is called to a meeting. When returning to the unit, the new nurse finds extensive assignment changes were made. Which response by the new nurse is best? 1. "I noticed the assignments were changed. Did something happen while I was gone?" 2. "Why did you change the assignments? I was asked to make them today." 3. "Changing the assignments makes me appear incompetent. Next time, please ask first." 4. "I would appreciate it if you would not make changes in the assignments I make."

1. "I noticed the assignments were changed. Did something happen while I was gone?" - Seeking information in a non-accusatory way allows staff members to discuss the situation so that the nurse can learn from the changes made. Think like a nurse: The nurse should use assertive communication techniques to find out why the assignments were changed, but should avoid asking "why?" directly. Client conditions may have changed, which necessitated making adjustments. The nurse should not assess the reason for the assignment changes in an accusatory, emotional, or hostile way since this will not support intra-professional communication.

The nurse assists a graduate nurse with the care of a client whose blood glucose is 525 mg/dL (29.14 mmol/L), pH is 7.1, and serum bicarbonate level is 14 mEq/L (14 mmol/L) and has ketonuria. The nurse intervenes if the graduate nurse makes which statement? (Select all that apply.) 1. "I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL (5.55 mmol/L)." 2. "The client's potassium level will increase as the blood glucose decreases." 3."The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS)." 4. "The client requires a STAT electrocardiogram (ECG)." 5. "I should check the client's blood glucose every 2 hours."

1. "I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL (5.55 mmol/L)." CORRECT - Once the client's blood glucose level falls below 250 to 300 mg/dL (13.88 to 16.65 mmol/L), 5% dextrose should be added to IV fluids. Therefore, the nurse needs to intervene with this statement. 2. "The client's potassium level will increase as the blood glucose decreases." CORRECT - As the client's blood glucose drops, potassium level will drop. Low serum potassium levels may result from rehydration, increased urinary excretion of potassium, movement of potassium from the extracellular fluids into the cells with insulin administration, and restoration of the cellular sodium-potassium pump. Therefore, the nurse needs to intervene with this statement. 3."The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS)." CORRECT - The client's lab results are indicative of diabetic ketoacidosis. In HHS, blood glucose is greater than 600 mg/dL (33.3 mmol/L), pH is greater than 7.30 or normal, serum bicarbonate is greater than 18 mEq/L or normal, and urine ketones absent to small. Therefore, the nurse needs to intervene with this statement. 4. "The client requires a STAT electrocardiogram (ECG)." INCORRECT - The nurse does not need to intervene with this statement. The client requires an ECG because myocardial infarction is a possible cause of diabetic ketoacidosis (DKA). The nurse should also monitor cardiac rhythm because of potassium shifts. 5. "I should check the client's blood glucose every 2 hours." CORRECT - The client's blood glucose should be monitored hourly. Therefore, the nurse needs to intervene with this statement.

The client is on high-dose methotrexate for treatment of non-Hodgkin lymphoma. Which statement made by the client indicates understanding of appropriate precautions?(Select all that apply.) 1. "I should brush and floss my teeth three times a day." 2. "I should tell my friends and family not to send flowers." 3. "I should plan to bring in a heavy afghan from home because I will probably get cold easily." 4. "I should bring in my electric razor to shave." 5. "If my visitor has a cold, they can visit as long as they wear a mask."

1. "I should brush and floss my teeth three times a day." INCORRECT — While oral hygiene is important, flossing the teeth may lead to bleeding. The client's platelet levels may be low due to myelosuppression. 2. "I should tell my friends and family not to send flowers." CORRECT — Fresh flowers and potted plants are a medium for bacterial growth and should be avoided, as this client will be high risk for infection due to myelosuppression. 3. "I should plan to bring in a heavy afghan from home because I will probably get cold easily." INCORRECT — Anemia related to myelosuppression from the high dose methotrexate may cause the client to feel cold. But an afghan from home has the potential to bring in infectious pathogens and should not be brought to the hospital. 4. "I should bring in my electric razor to shave." CORRECT — Electric razors should be used instead of razor blades to decrease the risk of bleeding. The client may experience thrombocytopenia secondary to myelosuppression. 5. "If my visitor has a cold, they can visit as long as they wear a mask." INCORRECT — Visitors with infections should not visit the client who is immunocompromised.

The nurse provides instructions to a client diagnosed with peptic ulcer disease (PUD) receiving cimetidine. Which statement by the client indicates that teaching is successful? 1. "I should eat foods like creamed soups, oatmeal, and pudding. " 2. "I should eat three meals each day. " 3. "I can't eat salad or strawberries. " 4. "I can drink coffee as long as it is decaffeinated.

1. "I should eat foods like creamed soups, oatmeal, and pudding. " INCORRECT - Client should avoid diets rich in milk and cream, as it stimulates acid secretions. Symptoms of PUD include a dull, gnawing pain or burning in the mid-epigastrium. 2. "I should eat three meals each day. " CORRECT— If taking a histamine blocker, small frequent feedings are not necessary. A client with PUD should avoid aspirin, meat extracts, alcohol, and caffeinated beverages. 3. "I can't eat salad or strawberries. " INCORRECT - A client should avoid aspirin, meat extracts, alcohol, and caffeinated beverages, but other foods are based on the client's tolerance. 4. "I can drink coffee as long as it is decaffeinated. INCORRECT - Avoid all coffee because it stimulates acid secretion. Encourage a client to take medication until the ulcer has healed. Many clients are symptom-free after a week and might discontinue medication.

The home health nurse instructs a client with right-sided weakness about how to ambulate safely up the stairs using a cane. Which client statement indicates that the teaching was effective? 1. "I should first step up with my left leg." 2. "I should hold the cane in my right hand." 3. "I should step up with my right leg." 4. "I should not go up or down stairs using the cane."

1. "I should first step up with my left leg." — When going up stairs, the client should lead with the strong extremity and follow with the weaker extremity and the cane. Because the client is experiencing right-sided weakness, the client should first step up with the left leg. This statement indicates that the teaching was effective.

The nurse assists a new novice nurse to provide care for a client with a magnesium level of 0.8 mEq/L (0.4 mmol/L). The nurse intervenes if the novice nurse makes which statements? (Select all that apply.) 1. "I should look for a short QT interval on the EKG." 2. "I should keep lorazepam (Ativan) on hand." 3. "I should let my client eat bananas and oranges." 4. "My client may have a positive Chvostek sign." 5. "I may have to administer calcium gluconate." 6. "Taking magaldrate has contributed to the client's problem."

1. "I should look for a short QT interval on the EKG." CORRECT - This statement requires intervention. The client is experiencing hypomagnesemia, which causes a prolonged, not a short, QT interval. The normal magnesium level is 1.5 to 2.5 mEq/L (0.75 to 1.25 mmol/L). 2. "I should keep lorazepam (Ativan) on hand." INCORRECT - The client is at risk for seizures, so a benzodiazepine medication should be easily accessible. Seizure activity may occur when the magnesium drops below 1 mEq/L (0.5 mmol/L). 3. "I should let my client eat bananas and oranges." INCORRECT - These foods are high in magnesium and appropriate for the client experiencing hypomagnesemia. 4. "My client may have a positive Chvostek sign." INCORRECT - A positive Chvostek sign occurs due to the accompanying hypocalcemia that occurs with hypomagnesemia. 5. "I may have to administer calcium gluconate." CORRECT - This statement requires intervention. Calcium administration would be considered if the client had hypermagnesemia, not hypomagnesemia. Therefore, calcium would not be used. Therapeutically, calcium binds to excess magnesium. 6. "Taking magaldrate has contributed to the client's problem." CORRECT - This statement requires intervention. Magaldrate, an antacid, can cause hypermagnesemia, not hypomagnesemia.

The nurse provides discharge teaching to a young adult client diagnosed with HIV and AIDS. Which client statement indicates the nurse's discharge teaching is effective? 1. "I should not share a razor with anyone else." 2. "I should have a private bathroom that no one else uses." 3. "I should not eat my meals at the same table as my family members." 4. "I should wash my laundry separately from my family members' clothing."

1. "I should not share a razor with anyone else." — HIV is transmitted through exposure to contaminated blood and body fluids. Sharing a razor may promote disease transmission if the blade is contaminated with blood that contains HIV. Think like a nurse: The nurse provides discharge teaching for a client diagnosed with human immunodeficiency virus (HIV) that has progressed to acquired immunodeficiency syndrome (AIDS). The nurse should think, "What important points should the client know to avoid spreading HIV to others?" HIV spreads through contact with infectious blood or body fluids, not through casual contact. Such personal care items as a razor or toothbrush should not be shared, because they may contain infectious blood or body fluids. Silverware and plates do not require designation for client use only. Only visibly soiled clothing requires separate washing from other household clothing.

The nurse teaches a client about a new medication for hypertension. Which client statement indicates that further teaching is needed? (Select all that apply.) 1. "I should not take acetaminophen with this medication." 2. "I will get up slowly from sitting or lying down while taking this medication." 3. "I will check with my health care provider before taking herbal supplements." 4. "I do not need to stop smoking now that I have this medication." 5. "I need to continue to monitor my blood pressure."

1. "I should not take acetaminophen with this medication." - There are no interactions noted between acetaminophen and antihypertensives. 4. "I do not need to stop smoking now that I have this medication." - Smoking can reduce the effects of antihypertensives as smoking causes vasoconstriction. Think like a nurse: Antihypertensives do not interact with acetaminophen and can be safely taken together. Smoking cessation efforts should be encouraged because nicotine constricts blood vessels, which counteracts the effects of the antihypertensive medication. The effectiveness of all medication should be routinely evaluated.

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

1. "I should wear a loose-fitting bra made of 100% cotton." - The client should wear cotton clothing to prevent irritation and avoid restrictive or tight-fitting clothing to prevent skin chafing or irritation. Cotton is a breathable fabric that will reduce the perspiration buildup on the skin. Think like a nurse: The nurse is visiting a client receiving radiation treatment for breast cancer. The nurse is aware this type of treatment is performed by focusing a beam of radiation onto the area of pathology. Since the radiation enters the body through the skin, the nurse recognizes the high risk for injury and understands that protection and care of the skin is a priority. Skin care teaching for this client will included actions to prevent skin irritation, cleansing methods, and strategies to protect skin integrity. Evidence that teaching provided was effective is if the client's statement about the type of undergarment being worn is correct.

The nurse instructs clients in an assisted living facility on ways to prevent falls. Which client statements indicate that teaching is effective? (Select all that apply.) 1. "I started taking tai chi classes." 2. "I have a new pair of athletic shoes with deep treads." 3. "I had my vision checked." 4. "My health care provider reviewed all of my medications." 5. "I stopped exercising so I won't fall." 6. "I bought some new lamps for my home."

1. "I started taking tai chi classes." CORRECT - Exercise is one of the most important ways to decrease the chance of falling. Tai chi improves balance and coordination. 2. "I have a new pair of athletic shoes with deep treads." INCORRECT - Shoes with thin, nonslip soles are the safest to prevent falls. The client should avoid slippers and athletic shoes with deep treads. 3. "I had my vision checked." CORRECT - Having an eye examination ensures that glasses are correct and will either rule out or diagnose glaucoma and cataracts, which can limit vision and lead to falls. 4. "My health care provider reviewed all of my medications." CORRECT - Some medications can cause drowsiness or lightheadedness, which can contribute to falls. 5. "I stopped exercising so I won't fall." INCORRECT - Not exercising causes weakness and increases an older adult client's risk for falls. 6. "I bought some new lamps for my home." CORRECT - Adequate lighting helps to prevent falls.

The nurse provides care to a client 4 weeks after a kidney transplant. Which client statements require immediate follow-up by the nurse? (Select all that apply.) 1. "I take an antacid after meals, which helps with my indigestion." 2. "My family was disappointed when I told them I would stay home from vacation this year." 3. "I found that a little wine in the evening helps me sleep better." 4. "My feet were so itchy until my adult child told me to start using lotion twice a day." 5. "I worry that my new kidney will quit working." 6. "I saw that my blood pressure was up a little. I think I get nervous when I come to the office."

1. "I take an antacid after meals, which helps with my indigestion." CORRECT — Indigestion is a symptom of a peptic ulcer, which is common when corticosteroids are used for immunosuppression after organ transplantation. This statement requires immediate follow-up. 2. "My family was disappointed when I told them I would stay home from vacation this year." INCORRECT— Immunosuppression is required for months or years after a transplant and puts the recipient at increased risk for an infection. The client is correct to avoid crowds. 3. "I found that a little wine in the evening helps me sleep better." CORRECT — Cyclosporine is commonly prescribed for immunosuppression after organ transplantation. It can be hepatotoxic, so alcohol is contraindicated. The nurse should determine if the client needs a different intervention to aid in sleep. 4. "My feet were so itchy until my adult child told me to start using lotion twice a day." CORRECT — Symptoms of graft-versus-host disease start with a pruritic or painful rash on the palms and soles of the feet. The client's report of itching requires follow-up. 5. "I worry that my new kidney will quit working." INCORRECT— The client's concern that the kidney will stop working is not unusual. There is a small risk that the transplanted kidney will fail or the body will reject it. The nurse should allow the client to verbalize fears. 6. "I saw that my blood pressure was up a little. I think I get nervous when I come to the office." CORRECT— Cardiovascular disease, including hypertension, is a common problem after transplantation and needs immediate follow-up.

The nurse completes dietary teaching with a client who has chronic kidney failure. The nurse determines more teaching is needed when the client makes which statement? (Select all that apply.) 1. "I will eat more oranges and other foods with vitamin C." 2. "I should increase dairy products in my diet." 3. "I can no longer drink my prune juice in the mornings." 4. "I will avoid canned and boxed foods." 5. "I should add protein powder to my fruit smoothies."

1. "I will eat more oranges and other foods with vitamin C." CORRECT - Citrus fruits are high in potassium and should be avoided, as kidneys cannot excrete excess potassium. Other foods that are high in potassium include dried fruits, avocado, tomato, potatoes, and bananas. This statement indicates that additional teaching is needed. 2. "I should increase dairy products in my diet." CORRECT - Kidney failure can lead to hypocalcemia, and regular intake of calcium is needed. However, dairy products are high in phosphorus, which binds to calcium and should be avoided. This statement indicates that additional teaching is needed. 3. "I can no longer drink my prune juice in the mornings." INCORRECT - Dried fruits, including raisins and prunes, are high in potassium. This statement indicates that the client understands that hyperkalemia is a complication of kidney failure. 4. "I will avoid canned and boxed foods." INCORRECT - Processed foods are high in sodium and a low-sodium diet should be followed. This statement indicates client understanding. 5. "I should add protein powder to my fruit smoothies." CORRECT - Excess dietary protein increases uric acid, a byproduct of protein metabolism, which is cleared by the kidneys. In kidney failure, kidneys will be unable to excrete urea, and low to normal amounts of dietary protein are prescribed. This statement indicates that additional teaching is needed.

The home care nurse provides care to a client with alcoholic cirrhosis. Which caregiver statement requires intervention by the nurse? (Select all that apply.) 1. "I will give the low dose aspirin with breakfast." 2. "Elastic-waist pants are more comfortable for my client." 3. "I'm trying to prepare more salads and leafy green vegetables." 4. "We often have to wake the client to eat meals." 5. "Sometimes the client doesn't get to the commode in time." 6. "The client's appetite is not good, so I'm glad to see a weight gain."

1. "I will give the low dose aspirin with breakfast." — Bleeding esophageal varices are the most life-threatening complication of cirrhosis. The client should not receive even low dose aspirin regularly. 4. "We often have to wake the client to eat meals." — Encephalopathy from cirrhosis is caused by increasing ammonia levels, and it causes changes in consciousness, including lethargy. This requires follow-up. 6. "The client's appetite is not good, so I'm glad to see a weight gain." — Weight gain may be due to fluid retention and ascites, because it is clearly not from nutritional intake. This requires follow-up.

A client is scheduled for knee replacement surgery and expresses a desire to make an autologous blood donation. Which client statement about autologous blood donation is most important for the nurse to follow up on? 1. "I will make the first donation this week since my surgery is scheduled in 8 weeks." 2. "I may have to start taking oral iron supplements." 3. "I am glad that I can give up to 6 units of blood." 4. "I have to make the last donation at least 1 week before surgery."

1. "I will make the first donation this week since my surgery is scheduled in 8 weeks." - Blood for the autologous donation is collected 6 weeks before the scheduled surgery. This statement would require additional follow up by the nurse. Think like a nurse: he nurse must provide education to the client who wishes to make an autologous blood donation prior to a surgical procedure. Once the information is presented, the nurse must evaluate whether the client has an appropriate understanding of the process and requirements. The earliest time the client can donate blood for this purpose is 6 weeks prior to the scheduled procedure. Therefore, the client statement indicating the first donation at 8 weeks prior to the surgery indicates the need for further teaching on this subject matter.

The nurse prepares to discharge a newborn home with the parents. Which statement by one of the parents indicates to the nurse a need for further teaching about newborn care? 1. "I will notify my health care provider about absence of breathing for 10 seconds. " 2. "I will notify my health care provider about more than one episode of projectile vomiting. " 3. "I will notify my health care provider if my baby 's temperature is greater than 101 °F (38.3 °C). " 4. "I will rock and cuddle my infant frequently to promote a sense of trust. "

1. "I will notify my health care provider about absence of breathing for 10 seconds." - It is normal for a neonate to have periods of apnea. Apnea lasting longer than 20 seconds should be reported to the health care provider. Think like a nurse: Infant apnea is diagnosed for any unexplained episode of the cessation of breathing that lasts 20 seconds or longer or when a shorter respiratory pause is associated with other symptoms (e.g. bradycardia, cyanosis, pallor, and the occurrence of marked hypotonia). While apnea is fairly common in preterm infants, it is rare among full-term healthy infants. When apnea occurs for full-term infants, it is usually an indication of an underlying pathology. The nurse should offer reassurance to parents by explaining the difference between true apnea and periodic breathing (pauses in respiration that last less than 10 seconds). Periodic breathing is not dangerous and no intervention is required.

The nurse prepares a client diagnosed with oral and esophageal candidiasis for discharge to home. Which statement from the client indicates to the nurse that teaching is successful? 1. "I will stop on the way home to get mouthwash at the store." 2. "I will swish the nystatin in my mouth before I spit it out." 3. "I think I will take it easy for a while by reading some books." 4. "I will cook with spices to cover the taste in my mouth."

1. "I will stop on the way home to get mouthwash at the store." INCORRECT - Commercial mouthwash should be avoided because of high alcohol content that irritates and dries out the oral mucosa, which is counterproductive to healing. Using warm saline, hydrogen peroxide, or biotene mouthwashes between nystatin doses is allowed. 2. "I will swish the nystatin in my mouth before I spit it out." INCORRECT - Nystatin is an antifungal agent in an oral suspension and should be swished around in the mouth and then swallowed to coat all affected surfaces. 3. "I think I will take it easy for a while by reading some books." CORRECT - Relaxation can help the immune system repair itself, and engaging in an enjoyable activity can be a distraction from the pain of the stomatitis and esophatitis. 4. "I will cook with spices to cover the taste in my mouth." INCORRECT - Soft, bland, non-acidic, and cool liquids and foods will help the eating process be more comfortable. Spicy foods, hot liquids, and citrus juices cause mucosal irritation. Even salty or peppered foods can increase irritation.

The nurse instructs a client prescribed hydralazine as treatment for hypertension. Which client statements indicate to the nurse that the teaching is effective? (Select all that apply.) 1. "I will take my hydralazine with my breakfast." 2. "I will call my health care provider before taking ibuprofen." 3. "I need to have my blood drawn twice a week." 4. "I will feel hungry while on this medication." 5. "I will sit on the edge of my bed for 2 minutes before I get out of bed."

1. "I will take my hydralazine with my breakfast." - Hydralazine should be taken with food to increase bioavailability of the medication. 2. "I will call my health care provider before taking ibuprofen." - Over-the-counter medications should be avoided when taking hydralazine unless otherwise directed by the health care provider. 5. "I will sit on the edge of my bed for 2 minutes before I get out of bed." - Orthostatic hypotension is a possible adverse effect of hydralazine. The client should be instructed to sit on the edge of the bed prior to standing to prevent this effect. Think like a nurse: During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. The nurse ensures the client understands the indications for hydralazine administration, as well as health management related to the hypertension. Dizziness, which is a potential adverse side effect of hydralazine, may increase the client's risk for falls. Adverse effects such as fainting, tachycardia, edema, or chest pain require immediate care. Dietary recommendations include a low-sodium diet. Reinforce the importance of adhering to the prescribed medication regimen. Educate the client about health risks associated with ineffective management of hypertension, including stroke and heart attack.

The nurse teaches a client about measures to prevent deep vein thrombosis formation. Which client statement indicates to the nurse the need for further teaching? 1. "I'm glad I can travel by plane without any special precautions." 2. "I just bought some tight-fitting clothing. Now I can't wear it." 3. "It's going to be hard to remember to avoid crossing my legs when sitting." 4. "I sit at a desk all day. I'll have to remember to take a walk every hour or two."

1. "I'm glad I can travel by plane without any special precautions." - The client should exercise the feet and legs while seated and walk around when possible during long plane trips. Think like a nurse: The nurse knows a deep vein thrombosis (DVT) is a blood clot in a blood vessel of the leg. When preparing teaching material on actions to prevent the development of this disorder, the nurse should mentally explore the possible causes for the blood to pool in the lower extremities. A DVT is closely associated with immobility, including sitting or lying in one position for an extended period of time. The client should be instructed to avoid sitting for longer than 1 to 2 hours regardless of the situation. The nurse should recognize that because of erroneous thoughts, the client in this scenario needs additional teaching.

The home health nurse visits a client diagnosed with heart failure who is prescribed a diuretic. Which client statement causes the nurse to assess the client further? (Select all that apply.) 1. "I'm hardly making urine, but I haven't been drinking well" 2. "I take my water pill in the morning because I urinate so much." 3. "I have a bowel movement every other day." 4. "I've been dizzy, and I almost passed out yesterday." 5. "I'm noticing that I bruise really easily."

1. "I'm hardly making urine, but I haven't been drinking well" — Failure to make urine, especially while on a diuretic, may indicate kidney insufficiency due to lack of perfusion. 4. "I've been dizzy, and I almost passed out yesterday." — Dizziness and near syncope indicate dehydration and decreased perfusion. The client may require a dose adjustment, alteration in activities or activity level, or further instruction about hydration and safety while on diuretics. 5. "I'm noticing that I bruise really easily." — Bruising indicates a potential coagulation issue, possibly due to liver insufficiency secondary to decreased perfusion or medication toxicity.

The home care nurse visits a client diagnosed with cardiomyopathy. The client asks the nurse, "How will I know if I am overdoing it? " Which response by the nurse is best? 1. "If you feel fatigued, you have done too much. " 2. "Follow the list that the health care provider gave you. " 3. "Coughing up more sputum is a good indication. " 4. "To prevent doing too much, allow your family to help you. "

1. "If you feel fatigued, you have done too much. " - Fatigue is a useful guide in gauging activity tolerance in clients with decreased cardiac output. Think like a nurse: One of the first symptoms that indicates activity intolerance is fatigue. Another is acute dyspnea or shortness of breath. Increased sputum production could mean the development of pulmonary edema and should be reported to the health care provider. The client should be encouraged to maintain as much independence as is physically possible. The nurse's advice to follow the health care provider's directions does not address the client's question.

The nurse provides care to an older adult client diagnosed with right-sided paralysis caused by a cerebrovascular accident (CVA). Which sign is most important for the nurse to post in the client's room? 1. "Keep floor dry and free of debris." 2. "Do not use the right arm for lifting." 3. "Client is hard of hearing." 4. "Client is paralyzed on the right side."

1. "Keep floor dry and free of debris." INCORRECT - Keeping the floor dry and free of debris is appropriate for every client and not just the client with right-sided paralysis. 2. "Do not use the right arm for lifting." CORRECT - Because the paralyzed muscles cannot offer resistance, the shoulder can be easily dislocated if the arm is used for lifting. This is a common injury in clients with paralysis, and the sign will help prevent it from occurring. 3. "Client is hard of hearing." INCORRECT - Posting a sign about a sensory deficit is appropriate, but it is not as significant as the risk for a dislocated shoulder. 4. "Client is paralyzed on the right side."

The nurse prepares to administer the Haemophilus influenzae type b (Hib) vaccine to a 4-month-old infant. The nurse teaches the infant's parent about the vaccine. Which information does the nurse include in the teaching? 1. "Monitor your child for signs of allergic reaction for a few hours after the vaccine." 2. "Your child will receive 1 or 2 doses of the vaccine, depending on the vaccine used." 3. "Immediately notify the health care provider of a low-grade fever." 4. "This vaccine cannot be given at the same time as other vaccines."

1. "Monitor your child for signs of allergic reaction for a few hours after the vaccine." -Signs of allergic reaction to the Hib vaccine include hives, facial and airway edema, difficulty breathing, tachycardia, dizziness, and weakness. These typically begin a few minutes to a few hours after the child receives the vaccine. Think like a nurse: Health promotion and disease prevention activities include providing vaccinations at the appropriate age. Even though a vaccination is intended to prevent the onset of disease, the actual vaccination is not without risk. Some individuals will react immediately to the introduction of foreign material into the body, whereas others may not have a reaction until several hours have passed. Since it is not realistic to expect a client to remain in the presence of the health care provider until all risk of a reaction has passed, the nurse should instruct the parent or person receiving the vaccination of what to expect as signs of a reaction, and what actions to take should any of the signs occur.

The nurse provides discharge teaching to the family of a pediatric client who had a cleft palate repair. Which parental statement indicates to the nurse the need for further teaching? 1. "My child can use a straw for drinking milk." 2. "It is going to be hard keeping my child from sucking the fingers." 3. "I cannot give my child cookies." 4. "My child should eat in a sitting position."

1. "My child can use a straw for drinking milk." — This statement indicates a need for further teaching. A cleft palate is usually repaired around 18 months of age to allow for bone growth. Suction should not be used, nor objects placed in the child's mouth, such as a tongue depressor, thermometer, small spoon, or straws. These objects should be restricted for about 6 weeks post-surgery or until the palate heals.

The home health nurse visits a home occupied by two parents, their preschool-age child, and an older adult grandparent who has been living with them for 2 months. The nurse visits to assess the grandparent after treatment for a fall and broken arm. Which statement by the child most concerns the nurse? 1. "My grandparent's cat got a cut on his stomach and will not come out of the corner. Can you fix it?" 2. "Sometimes when I drink milk, I throw up." 3. "We never go anywhere anymore since my grandparent 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 grandparent's cat got a cut on his stomach and will not come out of the corner. Can you fix it?" — The cat's 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 people at risk for abuse: child, spouse, and older adult. The grandparent was treated for injuries that might have been related to abuse. The nurse should further assess the situation for indicators of abuse. Think like a nurse: Older adults are vulnerable and may be at risk for abuse. The nurse should be aware of various forms of abuse, including financial, physical, emotional, and sexual. For clients who are suspected of being abuse victims, a detailed medical evaluation is necessary as signs and symptoms of medical and psychiatric conditions may mimic manifestations of abuse. Signs of abuse may include specific patterns of injury. The nurse should interview clients separately from caregivers. Cognitive function should be assessed in all clients who are possibly being abused.

The home care nurse visits a client with dementia. The client's adult child tells the nurse, that after talking with the health care provider, the client is taking ginkgo. Which statement, if made by the client's child 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 at the same time every day"

1. "My mother takes ibuprofen every day for arthritis." - Ginkgo is an antiplatelet agent and central nervous system stimulant sometimes taken for dementia syndromes. The risk of bleeding increases when given with NSAIDs. Think like a nurse: The nurse evaluates the client for safety issues and medication interactions. The nurse evaluates the client's dementia and use of ginkgo biloba, ibuprofen, and digoxin. All the statements indicate correct actions by the client and adult child, except the use of ibuprofen with gingko. Gingko increases the risk for bleeding. Some research suggests the beneficial effects of ginkgo may outweigh the risks. However, when taken with a nonsteroidal anti-inflammatory drug (NSAID), the bleeding risk is much more significant and presents an immediate physiological threat to the client.

The home health nurse visits an older adult client with diabetes and osteoporosis. The client lives with an adult child in a two-story home. Which statement by the child most concerns the nurse? 1. "My parent loves taking a hot bath with scented bath oil." 2. "My parent is taking more interest in daily activities." 3. "I feel guilty leaving my parent alone, even for half an hour." 4. "I am not sure what we are going to do when winter comes."

1. "My parent loves taking a hot bath with scented bath oil." - The hot bath with oils presents a safety risk. Oils in the bath water can result in a slippery shower or bathtub surface. This is particularly concerning for the client with osteoporosis. Hot bath water can dry or damage the skin. The client with diabetes may have neuropathy, which can decrease the client's ability to perceive pain and recognize an injury. Think like a nurse: This client has co-morbidities and multiple risk factors to consider. The client is older, will likely have altered gait stability, and lives in a home with stairs. Diabetes decreases sensation in the feet and increases risk of injury. Osteoporosis increases the risk of fractures. The client may experience vasodilation and hypotension after a hot bath and is creating slippery skin by using oil. The risk of injury is a more immediate threat compared to the other concerns and is a physiological need according to the Maslow hierarchy, making this the nurse 's priority.

The nurse provides care for a client diagnosed with heart failure. Which client statements indicate to the nurse that medication therapy is effective? (Select all that apply.) 1. "Since I've been taking captopril, my feet are not as puffy." 2. "Taking spironolactone has kept my pulse less than 60." 3. "Lisinopril seems to help me not be as short of breath." 4. "Now that I'm taking carvedilol, I don't have palpitations." 5. "Before taking valsartan, I had to stop and rest while cooking." 6. "I seem to urinate more when I take digoxin."

1. "Since I've been taking captopril, my feet are not as puffy." - ACE inhibitors, such as captopril, reduce peripheral edema. This statement indicates the medication therapy is effective. 3. "Lisinopril seems to help me not be as short of breath." - ACE inhibitors, such as lisinopril, reduce pulmonary congestion, which will decrease dyspnea. This statement indicates the medication therapy is effective. 5. "Before taking valsartan, I had to stop and rest while cooking." - Angiotensin II receptor blockers (ARBs), such as valsartan, decrease pulmonary congestion and improve cardiac output, which should reduce client's fatigue and dyspnea. This statement indicates the medication therapy is effective. 6. "I seem to urinate more when I take digoxin." - Cardiac glycosides, such as digoxin, improve cardiac output, which increases urine output. This statement indicates the medication therapy is effective. Think like a nurse: In evaluating effectiveness of medications used to treat heart failure, the nurse should look for manifestations indicating an improvement of cardiac output, renal function, tissue perfusion, and activities of daily living. The client is informed to report to the provider sudden or steady gain in daily weight, such as 2 to 3 lbs (0.91 to 1.4 kg) in 24 hours or 5 lbs (2.3 kg) or more in 1 week. If taking digoxin, the client should be taught how to take their pulse rate for a full minute and be aware not to take digoxin if rate is less than 60 beats/minute.

During a well-child checkup, the parent of two children (2 and 4 years of age) appears tired and frustrated. The parent states, "I feel like I have been on a whirlwind for over a year. I never thought two children could be so much work. If I have to discipline my kids one more time, I think I will scream!" Which response does the nurse implement with the parent? 1. "Tell me about the types of limits you are setting for each child." 2. "Have you thought about preschool for your children?" 3. "As they grow, you will miss these busy days with them." 4. "Do you and your spouse agree on the use of time-out?"

1. "Tell me about the types of limits you are setting for each child." - This is an open-ended question that allows the parent to talk more about the limits for each child. This will open further discussion about options. Think like a nurse: Since the parent is tired and frustrated, the nurse may be able to help the parent with the situation. However, before offering suggestions, the nurse needs to assess what the parent means by "discipline." The best way to assess for this information is to use an open-ended question. Once the discipline and limits are identified, the nurse can proceed with strategies or alternatives for the parent to effectively deal with the toddler and preschool age children's behaviors.

The nurse teaches a client diagnosed with Addison disease about the health condition. Which client statements indicate to the nurse that teaching is effective? (Select all that apply.) 1. "The disease is characterized by secretion of too many hormones." 2. "My own antibodies probably destroyed my adrenal tissue." 3. "I now have to follow a low-sodium diet." 4. "Stress may trigger an Addisonian crisis." 5. "I have increased adrenocorticotropic hormone levels." 6. "Treatment for my disease will place me at greater risk for diabetes mellitus."

1. "The disease is characterized by secretion of too many hormones." INCORRECT - Addison disease is characterized by a deficiency in glucocorticoids, mineralocorticoids, and androgens. 2. "My own antibodies probably destroyed my adrenal tissue." CORRECT— An autoimmune response is the most common cause of Addison disease in the United States. Other causes include tuberculosis, infarction, fungal infections, acquired immunodeficiency syndrome (AIDS), and metastatic cancer. 3. "I now have to follow a low-sodium diet." INCORRECT - Hyponatremia is a common laboratory finding in a client diagnosed with Addison disease. The client should not follow a low-sodium diet. 4. "Stress may trigger an Addisonian crisis." CORRECT— Stress from an infection or surgery and psychological stress can trigger an Addisonian crisis. 5. "I have increased adrenocorticotropic hormone levels." CORRECT— Adrenocorticotropic hormone levels increase in primary adrenal insufficiency or Addison disease. 6. "Treatment for my disease will place me at greater risk for diabetes mellitus." CORRECT— Corticosteroids used to treat Addison disease can lead to glucose intolerance and predispose a client to developing diabetes mellitus.

The nurse observes the parent of an adult client crying in the waiting area. The parent says to the nurse, "My father died of meningitis and it was awful. Now my child may die of the same thing." Which is the best initial response by the nurse? 1. "The outlook for meningitis is better now than it was then." 2. "I can have the chaplain come speak with you if you like." 3. "This must be bringing back a lot of memories." 4. "Not necessarily. You can't make that assumption."

1. "The outlook for meningitis is better now than it was then." CORRECT - This response directly responds to the parent's expressed concerns and offers factual information (family teaching) of which the parent may not have been aware. This may help alleviate some distress. 2. "I can have the chaplain come speak with you if you like." INCORRECT - The nurse should respond to the parent first and then assess if the chaplain is required or desired. 3. "This must be bringing back a lot of memories." INCORRECT - This is an empathetic statement that reflects the obvious and provides opening for further discussion. However, the nurse can first allay some of the parent's fears about what is occurring. 4. "Not necessarily. You can't make that assumption." INCORRECT - While factual, this statement blocks further communication by not encouraging the parent to express thoughts and feelings. Think like a nurse: Providing information is an example of therapeutic communication. Providing relevant information tells clients what they need to know or want to know so they are able to make decisions, experience less anxiety, and feel reassured. The nurse should exercise active listening and be "in the moment." Other forms of therapeutic communication techniques that the nurse can use are clarifying, focusing, and asking relevant questions.

The nurse provides care for a client diagnosed with atherosclerosis. Which client statements about clopidogrel require follow-up by the nurse? (Select all that apply.) 1. "This medication may cause my blood pressure to be low. " 2. "I play racquetball three times each week for exercise. " 3. "I need to go back to the health care provider next year. " 4. "I take my medications at the same time each day. " 5. "I take this medication so I don 't have a stroke." 6. "I will notify my health care provider if I notice bruises. "

1. "This medication may cause my blood pressure to be low. " — Adverse effects of clopidogrel include hypertension, so this statement requires the nurse to follow up. 2. "I play racquetball three times each week for exercise. " — Because clopidogrel increases the client 's risk of bleeding, contact sports such as racquetball should be avoided. The nurse will discuss safe exercise choices with the client. 3. "I need to go back to the health care provider next year. " — Clients taking clopidogrel will need regular medical supervision and periodic blood tests. The nurse should discuss follow-up care with the client. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. The client should demonstrate understanding of the medication 's therapeutic effects, side effects, and adverse effects. Clients who are prescribed antiplatelet medications (such as clopidogrel) or anticoagulant medications (such as warfarin or heparin) often require lifestyle changes, including increased health care provider visits and careful choices in activities. The client with atherosclerosis may also require blood pressure management. However, education is indicated to explain that clopidogrel is not used to decrease blood pressure.

The nurse screens an 8-month-old client in a pediatric clinic. Which statement from the parent concerns the nurse? 1. "Today's weight is almost doubled from birth." 2. "When I walk in the room, my child smiles at me." 3. "My child cries around my parents." 4. "I haven't heard my child say 'mama' yet."

1. "Today's weight is almost doubled from birth." — Weight should double by 6, not 8, months of age. Think like a nurse: A diagnosis of failure to thrive (FTT) is made when a child's weight or rate of weight gain is significantly below that of other children who are of similar age and sex. If an infant or child experiences FTT, the nurse will note that head circumference, height, and weight do not match standard growth charts, and weight falls lower than the third percentile (as outlined in standard growth charts) or 20% below the child's ideal weight for height. Also, the nurse may observe that growth has slowed or stopped after a previously established growth curve. Physical skills, such as rolling over, sitting, standing, and walking, are delayed or slow to develop in an infant with FTT.

A client diagnosed with peptic ulcer disease asks if an over-the-counter antacid can be taken instead of esomeprazole because of the cost. Which responses by the nurse are appropriate? (Select all that apply.) 1. "Try the antacids for a few days. If you start to feel worse, call your health care provider." 2. "I will call your pharmacy and find out the cost." 3. "Esomeprazole helps reduce stomach acid, and you will need to take it for several weeks to achieve healing." 4. "Increase your intake of caffeinated liquids to promote healing of the ulcer." 5. "Here is information about smoking cessation classes available in your area." 6. "Notify your health care provider if you have stools that are black and tarry."

1. "Try the antacids for a few days. If you start to feel worse, call your health care provider." INCORRECT— Antacids are not the treatment of choice for peptic ulcer disease. 2. "I will call your pharmacy and find out the cost." CORRECT — Volunteering to call the pharmacy demonstrates advocacy in order for the client to receive appropriate treatment for the health problem. 3. "Esomeprazole helps reduce stomach acid, and you will need to take it for several weeks to achieve healing." CORRECT — Esomeprazole acts to reduce stomach acid, which is the desired mechanism to help heal the ulcer. 4. "Increase your intake of caffeinated liquids to promote healing of the ulcer." INCORRECT— Caffeine exacerbates peptic ulcers and should be eliminated from the diet. 5. "Here is information about smoking cessation classes available in your area." CORRECT — Nicotine increases stomach acid. Smoking cessation information is appropriate to provide to the client. 6. "Notify your health care provider if you have stools that are black and tarry." CORRECT — Black, tarry stools indicate gastrointestinal bleeding. The health care provider should be notified if this occurs.

A client at 16 weeks' gestation asks the nurse what her baby looks like at this point in the pregnancy. Which is an accurate response by the nurse? 1. "Your baby has a heartbeat, and its arms and legs are just starting to form." 2. "Your baby can hear and breathe at this point." 3. "Your baby likes to suck his or her thumb and weighs about half a pound." 4. "Your baby's heart has formed, and we can tell if you are having a boy or a girl."

1. "Your baby has a heartbeat, and its arms and legs are just starting to form." INCORRECT — This response by the nurse describes fetal development at 8 weeks. 2. "Your baby can hear and breathe at this point." INCORRECT — The baby is able to hear at 38 weeks, whereas the lungs acquire definitive shape at 12 weeks. 3. "Your baby likes to suck his or her thumb and weighs about half a pound." INCORRECT — At 20 weeks, the fetus can suck and weighs approximately 11 ounces. 4. "Your baby's heart has formed, and we can tell if you are having a boy or a girl." CORRECT — At 16 weeks, intestines begin to collect meconium, lanugo is present on the body, and the skin is transparent with visible blood vessels. In addition, the heart is formed and sex determination is possible.

The emergency department triage nurse has a limited number of open beds. Which client does the nurse place in an emergency bed? (Select all that apply.) 1. 17-year-old client who intentionally ingested 15 acetaminophen tablets prior to arrival. 2. 24-year-old client who reports dental pain, rating pain 10/10 on pain scale. 3. 63-year-old client who reports a severe, localized headache with no history of headaches. 4. 77-year-old client who has had generalized weakness for the past day. 5. 88-year-old client who has a rash, and whose spouse is being treated with permethrin cream. 6. 92-year-old client who is requesting suture removal, with dehiscence noted at site.

1. 17-year-old client who intentionally ingested 15 acetaminophen tablets prior to arrival. - This client requires activated charcoal and possible administration of acetylcysteine. Therefore, the nurse places this client in an emergency bed. 3. 63-year-old client who reports a severe, localized headache with no history of headaches. - This client requires a head CT to rule out hemorrhage. Therefore, the nurse places this client in an emergency bed. 4. 77-year-old client who has had generalized weakness for the past day. - This client requires assessment and diagnostic work-up to exclude myocardial infarction, electrolyte imbalance, and stroke. Therefore, the nurse places this client in an emergency bed. Think like a nurse: Maslow's hierarchy of needs can be used to make decisions regarding the acuity of the clients. An attempted suicide places the client at high risk for self-harm and needs immediate intervention. A severe localized headache could represent a cerebral hemorrhage and needs immediate assessment. Generalized weakness could indicate a cardiac, neurologic, or electrolyte imbalance problem and requires immediate assessment.

The nurse in a well-baby clinic assesses several infants. Which infant will the nurse identify as needing to be seen by the health care provider? 1. 3-month-old who does not smile when played with. 2. 5-month-old who does not hold own bottle. 3. 7-month-old who does not have a Moro reflex. 4. 9-month-old who does not release objects at will.

1. 3-month-old who does not smile when played with CORRECT - At 2 months of age, an infant should demonstrate a social smile. This infant should be the priority to follow up with the health care provider 2. 5-month-old who does not hold own bottle INCORRECT - An infant should hold the bottle at 6 months of age. This situation does not require a follow up 3. 7-month-old who does not have a Moro reflex INCORRECT - The Moro disappears at 4 months of age. This situation does not require a follow up. 4. 9-month-old who does not release objects at will INCORRECT - Infants are not expected to release objects at will until the age of 11 months. This situation does not require a follow up.

The nurse in the newborn nursery receives report on a group of clients. Which client does the nurse assess first? 1. A 2-day-old client, quietly alert, heart rate of 185 beats per minute. 2. A 1-day-old client, crying, and the anterior fontanel is bulging. 3. A 12-hour-old client, respirations 45 and irregular. 4. A 5-hour-old client, hands and feet are blue bilaterally.

1. A 2-day-old client, quietly alert, heart rate of 185 beats per minute. — This newborn has tachycardia. The normal resting rate is 120 to 160 beats per minute, and this finding requires further investigation. Think like a nurse: Supraventricular tachycardia (SVT) is the most common arrhythmia diagnosed in pediatric clients. The newborn exhibiting tachycardia, especially at rest, requires further examination and should be seen by the nurse first. The nurse first compares the current readings with the baseline. Any abnormalities in vital signs during the neonatal period, especially with heart rate and respiration, may be indicative of infection. When assessing the newborn client, both the heart rate and respiratory rate should be counted for a full 60 seconds. The nurse should keep in mind that bradycardia in pediatric clients is an ominous sign, usually a result of hypoxia, requiring prompt intervention.

The nurse provides care for clients on the medical and surgical unit. Which situation requires immediate intervention by the nurse? 1. A client who had a liver biopsy is resting quietly on his back after the procedure. 2. A visitor is sitting without a mask just inside the doorway of a client on droplet precautions. 3. A client who had a cholecystectomy 2 days ago is draining purulent fluid through the T-tube. 4. A client scheduled for a cardiac catheterization is expressing anxiety and reservations about undergoing the procedure.

1. A client who had a liver biopsy is resting quietly on his back after the procedure. CORRECT - The client should be lying on his right side for several hours after the procedure in order to promote hemostasis and thereby prevent hemorrhage and bile leakage. 2. A visitor is sitting without a mask just inside the doorway of a client on droplet precautions. INCORRECT - The doorway is likely to be 3 feet away from the client, and that is the safe distance for not wearing a mask. 3. A client who had a cholecystectomy 2 days ago is draining purulent fluid through the T-tube. INCORRECT - The client has an infection that may have been present prior to surgery and is being drained or it may be currently infected. This client is not the priority, though. 4. A client scheduled for a cardiac catheterization is expressing anxiety and reservations about undergoing the procedure. INCORRECT - Assessment of the client's concerns is essential, with possible patient teaching. If the client has signed a consent and decides to rescind it, the client can do so and the HCP should be notified.

The nurse provides care to several clients in an outpatient clinic. For which client does the nurse conduct a hearing assessment? 1. A client who is receiving cisplatin. 2. A client who is receiving levothyroxine. 3. A client who is receiving flurazepam. 4. A client who is receiving cimetidine.

1. A client who is receiving cisplatin. CORRECT— Cisplatin, which is an antineoplastic medication, is ototoxic. For the client who is prescribed cisplatin, hearing acuity should be assessed. 2. A client who is receiving levothyroxine. INCORRECT — Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. Ototoxicity is not a known complication of levothyroxine. Cisplatin, which is an antineoplastic medication, may cause ototoxicity. 3. A client who is receiving flurazepam. INCORRECT — Ototoxicity is not a known complication of flurazepam, which is a sedative/hypnotic medication used for short-term management of insomnia. Cisplatin, which is an antineoplastic medication, may cause ototoxicity. 4. A client who is receiving cimetidine. INCORRECT — Cimetidine, which is an H2 histamine-receptor antagonist, is not known to cause ototoxicity. Cisplatin, an antineoplastic medication, may cause ototoxicity. Think like a nurse: Many medications can result in ototoxicity by damaging sensory cells in the middle ear. This results in ear damage, hearing loss, tinnitus, or balance issues. Aminoglycoside antibiotics, platinum chemotherapy agents, aspirin, non-steroidal anti-inflammatories (NSAIDs), quinine, and loop diuretics are known to cause this effect. When these drugs are administered in combination, the risk of developing ear damage increases. In some instances, ear damage is temporary; in many cases, it is permanent.

The nurse views the cardiac monitors for clients on the unit and notes the presence of elevated T waves. Which client is likely to have this appear on the ECG? (Select all that apply.) 1. A client with Cushing syndrome who has hypertension and a pathologic fracture of the spine. 2. A client with alcoholic liver cirrhosis who has severe ascites and shallow respirations. 3. A client who was in a house fire and suffered extensive burns on the arms, trunk, and face. 4. A client who reports severe vomiting for 3 days and shows symptoms of mild dehydration. 5. A client who has been on prednisone for 6 months.

1. A client with Cushing syndrome who has hypertension and a pathologic fracture of the spine. INCORRECT - Elevated T waves indicate hyperkalemia. Cushing disease is caused by an overproduction of corticosteroids. Hypercortisolism is associated with increased blood glucose levels, increased sodium levels, and decreased levels of potassium and calcium. This client will not likely have an elevated T wave. 2. A client with alcoholic liver cirrhosis who has severe ascites and shallow respirations. CORRECT- Clients with liver failure may have an underproduction of bicarbonate, leading to metabolic acidosis. Ascites pushes on the lungs, decreasing lung capacity. Shallow respirations lead to buildup of CO2 and respiratory acidosis. Hyperkalemia is associated with acidosis. This client will likely have an elevated T wave. 3. A client who was in a house fire and suffered extensive burns on the arms, trunk, and face. CORRECT - There is a release of intracellular potassium because of cell destruction from the burns, which will increase serum potassium. This client will likely have an elevated T wave. 4. A client who reports severe vomiting for 3 days and shows symptoms of mild dehydration. INCORRECT - A loss of acid from vomiting leads to metabolic alkalosis, which is associated with hypokalemia. This client likely will not likely have an elevated T wave. 5. A client who has been on prednisone for 6 months. INCORRECT - Excessive and long-term use of corticosteroids leads to hypokalemia. This client will not likely have an elevated T wave.

A nurse from the emergency department (ED) is floated to the surgical unit. Which clients will the charge nurse appropriately assign to the ED nurse? (Select all that apply.) 1. A client with a new diagnosis of heart failure to be discharged in 24 hours. 2. A client who had a cholecystectomy 6 hours ago. 3. A client who had a stroke 3 days ago and requires total care and enteral feedings. 4. A client admitted with pneumonia requiring IV antibiotics. 5. A client admitted with anemia requiring a blood transfusion.

1. A client with a new diagnosis of heart failure to be discharged in 24 hours. INCORRECT - The client with heart failure will require specialized teaching and management of care due to the complex new diagnosis. Assign this client to regular staff. 2. A client who had a cholecystectomy 6 hours ago. INCORRECT - The early postoperative client is at risk for complications. Assign the client to staff who routinely care for postop clients. 3. A client who had a stroke 3 days ago and requires total care and enteral feedings. CORRECT — Delegate stable clients with expected outcomes and routine tasks. The client with a stroke 3 days ago requiring enteral feedings is a stable client. 4. A client admitted with pneumonia requiring IV antibiotics. CORRECT — The client with pneumonia is stable with expected outcomes and a routine task of IV antibiotics. 5. A client admitted with anemia requiring a blood transfusion. CORRECT — Delegate stable clients, such as anemia, with expected outcomes, and the routine task of a blood transfusion.

The nurse provides care for clients in an inpatient setting. Which client does the nurse determine is at the highest risk to develop a healthcare-associated infection (HAI)? 1. A client with full-thickness burns who has a nasogastric tube and a urinary catheter. 2. A client who has a history of gastric ulcer and is recovering from an appendectomy. 3. A client diagnosed with type 1 diabetes mellitus admitted for evaluation of peripheral neuropathy and cardiac palpitation. 4. A client with a history of migraine headaches who is diagnosed with alcohol abuse and admitted for alcohol detoxification.

1. A client with full-thickness burns who has a nasogastric tube and a urinary catheter. — An HAI results from care being delivered in the health care setting. Burns, an NG tube, and a urinary catheter all are risk factors for organisms entering the body. Follow strict standard precautions to prevent HAIs. Think like a nurse: When considering who is at highest risk for infection, the nurse considers the risk factors for infection and counts the number of risk factors that each client has. The client with burns has impaired skin integrity, which hinders the first line of defense against infection. The presence of catheters and tubes into the body also are potential routes for the development of an infection. This client has three risk factors, the highest number of any client listed. Strict standard precautions should be followed to ensure that an infection does not develop in this client.

The nurse receives report from the previous shift. Which client does the nurse see first? 1. A client with myocardial infarction whose monitoring shows four to six premature ventricular beats per hour. 2. A client with dementia who is confused, agitated, and incontinent of urine and feces. 3. A client with pneumonia who is increasingly confused and has a temperature of 104 °F (40 °C). 4. A client with diabetes who is restless during the night and whose fasting blood glucose is 170 g/dL (9.4 mmol/L).

1. A client with myocardial infarction whose monitoring shows four to six premature ventricular beats per hour. INCORRECT - Four to six premature ventricular beats per hour is benign. The nurse is concerned when the client has four to six premature ventricular beats per minute. 2. A client with dementia who is confused, agitated, and incontinent of urine and feces. INCORRECT - The client with dementia who is confused and agitated requires close monitoring but is not urgent. 3. A client with pneumonia who is increasingly confused and has a temperature of 104 °F (40 °C). CORRECT- An elevated temperature indicates pneumonia is worse, but by itself is not concerning. Confusion can indicate hypoxia. Fever increases metabolic and oxygen demand, and combined with increasing confusion indicates this client's condition may worsen quickly. 4. A client with diabetes who is restless during the night and whose fasting blood glucose is 170 g/dL (9.4 mmol/L). INCORRECT - This blood glucose level is not urgently concerning. The nurse will want to assess the cause of the client's restlessness as soon as possible.

A client is in the emergency department to rule out a cerebral vascular accident (CVA). The client suddenly develops a severe headache and loses consciousness. Which finding is a priority for the nurse to report to the health care provider? 1. A history of atrial fibrillation. 2. The client takes warfarin every day. 3. The blood glucose level is 200 mg/dL (11.1 mmol/L). 4. Lung sounds are diminished bilaterally at bases.

1. A history of atrial fibrillation. - Atrial fibrillation results in a decrease in cardiac output because of ineffective atrial contractions or a rapid ventricular response. Thrombi form in the atria because of blood stasis. An embolus may develop and move to the brain, causing a CVA. Atrial fibrillation accounts for as many as 17% of all CVAs. Think like a nurse: While assessing a client with symptoms of a cerebrovascular accident (CVA) or stroke who loses consciousness, the nurse pauses and asks, "What information in the health history could be contributing to the current health problem?" The nurse recalls the risk for CVAs, which include blood clots or hemorrhage. When comparing the client's health history with potential causes of stroke, the nurse identifies that atrial fibrillation increases this client's risk stroke due to blood stasis in the right atrium. This is the information the nurse immediately shares with the health care provider.

Four clients give birth to their newborns vaginally within a 10-minute period. Which client does the nurse evaluate first? 1. A multipara who gives birth to a 5-lb, 8-oz neonate after 2.5 hours of labor. 2. A primipara who is crying after giving birth to a 9-lb, 6-oz neonate. 3. A multipara who gives birth to a 6-lb, 3-oz neonate and has a recent substance use history. 4. A primipara who has a personal physical abuse history and gives birth to a 7-lb, 10-oz neonate.

1. A multipara who gives birth to a 5-lb, 8-oz neonate after 2.5 hours of labor. - Precipitous labor is a risk factor for early postpartum hemorrhage and amniotic fluid embolism. Precipitous labor is defined as a labor pattern that progresses quickly and ends less than 3 hours after it began. The physiological risks to this mother are higher than risks to the other clients, particularly since she is multipara.

A female adolescent client learns about having had intercourse 3 weeks ago with a person who has syphilis. Which manifestation does the nurse expect to see if the client has contracted syphilis? 1. A papule-like lesion in the vaginal area. 2. An abnormal Pap smear. 3. A non-reactive blood serology test. 4. A cluster of painful blisters on the genital area.

1. A papule-like lesion in the vaginal area. — In primary syphilis a chancre develops within 2 to 6 weeks. It appears at the point of entry and starts as small papule that develops into a painless ulcer. Think like a nurse: The nurse understands it is not unusual for an adolescent to engage in sexual experimentation; however, there is a risk of contracting a sexually transmitted infection (STI). Since the client learned of exposure to such an illness, the nurse needs to consider the characteristic signs of the infection. For syphilis, the nurse should assess the genital region for the presence of a chancre sore. The signs for other STIs will depend upon the infecting organism. It is important for the nurse to interact with the client therapeutically and to present a non-judgmental attitude with the client. The scenario presents an excellent opportunity for the nurse to provide education.

The nurse instructs a client recovering from a right above-the-knee amputation (AKA). Which information does the nurse include in the client's teaching plan? (Select all that apply.) 1. A prosthesis will be fitted in about 3 months. 2. Phantom limb pain is common after extremity amputation. 3. Maintain the prone position several times daily. 4. No exercise or ambulation is allowed for several weeks. 5. Anti-seizure medications may help with phantom limb pain.

1. A prosthesis will be fitted in about 3 months. INCORRECT - After an AKA, a prosthesis may be fitted immediately or delayed until the site is completely healed. 2. Phantom limb pain is common after extremity amputation. CORRECT - Phantom limb pain occurs frequently in clients recovering from an amputation of an extremity. 3. Maintain the prone position several times daily. CORRECT - The prone position helps prevent contractures when recovering from an AKA. 4. No exercise or ambulation is allowed for several weeks. INCORRECT - When recovering from an AKA, early ambulation is encouraged with or without a prosthetic limb. 5. Anti-seizure medications may help with phantom limb pain. CORRECT - Anti-seizure medications are effective for neuropathic pain and may be prescribed if required.

The nurse schedules a client for a myelogram. Which teaching will the nurse provide to prepare the client for this test? (Select all that apply.) 1. A trained radiology technician will perform the procedure. 2. Jewelry and metal objects will need to be removed. 3. An informed consent form will need to be signed. 4. Food and fluids will be restricted for 4 to 8 hours before the procedure. 5. The procedure will take about 45 minutes.

1. A trained radiology technician will perform the procedure. INCORRECT - A health care provider will perform the procedure. 2. Jewelry and metal objects will need to be removed. CORRECT- Jewelry and metal objects from the chest area need to be removed. 3. An informed consent form will need to be signed. CORRECT- An informed consent is required because the procedure is invasive. 4. Food and fluids will be restricted for 4 to 8 hours before the procedure. CORRECT- Preparation for a myelogram includes restricting food and fluids for 4 to 8 hours before the procedure. 5. The procedure will take about 45 minutes. CORRECT- The procedure takes about 45 minutes to complete.

The triage nurse prioritizes clients for evaluation. Which client does the nurse determine needs to be seen first? 1. A woman at 6 weeks' gestation and who reports left lower quadrant abdominal pain and vaginal spotting. 2. A toddler whose parents report nausea and vomiting for 2 hours and a fever of 102.8°F (39.3°C). 3. A client who is diagnosed with renal disease and who missed dialysis the day before and reports dependent edema. 4. A school-age client with a forehead laceration from a fall and who is smiling and playful.

1. A woman at 6 weeks' gestation and who reports left lower quadrant abdominal pain and vaginal spotting. - The symptoms are indicative of an ectopic pregnancy, which may result in death if allowed to progress. Think like a nurse: The nurse should begin by determining the level of distress each client is experiencing. Most importantly, the nurse must determine which client is least stable and at greatest risk. The client who is early in a pregnancy experiencing acute left lower quadrant abdominal pain and vaginal spotting may be experiencing an ectopic pregnancy. This can be life-threatening and must be addressed first. In this type of pregnancy the embryo is implanted in a fallopian tube instead of the uterus. The growth of the embryo is restricted by the fallopian tube, which can rupture. This causes pain and possible bleeding within the lower abdominal region.

The nurse monitors a client for the early signs and symptoms of dumping syndrome. Which assessment findings indicate to the nurse that this complication has occurred? (Select all that apply.) 1. Abdominal cramping. 2. Vertigo. 3. Tachycardia. 4. Profuse sweating. 5. Pallor.

1. Abdominal cramping. INCORRECT - Abdominal cramping may be a late manifestation of dumping syndrome. 2. Vertigo. CORRECT - Vertigo is an early manifestation that occurs 5 to 30 minutes after eating. 3. Tachycardia. CORRECT -Tachycardia is an early manifestation that occurs 5 to 30 minutes after eating. 4. Profuse sweating. CORRECT - Profuse sweating is an early manifestation that occurs within 5 to 30 minutes after eating. 5. Pallor. CORRECT - Pallor is an early manifestation that occurs 5 to 30 minutes after eating.

The nurse provides care to a client who is diagnosed with chronic cirrhosis due to long-term alcohol abuse. Which nursing assessment finding leads the nurse to suspect the client may also be experiencing early-stage hepatic encephalopathy? 1. Abdominal distention with umbilical protrusion. 2. Alternating periods of euphoria and lethargy. 3. Flaccidity of the arms and legs. 4. Absence of deep tendon reflexes.

1. Abdominal distention with umbilical protrusion. INCORRECT— Ascites with umbilical protrusion generally are consistent with the diagnosis of cirrhosis. 2. Alternating periods of euphoria and lethargy. CORRECT - Alternating periods of euphoria and lethargy are consistent with early-stage hepatic encephalopathy. Other manifestations of early-stage hepatic encephalopathy include a normal level of consciousness and reversal of day-night sleep patterns. 3. Flaccidity of the arms and legs. INCORRECT— Flaccidity of the extremities is a sign of late-stage hepatic encephalopathy. 4. Absence of deep tendon reflexes. INCORRECT— Absence of deep tendon reflexes is a sign of late-stage hepatic encephalopathy.

The nurse is performing an assessment of a 10-year-old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply. 1. Abdominal pain. 2. Fever and malaise. 3. Anorexia and weight loss. 4. Painful, enlarged inguinal lymph nodes. 5. Painless, firm and moveable adenopathy in the cervical area.

1. Abdominal pain. 5. Painless, firm and moveable adenopathy in the cervical area.

The health care provider prescribes several new treatments for a client. For which prescribed treatment does the nurse request clarification? (Select all that apply.) 1. Acetaminophen 500 mg 1 to 2 tablets PO every 4 hours. 2. Ibuprofen 600 mg PO every 8 hours PRN pain. 3. Clonidine 0.1 mg SL every 4 hours PRN for elevated blood pressure. 4. Lovastatin 20 mg PO every morning. 5. Insulin glargine 10 units subcutaneous before meals and at bedtime.

1. Acetaminophen 500 mg 1 to 2 tablets PO every 4 hours. CORRECT- The total daily dosage may exceed the maximum daily recommended dosage of 4 g/day. 2. Ibuprofen 600 mg PO every 8 hours PRN pain. INCORRECT- The maximum dosage of ibuprofen is 3200 mg/day. This prescription is appropriate. 3. Clonidine 0.1 mg SL every 4 hours PRN for elevated blood pressure. CORRECT- The parameters for blood pressure need to be specific and numerical. The nurse would request clarification as to the parameters for "elevated" blood pressure. 4. Lovastatin 20 mg PO every morning. CORRECT - Statin medications are most effective at night when cholesterol synthesis is highest. The nurse should clarify whether medication is to be given at bedtime rather than in morning. 5. Insulin glargine 10 units subcutaneous before meals and at bedtime. CORRECT - Insulin glargine is a long-acting insulin and should be given once daily.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for TB. Which instructions should the nurse include on the list? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members for at least 6 months. 3. A sputum culture is needed every 2-4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1. Activities should be resumed gradually. 3. A sputum culture is needed every 2-4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. - After 2-3 weeks of medication therapy, it is unlikely the client will infect anyone. Activities should be resumed gradually and a well-balanced diet rich in iron, protein, and Vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary since family members have been exposed. - When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to work.

A patient is admitted to the ER. The patient is unconscious on arrival. However, the patient's family is with the patient and reports that before the patient became unconscious she was complaining of severe pain in the abdomen, legs, and back, and has been experiencing worsening confusion. In addition, they also report the patient has not been taking any medications. The patient was recently discharged from the hospital for treatment of low cortisol and aldosterone levels. On assessment, you note the patient's blood pressure is 70/45. What disorder is this patient most likely experiencing? 1. Addisonian Crisis 2. Cushing Syndrome 3. Thyroid crisis 4. Hashimoto thyroiditis

1. Addisonian Crisis Note the patient is experiencing the signs and symptoms of Addisonian Crisis. The red flag in this scenario are the patient's symptoms, recent hospitalization diagnosis, and that she is not taking any medications. Remember that patients who have Addision's disease are at risk for Addisonian Crisis, especially if they are not taking their prescribed hormone therapy replacement.

The nurse provides care for a client who has been raped. Which action by the nurse is most appropriate? 1. Address the immediate needs and concerns of the client. 2. Refer the client for crisis counseling. 3. Determine how the rape occurred. 4. Determine how the client previously responded to trauma.

1. Address the immediate needs and concerns of the client. — The first action is to assist the client to identify immediate needs and concerns. The nurse should first ensure that the client is physically stable. Think like a nurse: The nurse caring for a victim of rape should mentally ask, "Which actions will convey feelings of compassion and support, and not appear judgmental?" The priority when caring for a client who is a victim of rape is to address the client's immediate needs and concerns. The client has been physically, psychologically, and emotionally violated. The nurse needs to ensure for the client's physical needs while addressing psychological and emotional needs to the best of the nurse's ability. Keep in mind though that the nurse should not perform any tasks that may harm the trail of evidence.

A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply 1. Administer methimazole with food. 2. Place the client on a low-calorie, low protein diet. 3. Assess the client for unexplained bruising or bleeding. 4. Instruct the client to report side and adverse effects such as sore throat, fever or headaches. 5. Use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration.

1. Administer methimazole with food. 3. Assess the client for unexplained bruising or bleeding. 4. Instruct the client to report side and adverse effects such as sore throat, fever or headaches. - Common side effects of methimazole include N/V/D, thus should taken with food. Antithyroid medications can cause agranulocytes with leukopenia and thrombocytopenia. Sore throat, fever, headache, or bleeding may indicate agranulocytes and the HCP should be notified immediately.

The nurse provides care for a 12-month-old client during a wellness visit. The client is due to receive the first dose of the measles, mumps, and rubella (MMR) vaccine. The nurse notes that the client has a low-grade fever and signs of a minor respiratory illness. Which action by the nurse is appropriate? 1. Administer the vaccine on schedule. 2. Postpone the vaccination until the child becomes afebrile. 3. Postpone the vaccination until the respiratory illness is gone. 4. Administer an antipyretic and then administer the vaccine.

1. Administer the vaccine on schedule. —The child should receive the vaccine as scheduled. Vaccination should not be postponed because of low-grade fever or minor respiratory illness. Think like a nurse: After birth, the newborn is protected for a short period of time by the mother's immunity, which is provided while in utero. For future immunity, the newborn needs to receive vaccinations in order to prevent the development or contraction of certain illnesses. A schedule of immunizations has been created, which identifies the appropriate times when vaccination should be provided. Reasons to withhold the vaccine would be evidence of immunosuppression or allergy to the vaccine. Since these reasons are not present in this scenario, the nurse should proceed and provide the vaccination as recommended.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, causing the nurse to suspect pulmonary edema. The nurse immediately asks another nurse to contact the HCP while s/he prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's, side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously - The patient would be placed on oxygen and in a high Fowler's position to ease the work of breathing with furosemide is administered to eliminate accumulated fluid, with a Foley catheter inserted to accurately measure output. Morphine sulfate will reduce venous return (preload), decrease anxiety and the work of breathing.

The nurse is monitoring a client who is in active labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility 4. Administration of oxytocin for induction 5. Potassium level of 3.6 mEq/L

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility - Risk factors: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of analgesic early in labor, and use of epidural analgesic.

A client with a history of alcoholism and cirrhosis of the liver is admitted to the medical unit for ascites management. Which prescribed substance will the nurse administer first? 1. Albumin. 2. Spironolactone. 3. Indomethacin. 4. Platelets.

1. Albumin. - Albumin is a hyperosmotic protein solution. It is given to pull fluid back into the blood vessels. Once the fluid has been moved into the bloodstream, diuretics can then promote excess fluid excretion. Think like a nurse: The nurse needs to understand the manifestations of the client's diagnosis of cirrhosis. The nurse also needs to know the actions of prescribed medications, how it will affect the client's symptoms, and what the expected outcome will be. Albumin is a form of protein used to pull fluid back into the general circulation and decrease the symptom of ascites. This is the prescription that the nurse should implement first. After the infusion, the diuretic can be given to help remove excess fluid from the blood stream.

The nursing staff at the pediatric hospital discuss instituting a community education program regarding intellectual disabilities, particularly prevention. It is most beneficial for the nurses to emphasize which area? 1. Alcoholism treatment. 2. Phenylketonuria (PKU) screening. 3. Nutritional supplementation. 4. Prenatal classes.

1. Alcoholism treatment. - Alcohol is recognized as the leading cause of preventable intellectual disability. This is included in the fetal alcohol syndrome (FAS) complex of symptoms. Think like a nurse: In many cases of intellectual disability, the exact cause is unknown. Prenatal exposure to alcohol or other drugs can be a cause. Prenatal errors in central nervous system development also may be responsible. Public health efforts to prevent intellectual disability should be geared toward adequate prenatal care that emphasizes abstinence from alcohol and other teratogens. In assessing clients with intellectual disability, the nurse should keep in mind that the most sensitive early indicator is delayed language development due to the extent of cognition required to understand and produce speech.

The nurse prepares to assess an adolescent during a visit to the clinic for a sports physical examination. Which developmentally appropriate intervention does the nurse include with an adolescent? 1. Allow time for questions without the parent present in the room. 2. Expose the entire body to allow for a quick examination. 3. Allow adolescent females to keep their bra on during the examination. 4. Remain in the examination room while the adolescent undresses.

1. Allow time for questions without the parent present in the room. -The nurse allows time for questions without the parent present in the room. This intervention gives the adolescent an opportunity to ask sensitive questions that they might not feel comfortable asking in front of a parent. Think like a nurse: An adolescent client must have time alone with the nurse and health care provider to discuss health care needs privately and for the nurse to be able to teach about important issues (such as sexuality) without embarrassing the client. Certain sex-related issues are protected topics between the health care team and the client. The nurse can make no assumptions about the adolescent-parent relationship. While some clients will be comfortable discussing private issues with parents present, most will not be comfortable. To optimize the client's health care visit, the nurse must ensure an opportunity for private conversation with the adolescent client.

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement. 2. Surrounds, cushions, and protects the fetus. 3. Maintains the body temperature of the fetus. 4. Can be used to measure fetal kidney function. 5. Prevents larger particles such as bacteria from passing to the fetus. 6. Provides an exchange of nutrients and waste products between the mother and the fetus.

1. Allows for fetal movement. 2. Surrounds, cushions, and protects the fetus. 3. Maintains the body temperature of the fetus. 4. Can be used to measure fetal kidney function.

The nurse observes the unlicensed assistive personnel (UAP) providing care for a client diagnosed with disseminated herpes zoster (shingles). Which UAP action requires the nurse to intervene ? (Select all that apply.) 1. Ambulating the client to the nurses station. 2. Donning gloves, a gown, and N-95 mask prior to entering the client's room. 3. Refusing to enter the client's room due to a personal positive titer. 4. Performing hand hygiene upon entering the client's room. 5. Using the unit equipment to monitor the client's vital signs.

1. Ambulating the client to the nurses station. - The client diagnosed with disseminated herpes zoster is placed in contact and airborne isolation; therefore, ambulating the client to the nurses station increases the risk for infection to others who may not be immune. 3. Refusing to enter the client's room due to a personal positive titer. - The UAP is immune to varicella zoster (chickenpox) based on the positive titer, and the nurse will discuss this with the UAP. 4. Performing hand hygiene upon entering the client's room. - Hand hygiene will be done prior to entering a contact precaution room. 5. Using the unit equipment to monitor the client's vital signs. - Isolation rooms must have dedicated equipment to prevent hospital-acquired infections and cross-contamination of clients. Think like a nurse: Health care facilities should ensure that all health care workers have evidence of immunity to the varicella-zoster virus (VZV). This measure prevents VZV and nosocomial spread of VZV. A health care worker's immunity to VZV should be documented and readily available in the workplace. The health care worker who lacks evidence of immunity should receive teaching about the risks of possible infection and offered two doses of varicella vaccine (administered 4 to 8 weeks apart). An unvaccinated, susceptible health care worker who has been exposed to VZV is potentially contagious from days 8 to 21 after exposure, and the health care worker should be granted a leave of absence or temporarily transferred to a remote area that does not require contact with clients.

The nurse assesses a client during the client's first prenatal visit. The nurse determines that the client is at 6 weeks' gestation. The nurse identifies which finding as a probable sign of pregnancy? 1. Amenorrhea. 2. Uterine enlargement. 3. Urinary frequency. 4. Fetal heart tone auscultated by Doppler.

1. Amenorrhea. INCORRECT— Amenorrhea is a presumptive sign of pregnancy. Presumptive signs are felt by the woman, such as nausea/vomiting, breast sensitivity, fatigue, and quickening. 2. Uterine enlargement. CORRECT— Probable signs are findings observed by the health care provider. Uterine enlargement, souffle and contractions, positive urine pregnancy test, Hegar sign, and Chadwick sign are all probable signs of pregnancy. 3. Urinary frequency. INCORRECT — Urinary frequency is a presumptive sign of pregnancy. Presumptive signs are felt by the client. 4. Fetal heart tone auscultated by Doppler. INCORRECT — Fetal heart tones auscultated by Doppler are a positive sign of pregnancy, along with palpation of fetal movement and a sonogram of the fetus.

The nurse supervises a team of LPN/LVNs. Which actions by an LPN/LVN will cause the nurse to take action? (Select all that apply.) 1. An LPN/LVN prepares to administer carvedilol to a client with a documented allergy to nadolol. 2. An LPN/LVN prepares to administer hydralazine to a client with a documented allergy to hydroxyzine. 3. An LPN/LVN prepares to administer thioridazine to a client with a documented allergy to promethazine. 4. An LPN/LVN prepares to administer ciprofloxacin to a client with a documented allergy to azithromycin. 5. An LPN/LVN prepares to administer ceftriaxone to a client with a documented allergy to cefazolin.

1. An LPN/LVN prepares to administer carvedilol to a client with a documented allergy to nadolol. CORRECT— Carvedilol and nadolol are beta-blocker medications. An allergy to one type of beta-blocker likely means the client will be allergic to all beta-blockers. 3. An LPN/LVN prepares to administer thioridazine to a client with a documented allergy to promethazine. CORRECT— Thioridazine and promethazine are phenothiazine medications and should not be administered to a client who has a documented allergic reaction to promethazine. 5. An LPN/LVN prepares to administer ceftriaxone to a client with a documented allergy to cefazolin. CORRECT — Ceftriaxone and cefazolin are cephalosporin medications. A documented allergic reaction to any cephalosporin dictates that no medications in this classification should be prescribed or administered to the client.

The school nurse educates preschool faculty and staff about hepatitis A. Which information does the nurse include in the teaching? 1. Anorexia is one of the most common symptoms of hepatitis A among children. 2. The majority of young children who contract hepatitis A will develop jaundice. 3. The hepatitis A vaccine is administered to clients beginning at 1 month of age. 4. Black, tarry stools often occur among children diagnosed with with hepatitis A.

1. Anorexia is one of the most common symptoms of hepatitis A among children. - Among pediatric clients, symptoms of hepatitis A often are flu-like in nature. Common symptoms of hepatitis A among young children include anorexia, fever, malaise, and lethargy. However, among children 6 years of age and younger, up to 70 percent of individuals who contract hepatitis A will be asymptomatic. Think like a nurse: Hepatitis A is a fecal-oral disease, and as such, it flourishes in areas with poor sanitation or where poor sanitation occurs, such as schools and day cares. The Centers for Disease Control and Prevention is a great resource for the public to obtain information about hepatitis A. This severe and contagious illness lasts weeks to months and includes flu-like symptoms such as fever, fatigue, and loss of appetite. Disease-specific symptoms include gray color stools, jaundice, and dark urine.

The nurse provides care to a client diagnosed with sinus arrhythmia. The nurse uses which site to assess the client's pulse? 1. Apical. 2. Radial. 3. Femoral. 4. Carotid.

1. Apical. - Apical pulse assessment is indicated for use during initial cardiac examination or if the client's pulse is irregular. Sinus arrhythmia, which is most common among children and young adults, refers to minor variations in pulse regularity that occur in relationship to the respiratory cycle. In infants and children up to 3 years old, the apical pulse is the routine site for cardiac assessment. Apical pulse assessment is also indicated prior to administration of certain medications, such as digoxin. 2) INCORRECT - Assessment of the radial pulse is appropriate for routine use in the client with a stable, regular pulse rate and rhythm. Think like a nurse: The nurse should stop and recall the physiology of a sinus arrhythmia. The nurse is aware that arrhythmia is characterized by a change in rhythm that is associated with the phases of the respiratory cycle. The rate will typically increase during inspiration and slow down during expiration. Because this heart rate is irregular, measurement should be completed at the apical site for a more comprehensive assessment. Using a peripheral pulse measurement may not provide the correct heart rate for this client.

An adolescent client with a fractured tibia asks the nurse what can be done to relieve itching under the cast. Which response by the nurse is accurate? 1. Apply cool air under the cast with a blow-dryer. 2. Use sterile applicators to scratch the itch. 3. Insert crushed ice under the cast. 4. Apply hydrocortisone cream under the cast using sterile applicator.

1. Apply cool air under the cast with a blow- dryer. - Itching underneath a cast can be relieved by directing a blow-dryer, set on the cool setting, toward the itchy area. Think like a nurse. The nurse is aware a cast is applied to immobilize a bone while healing occurs. The integrity of the cast must be maintained and the client should be instructed on how to protect the cast from water (bathing) and damage from impact. Even if the cast is classified as "waterproof," the client needs to be aware of the parameters for acceptable water exposure. The nurse needs to provide teaching regarding the management of cast-related discomfort associated with excoriated skin and itching. It is important to reinforce that nothing should ever be introduced under a cast. In this scenario, the nurse should suggest that the client use a hair dryer on the cool setting to blow air gently under the cast.

The nurse provides care to a newly-admitted client for whom the use of hand restraints is prescribed. When delegating client care, the nurse assigns which activity to the unlicensed assistive personnel (UAP)? 1. Applying the restraints. 2. Identifying the reason for the use of restraints. 3. Selecting the restraints. 4. Determining the effectiveness of the restraints.

1. Applying the restraints. - The nurse may delegate the application of prescribed restraints, as well as their temporary removal to allow for skin monitoring, to the UAP who has been trained in the use and monitoring of restraints. The nurse is responsible for assessing the underlying cause or behavior that is the basis for restraint application, determining the appropriateness of the use of restraints, selecting the proper type of restraints, evaluating the effectiveness of the restraints, and assessing for potential complications related to their use. Think like a nurse: Prior to delegating a task to unlicensed assistive personnel UAP, the nurse needs to recall the scope of practice and identify tasks that are routine and have a predictable outcome. The nurse is aware the application of wrist restraints is within the scope of practice of the UAP. However, the nurse retains responsibility for identifying the reason for the restraint, selecting the restraint to be applied, evaluating the effectiveness of the restraint, assessing the client's skin condition, and assessing the client's response to restraint use. Assessment actions are beyond the UAP's scope of practice.

The parent of a toddler 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 suggestion 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 is time to go to sleep." 4. Ask your child, "Would you like to take your bear or elephant to bed with you?"

1. Ask your child, "Do you want to go to sleep now?" INCORRECT - Giving the toddler a choice about bedtime is inappropriate, as the child must go to sleep. Asking whether they would like to go to sleep now offers a false choice and can create mistrust if the child is then taken to bed after saying "no". 2. Say to your toddler, "After we read this story, it will be time for sleep." CORRECT— This statement avoids asking the toddler's permission to go to sleep. It sets clear and reasonable limits and allows time for adjustment. Having a clear routine builds trust when the parent follows through. Bedtime is paired with an enjoyable, calming activity and provides a ritual, which will cue the toddler that it is time to sleep. 3. Say to your toddler, "It is time to go to sleep." INCORRECT - While this statement avoids asking the toddler's permission to go to sleep and sets a clear limit, it does not allow time for adjustment. The parent should pair bedtime with an enjoyable and relaxed activity done beforehand to provide positive reinforcement of the desired behavior. 4. Ask your child, "Would you like to take your bear or elephant to bed with you?" INCORRECT - This question does allow appropriate and limited choices for the toddler. However, the parent should first create a sufficient ritual or transition time. Think like a nurse: Setting time limits has little meaning for the toddler-aged client, but the child must learn bedtime limits and have a preparatory transition to bedtime. An older child might be instructed that they have 15 more minutes, but the young child cannot understand the concept of time. Having a favorite story read at bedtime helps the child know how long until bedtime, offers a habitual transition, and respects their need to understand what is happening.

The nurse receives report on the client who had an extensive stroke and is aphasic with a do not resuscitate (DNR) prescription. Initial assessment reveals pulse is 102 beats/min, respirations 28 breaths/min, BP 82/42 mm Hg, temperature 96.7°F (35.9°C) orally, and O2 saturation of 84% on 4 L/min oxygen by nasal cannula. Which actions will the nurse implement based on these data? (Select all that apply.) 1. Assess for advance directives. 2. Contact the health care provider. 3. Confirm the DNR prescription. 4. Contact the family about impending death. 5. Provide pain medication. 6. Place the client in high-Fowler's position.

1. Assess for advance directives. 2. Contact the health care provider. 3. Confirm the DNR prescription. 4. Contact the family about impending death. 5. Provide pain medication.

The nurse provides care for a client who has just been intubated in preparation for mechanical ventilation. Which action does the nurse take next? 1. Assess lung sounds. 2. Call for a stat x-ray. 3. Obtain arterial blood gases. 4. Suction the endotracheal tube.

1. Assess lung sounds. — The priority is to assess for bilateral lung sounds and bilateral chest excursions. Always assess before implementing. Think like a nurse: The priority is to verify proper placement of the endotracheal (ET) tube immediately after intubation. The most reliable method is to obtain a chest radiography to verify placement of the ET tube. While waiting for the chest x-ray, the nurse can listen for bilateral breath sounds and adequate air entry. Quantitative waveform capnography (monitoring the partial pressure of carbon dioxide CO 2) can also be obtained if the equipment is available.

The nurse provides care for a client who just returned from surgery for a right total knee replacement. It is most important for the nurse to take which action? 1. Assess neurovascular status hourly for 12 hours. 2. Monitor incisional bleeding every 4 hours. 3. Instruct the client to remain in bed. 4. Administer intravenous pain medications.

1. Assess neurovascular status hourly for 12 hours. - Surgery may interrupt blood supply to the affected extremity, and immediate intervention is required if there is a change in assessment. Hourly neurovascular status checks allow the nurse to quickly identify symptoms of compartment syndrome, a rare complication, but one that can cause the loss of a limb if not identified and treated. Think like a nurse: Surgery to an extremity interrupts neurovascular integrity to the entire limb. Since the client has just returned from surgery, the priority is to assess the blood flow and neurologic status of the extremity. The wound site can be assessed afterward for bleeding and integrity of the operative site. It is highly unlikely that a client recovering from total knee replacement will attempt to ambulate without assistance because of the discomfort associated with the surgical procedure. However, to promote safety, the client should be reminded to call for assistance when needed. Pain medication would be provided as prescribed after completing a pain assessment.

The nurse provides care for a client who is one day postpartum. The client voids large amounts of urine frequently. Which action does the nurse implement? 1. Assure the client that this is expected after delivery. 2. Ask the client if the urine is cloudy. 3. Check the urine specific gravity of the urine. 4. Notify the health care provider.

1. Assure the client that this is expected after delivery. - Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Postpartum diuresis is caused by several factors, including a decrease in serum estrogen levels, the elimination of increased venous pressure in the lower extremities, and by the loss of any remaining pregnancy-induced increases in blood volume. All of these factors work together to aid the body in ridding itself of excess fluid. A urine output of 3000 mL or more each day during the first 2 to 3 days is expected. Think like a nurse: The body undergoes major physiological changes during pregnancy. Upon delivery, the body realizes that the changes needed to support the developing fetus are no longer needed, and begin sto adjust. One of the body changes in pregnancy is an increase in circulating blood volume. The extra blood is needed to support both the mother and developing fetus. Once the fetus is delivered, the extra blood is no longer needed and the body can start to remove the extra fluid from the general circulation. Evidence of the body making appropriate adjustments to the mother's fluid volume is an increase in the amount of urination. This is an expected occurrence that should be explained to the client.

The nurse provides care for a client who is one day postpartum. The client voids large amounts of urine frequently. Which action does the nurse implement? 1. Assure the client that this is expected after delivery. 2. Ask the client if the urine is cloudy. 3. Check the urine specific gravity of the urine. 4. Notify the health care provider.

1. Assure the client that this is expected after delivery. - Within 12 hours of birth, women begin to lose excess tissue fluid accumulated during pregnancy. Postpartum diuresis is caused by several factors, including a decrease in serum estrogen levels, the elimination of increased venous pressure in the lower extremities, and by the loss of any remaining pregnancy-induced increases in blood volume. All of these factors work together to aid the body in ridding itself of excess fluid. A urine output of 3000 mL or more each day during the first 2 to 3 days is expected. Think like a nurse: The body undergoes major physiological changes during pregnancy. Upon delivery, the body realizes that the changes needed to support the developing fetus are no longer needed, and begin sto adjust. One of the body changes in pregnancy is an increase in circulating blood volume. The extra blood is needed to support both the mother and developing fetus. Once the fetus is delivered, the extra blood is no longer needed and the body can start to remove the extra fluid from the general circulation. Evidence of the body making appropriate adjustments to the mother's fluid volume is an increase in the amount of urination. This is an expected occurrence that should be explained to the client.

The nurse develops a brochure on health promotion. Which example of primary prevention health promotion does the nurse include in the brochure? 1. Attending a stress management class. 2. Performing a testicular examination. 3. Having a blood test for diabetes. 4. Taking an analgesic for a headache.

1. Attending a stress management class. - Primary prevention aimed at health promotion includes activities that may prevent the disease from developing. These activities include health education programs, immunizations, and physical and nutritional fitness activities. Think like a nurse: The fight or flight response is designed to boost the body's ability to act in an emergency. Long-term stress results in chronic activation of the sympathetic nervous system, which leads to a continually elevated heart rate, blood pressure, and blood glucose level. Uncontrolled stress increases the risk for developing heart disease, cancer, and other health alterations. Increasing daily activity, taking purposeful deep breaths, eliminating distractions during certain hours, sleeping adequately, and taking time to enjoy healthy, balanced meals are all healthful strategies to combat stress.

The nurse develops a client teaching brochure on health promotion. Which interventions will the nurse include as examples of primary health promotion? (Select all that apply.) 1. Attending a stress management class. 2. Performing a testicular self-examination. 3. Determining glycated hemoglobin (HbA1C) level. 4. Taking an analgesic for a headache. 5. Determining foods low in cholesterol.

1. Attending a stress management class. - Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. 5. Determining foods low in cholesterol. - Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities. Think like a nurse: Primary prevention activities promote health and protect against exposure to risk factors that lead to health problems (e.g., immunization). Secondary prevention focuses on activities to stop or slow the progression of disease (e.g., annual screening test). Tertiary prevention includes actions to prevent the progression of negative consequences of chronic conditions, reduce disability, and minimize suffering, as well as preventing complications and deterioration (e.g., cardiac rehabilitation). Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify the client 's understanding. The nurse assesses a client 's risk and then screens the client for the condition.

A nurse assesses a female client who reports her last menstrual period was 2 months ago. Which finding does the nurse identify as a positive verification of pregnancy? 1. Auscultation of fetal heart tones. 2. Breast sensitivity. 3. Urinary frequency. 4. Uterine enlargement

1. Auscultation of fetal heart tones. - Auscultation of fetal heart tones can occur at 8 to 12 weeks of pregnancy with the use of a Doppler ultrasound stethoscope. There is no other cause for the presence of fetal heart tones except for pregnancy. Think like a nurse: The nurse is aware there are many reasons why a female client may stop menstruating. The most common reason is pregnancy. Even though many female clients experience signs of pregnancy in the early weeks, others may not. Even when present, early signs of pregnancy are considered presumptive. One way to validate pregnancy is through a urine pregnancy test; however, a more definitive way is to palpate the abdomen, identify uterine structures, and assess for fetal heart sounds. The presence of the fetal heart beat is a positive confirmation once the fetus reaches 2 to 3 months of gestation.

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

1. Avoid activities that requiring bending over 3. Take acetaminophen for minor eye discomfort 5. Place an eye shield on the surgical eye at bedtime 6. Contact the surgeon if a decrease in visual acuity occurs

The nurse prepares a teaching plan for a client who is prescribed captopril for hypertension. Which information does the nurse include in the teaching plan? (Select all that apply.) 1. Avoid using salt substitutes. 2. Do not stop the medication abruptly. 3. Take the medication with food. 4. Blood glucose should be tested monthly. 5. Don't report a dry cough because it is common. 6. Change positions slowly.

1. Avoid using salt substitutes. CORRECT — Salt substitutes contain potassium that can cause hyperkalemia when taken with captopril, an ACE inhibitor. 2. Do not stop the medication abruptly. CORRECT — Stopping the medication abruptly can cause rebound hypertension. 3. Take the medication with food. INCORRECT - Captopril should be taken on an empty stomach to increase absorption. 4. Blood glucose should be tested monthly. INCORRECT - Captopril does not affect blood glucose. 5. Do not report a dry cough because it is common. INCORRECT - A dry cough may indicate bronchospasm and should be reported, as it may be an adverse effect. 6. Change positions slowly. CORRECT — A sudden change in position can cause orthostatic hypotension that could result in a fall for a client.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply 1. Ballottement 2. Chadwick's Sign 3. Uterine Enlargement 4. Positive pregnancy test. 5. Fetal heart rate detected by nonelectronic device. 6. Outline of fetus via radiography or untrasonography.

1. Ballottement 2. Chadwick's Sign (violet coloration of the mucous membranes of the cervix, vagina and vulva, that occurs at about week 4) 3. Uterine Enlargement 4. Positive pregnancy test. - Probable signs in addition to above: Hegar's Sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's Sign (softening of the cervix that occurs at the beginning of the second month), and Braxton Hicks contractions. - Options 5 & 6 are positive signs of pregnancy vs probable.

While performing abdominal thrusts to remove a foreign body, the client becomes unconscious. Which action is appropriate for the nurse to implement at this time? (Select all that apply.) 1. Begin chest compressions. 2. Look in the client's mouth for a foreign body. 3. Insert an oropharyngeal airway. 4. Open the client's airway using a head-tilt, chin-lift maneuver. 5. Activate the emergency response system.

1. Begin chest compressions. — If the client with a foreign body airway obstruction becomes unresponsive and is not breathing, the nurse should begin chest compressions. 2. Look in the client's mouth for a foreign body. — Before delivering ventilations, the nurse should look into the client's mouth. If the nurse sees a foreign body that can be easily removed, the nurse should remove it. 4. Open the client's airway using a head-tilt, chin- lift maneuver. — The nurse should open the client's airway using the head-tilt, chin-lift maneuver. 5. Activate the emergency response system. — The nurse should call for nearby help to activate the emergency response system, so help is available to aid resuscitation efforts. Think like a nurse: Foreign bodies may cause either mild or severe airway obstruction. Poor air exchange (e.g., cyanosis, inability to speak, silent cough) and difficulty breathing are signs of choking. The nurse may observe the client clutch the neck, which is the universal sign of choking. The nurse should first ask, "Are you choking?" If the client nods the head to indicate "yes" and is unable to vocalize, this verifies the presence of a severe airway obstruction. The nurse should then perform abdominal thrusts on the adult client until the obstruction is relieved or until the client loses consciousness. Chest thrusts should be performed if the nurse is unable to encircle the client's abdomen due to obesity. If the client becomes unresponsive, the nurse should assist the client to the ground, shout for additional help, and immediately begin cardiopulmonary resuscitation (CPR). Content Refresher

The nurse provides care to a client receiving an epinephrine infusion following a cardiac arrest. Which assessment findings demonstrate that treatment is effective? (Select all that apply.) 1. Blood pressure 130/67 mm Hg . 2. Apical heart rate 99 beats/min. 3. Pedal pulses +1 and weak bilaterally. 4. Pupils constricted and equal bilaterally. 5. Capillary refill less than 2 seconds.

1. Blood pressure 130/67 mm Hg CORRECT - Epinephrine is a vasopressor and is used off-label to help maintain an adequate blood pressure. A BP within normal limits indicates the treatment is effective. 2. Apical heart rate 99 beats/min CORRECT - Epinephrine is a vasopressor and is used off-label to help maintain an adequate heart rate and rhythm. An apical pulse within normal limits indicates the treatment is effective. 3. Pedal pulses +1 and weak bilaterally INCORRECT - Pedal pulses that are +1 and weak bilaterally indicates inadequate perfusion and that treatment is not effective. Epinephrine is a vasopressor used to maintain adequate heart rate and rhythm. 4. Pupils constricted and equal bilaterally INCORRECT - Intravenous epinephrine has little to no effect on the pupils and does not indicate effectiveness of the treatment. 5. Capillary refill less than 2 seconds CORRECT - A capillary refill of less than 2 seconds indicates normal tissue perfusion and adequate cardiac output.

An older adult client's laboratory results reveal an elevated serum blood urea nitrogen (BUN) level. Which assessment data is most helpful when further evaluating the client's condition? 1. Blood pressure. 2. Oral temperature. 3. Heart tones. 4. Lung sounds.

1. Blood pressure. - In the older adult client, dehydration is a common cause of elevated serum BUN. Blood pressure assessment is most helpful when evaluating the client's fluid volume status. Elevated serum BUN may also occur due to renal dysfunction, in which case the client would require evaluation with additional laboratory and diagnostic tests. Think like a nurse: The nurse needs to review the physiologic changes that can occur with aging. This client has an elevated laboratory value that could be due to a normal age-related process or an undiagnosed health problem. An elevated blood urea nitrogen level could mean renal disease; however, it may also be due to low body fluid volume. To help rule out the reason for this laboratory value elevation, the nurse should first assess the client's blood pressure. If the blood pressure is low, increasing fluids should cause the laboratory value to become closer to normal. If fluids do not correct the value, then additional diagnostic testing would be required to identify the reason for the elevation.

The nurse reviews the blood-test results of four adult clients. Which result indicates to the nurse that the client has a high risk of falling? 1. Blood urea nitrogen (BUN) of 28 mg/dL (10 mmol/L). 2. Serum sodium (Na) of 140 mEq/L (140 mmol/L) and potassium (K) of 4.2 mEq/L (4.2 mmol/L). 3. Erythrocyte sedimentation rate (ESR) of 30 mm/hr (30 mm/hr). 4. Serum calcium (Ca) of 9 mg/dL (2.25 mmol/L) and magnesium (Mg) of 1.8 mEq/L (0.9 mmol/L).

1. Blood urea nitrogen (BUN) of 28 mg/dL (10 mmol/L). — The BUN is elevated in salt and water depletion and can cause confusion, disorientation, and convulsions, which could easily lead to falls. Water depletion could also result in falls due to orthostatic hypotension.

The nurse provides care for a school-age client hospitalized with a diagnosis of staphylococcal pneumonia. It is most important for the nurse to encourage the child to perform which activity? 1. Blowing bubbles using a hand-held wand. 2. Watching a movie while lying in bed. 3. Going to the activity room to play with a puzzle. 4. Coloring pictures with other children on the unit.

1. Blowing bubbles using a hand-held wand. — Blowing bubbles will promote lung expansion while not overexerting the client. The client should not be around the other children on the unit to avoid spreading infection. Think like a nurse: School-age clients require activities that are age appropriate. Because the child has an illness with the potential to cause illness in others, the child must not join other susceptible children in activities. A primary nursing intervention for pneumonia is promoting alveolar expansion. When the client takes in a deep breath, the alveoli expand and the air can move around the mucus, helping to propel it out of the alveoli and up to the airway for expectoration. Blowing bubbles is a much more entertaining way to accomplish this than using an incentive spirometer.

The professional development educator teaches novice nurses about the causes of systemic inflammatory response syndrome (SIRS). Which types of injury will the nurse include in the teaching? (Select all that apply.) 1. Burn injuries. 2. Crush injuries. 3. Major surgeries. 4. Bowel ischemia. 5. Viral infection.

1. Burn injuries 2. Crush injuries. 3. Major surgeries. 4. Bowel ischemia. - Viral infection causes microbial invasion, not mechanical trauma.

The nurse notes that the output for a client diagnosed with chronic kidney disease was not documented for the previous shift. Which action will the nurse take first? 1. Call the assigned nurse and request the information. 2. Complete an incident report. 3. Ask the client to provide the amount of output. 4. Notify the immediate supervisor of the incident.

1. Call the assigned nurse and request the information. — The goal is to make every effort to retrieve the data. Knowledge of the client 's output is used to support decision making about fluid balance. Since nurses often carry notes home or store work sheets in lockers, this approach seeks a possible source for the missing data. Think like a nurse: One action that is essential when providing client care is thorough and accurate documentation. However, accidental omissions of documentation do occur. The nurse may have been distracted with another client's care needs or an emergency situation. Even so, the nurse observes that the medical record of a client with a health problem that relies on the accurate measurement and documentation of urine output is missing vital information. The best action is for the nurse to contact the nurse who provided care to the client during the shift in question to find out what the output was, especially since the information is vital for continuity of care and disease management.

The nurse assesses a client who is diagnosed with hypoparathyroidism. Which data, if found in the client's medical history, are associated with the diagnosis of hypoparathyroidism? (Select all that apply.) 1. Carpal spasms. 2. History of convulsions. 3. Renal calculi. 4. Pathologic fractures. 5. Muscle irritability.

1. Carpal spasms. - Carpal spasms are associated with hypoparathyroidism. A positive Trousseau sign, a positive Chvostek sign, muscle irritability, and tetany occur as a result of hypocalcemia. 2. History of convulsions. - Convulsions may occur in the client diagnosed with hypoparathyroidism because of neuromuscular irritability secondary to hypocalcemia. 5. Muscle irritability. - Convulsions may occur in the client diagnosed with hypoparathyroidism because of neuromuscular irritability secondary to hypocalcemia. Think like a nurse: The parathormone (PTH) regulates serum calcium. Normally, in the bone, PTH stimulates bone resorption and inhibits bone formation, resulting in release of calcium and phosphate into the blood. When there is not enough PTH, hypocalcemia results. The client might report tingling of the lips and fingertips and increased muscle tension and stiffness. In extreme cases, laryngospasms may be observed. The nurse needs to monitor the client for airway obstruction. When giving IV calcium replacement, the nurse should infuse the medication slowly because rapid infusion may cause serious hypotension and cardiac arrest. Ideally, the client should be attached to a bedside cardiac monitor.

The nurse provides care for a client prescribed negative-pressure wound therapy for a wound on the left lower extremity. Which is the most important action for the nurse to take prior to initiation of the therapy? 1. Check serum protein levels. 2. Check serum calcium level. 3. Assess capillary refill of the upper extremities. 4. Check white blood cell count.

1. Check serum protein levels. — Protein is essential for wound healing. If the client's protein level is low, wound healing will be impaired and the negative-pressure wound therapy may not be helpful. Think like a nurse:Wound healing is largely dependent on the body's internal environment. The client needs adequate dietary protein or a nutrient-rich infusion to promote healing. If the client is anemic, this condition must be corrected. An adequate red blood cell (RBC) count is needed to ensure sufficient oxygen delivery to the traumatized tissue. If the client demonstrates impaired systemic oxygenation, then supplemental oxygen should be administered as prescribed. Nursing assessment includes identifying potential barriers to wound healing, including inadequate client hygiene, and educating the client about infection control.

The nurse provides care for a client admitted because of seizures that occurred while the client was at work. The client has no previous history of seizures. Which intervention is most appropriate for the nurse to include in the client's plan of care? 1. Check the oral suction equipment. 2. Place a padded tongue depressor at the head of the bed. 3. Teach the client about epilepsy. 4. Talk to the client about the importance of wearing a medical identification tag.

1. Check the oral suction equipment. — Oral suction equipment may be needed to keep the client safe in the event of another seizure. Think like a nurse: The nurse needs to consider the immediate need of the client in this scenario. The nurse should consider the airway, breathing, circulation (ABCs) of providing emergency care during a seizure. When providing emergency care, the airway is the priority. In the event that the client has another seizure, nursing actions should focus on ensuring and maintaining a patent airway. In a seizure disorder, the client may be drooling or coughing extra secretions, both of which should be removed through suctioning to maintain airway patency. Follow up teaching and expansion of the plan of care will be addressed as a more specific diagnosis is identified.

The nurse develops a teaching brochure about vision screening. Which statement is appropriate for the nurse to include in the brochure? 1. Children should have their eyes tested using the Snellen chart when they reach 2 years of age. 2. Adults age 65 and older should have the eyes examined every 5 years. 3. Adults between 40 and 60 years of age should have eyes tested for glaucoma every year. 4. Adults with type 1 diabetes mellitus should have a yearly eye exam, beginning at age 30.

1. Children should have their eyes tested using the Snellen chart when they reach 2 years of age. INCORRECT — Tests are listed in decreasing order of cognitive difficulty. The selected test should demonstrate the highest ability that the child is capable of performing. In general, Snellen letters or numbers are appropriate for children 6 years of age and older, and tumbling E or HOTV tests are appropriate for children 3 to 5 years of age. 2. Adults age 65 and older should have the eyes examined every 5 years. INCORRECT — After the age of 65, people should have their eyes examined yearly. 3. Adults between 40 and 60 years of age should have eyes tested for glaucoma every year. INCORRECT — Adults between 40 and 60 years of age should have a glaucoma test every 2 years. 4. Adults with type 1 diabetes mellitus should have a yearly eye exam, beginning at age 30. CORRECT — People with diabetes should have a dilated eye exam every year.

The nurse receives hand-off communication on assigned clients with traumatic injuries. In which order will the nurse prioritize the care of these client? (Please arrange in order. All options must be used.) - Client reporting pain 9/10, eight hours after surgery - Client prescribed to receive packed red blood cells - Client prescribed preoperative medication when called to the surgical site - Client experiencing indigestion 4 hours after surgery

1. Client experiencing indigestion 4 hours after surgery 2. Client prescribed to receive packed red blood cells 3. Client reporting pain 9/10, eight hours after surgery 4. Client prescribed preoperative medication when called to the surgical site - First, the client experiencing indigestion may be an indication of cardiac ischemia and the client is interpreting the discomfort as indigestion. This client is the priority. Second, the client requiring blood should be attended to. Blood products have short expiration times and the client's condition may warrant immediate transfusion. Third, the client experiencing pain as 9/10 needs to be addressed. Incisional pain deters effective ventilation and ambulation. And finally the client prescribed preoperative medication as the lowest priority, given there is no stated urgency/set time for transfer to the surgery suite.

A client with type 2 diabetes mellitus is prescribed pioglitazone and metformin. Which findings cause the nurse to question the prescription of these medications? (Select all that apply.) 1. Client is attempting to become pregnant. 2. Client has a history of essential hypertension. 3. Client has a history of nonalcoholic fatty liver disease. 4. Client has chronic kidney disease. 5. Client gained 10 pounds over the past 3 months.

1. Client is attempting to become pregnant. CORRECT — Pioglitazone is contraindicated in pregnancy and metformin must be used with caution. These medications should be questioned before providing to the client. 3. Client has a history of nonalcoholic fatty liver disease. CORRECT — A history of liver disease contraindicates the use of pioglitazone and metformin. 4. Client has chronic kidney disease. CORRECT — A history of kidney disease or renal malfunction contraindicates the use of metformin.

Which action involving the client does the nurse determine to be violations of the EMTALA (Emergency Medical Treatment and Active Labor Act)? (Select all that apply.) 1. Client is not provided with advance directives information. 2. Client who reports dental pain is denied a medical screening. 3. Client's protected health information is shared with those not participating in client's care. 4. Client prepares to sell kidney to the highest bidder. 5. Client is transferred to another facility before attempts are made to stabilize client.

1. Client is not provided with advance directives information. INCORRECT - The lack of information regarding advanced directives violates the Patient Self-Determination Act (PSDA). 2. Client who reports dental pain is denied a medical screening. CORRECT - Refusing to provide care violates EMTALA. All clients should receive medical screening examinations to determine whether emergency medical conditions exist. 3. Client's protected health information is shared with those not participating in client's care. INCORRECT - Sharing client's information violates the Health Insurance Portability and Accountability Act (HIPAA). 4. Client prepares to sell kidney to the highest bidder. INCORRECT - Private selling of organs violates the National Organ Transplant Act. 5. Client is transferred to another facility before attempts are made to stabilize client. CORRECT- A client should not be transferred prior to stabilization or until the transferring hospital has provided medical treatments within its capability.

The nurse assesses the pain level of clients recovering from surgery. Which clients' pain relief are appropriate for the nurse to delegate to the LPN/LVN? (Select all that apply.) 1. Client who had knee arthroplasty yesterday and is scheduled for physical therapy and reports pain as 3 out of 10. 2. Client who arrived from the post-anesthesia care unit a short while ago after an appendectomy, is dozing intermittently, and reports pain as 8 out of 10. 3. Client ambulating on the unit who is recovering from a hernia repair 2 days ago and reports pain as 4 out of 10. 4. Client who had surgery to repair a hip fracture yesterday evening and is difficult to arouse, yet moans when moved. 5. Client on NPO status after a colon resection 4 days ago who reports pain as 7 out of 10. 6. Client who had carpal tunnel release yesterday and reports pain as 6 out of 10.

1. Client who had knee arthroplasty yesterday and is scheduled for physical therapy and reports pain as 3 out of 10. 3. Client ambulating on the unit who is recovering from a hernia repair 2 days ago and reports pain as 4 out of 10. 6. Client who had carpal tunnel release yesterday and reports pain as 6 out of 10.

The nurse reviews the care needs for a group of postpartum clients. Which client does the nurse identify as being the most at risk for developing a hemorrhage? 1. Client with a distended bladder. 2. Client with an episiotomy. 3. Client with engorged breasts. 4. Client requesting assistance with fundal massage.

1. Client with a distended bladder. - A distended bladder is likely to displace the uterus to the left or the right. This will interfere with uterine contraction, which could cause a postpartum hemorrhage. Think like a nurse: A distended bladder prevents the contraction of the uterus after delivery. If bladder distention persists, the blood vessels in the uterus will continue to bleed, increasing the risk for a hemorrhage. Fundal massage helps constrict the uterus to expel clots and encourages the constriction of uterine vessels.

A nurse prepares to teach a health promotion class to a group of adult clients. Which recommendation does the nurse include regarding cancer screening? 1. Clients should have a colonoscopy every 10 years starting at age 40. 2. Clients should have a fecal occult blood test every year starting at age 30. 3. Women should have a Papanicolaou test every 3 years between 21 and 29 years of age. 4. Women should have a clinical breast examination every 5 years between 20 to 40 years of age.

1. Clients should have a colonoscopy every 10 years starting at age 40. INCORRECT - According to the American Cancer Society, clients should have a colonoscopy every 10 years starting at age 50. 2. Clients should have a fecal occult blood test every year starting at age 30. INCORRECT - According to the American Cancer Society, clients should have a fecal occult blood test every year starting at age 50. 3. Women should have a Papanicolaou test every 3 years between 21 and 29 years of age. CORRECT - According to the American Cancer Society, women should have a Papanicolaou (Pap) test every 3 years between the ages of 21 and 29 years. 4. Women should have a clinical breast examination every 5 years between 20 to 40 years of age. INCORRECT - According to the American Cancer Society, women should have a clinical breast examination every 3 years, between 20 to 40 years of age. After the age of 40, women should have annual clinical breast examinations.

The nurse provides care to a client who is prescribed diphenhydramine. Which client conditions cause the nurse to question the prescription? (Select all that apply.) 1. Closed-angle glaucoma. 2. Diarrhea. 3. Urinary retention. 4. Peptic ulcer. 5. Nausea. 6. Small bowel obstruction.

1. Closed-angle glaucoma. — Diphenhydramine is an antihistamine with anti-cholinergic effects. It is contraindicated in closed-angle glaucoma, as the anti-cholinergic effects will increase intra-ocular pressure. 3. Urinary retention. — Diphenhydramine should not be used in clients with urinary retention, as the anti-cholinergic effects will worsen the retention. 4. Peptic ulcer. — Diphenhydramine should be avoided in clients with peptic ulcer disease as it increases the risk for bleeding. 6. Small bowel obstruction. — Diphenhydramine should be avoided in clients with a small bowel obstruction, as the anti-cholinergic effects may contribute to the obstruction. Think like a nurse: The nurse must distinguish among a medication's therapeutic effects, side effects, and adverse effects. The nurse determines the medication's therapeutic effects based on the indications for administering the medication. Some drugs have unintended, beneficial side effects. However, adverse effects are always undesirable and may be life-threatening. Diphenhydramine blocks (antagonizes) histamine-1 receptors, which makes this medication useful for treating clients who are experiencing an allergic reaction. Diphenhydramine's anticholinergic action causes a side effect of drowsiness, which may be beneficial to clients who experience insomnia. The anticholinergic effects also may help with treatment of clients who experience diarrhea. Conversely, diphenhydramine may exacerbate constipation. The combination of antihistamine and anticholinergic effects may help reduce motion sickness for certain clients.

A client receiving an IV fluid infusion of dextrose 5% and 0.45% normal saline at 125 mL/hr develops restlessness; rapid, shallow respirations; crackles in both lung fields; and distended neck veins. Which action is appropriate for the nurse to implement? 1. Contact the health care provider. 2. Clamp the intravenous catheter. 3. Administer diphenhydramine, as prescribed. 4. Place in the Trendelenburg position.

1. Contact the health care provider. - The client exhibits signs of fluid overload (rapid, shallow respirations; distended neck veins; crackles on auscultation; and restlessness). The nurse should immediately contact the health care provider to prevent a delay in treatment.

The nurse presents information to staff regarding anatomic changes that occur shortly after birth to facilitate a newborn's adaptation to extrauterine life. Which anatomic changes are included by the nurse in the teaching session? (Select all that apply.) 1. Decrease in pulmonary vascular resistance. 2. Closure of the foramen ovale. 3. Closure of the ductus arteriosus. 4. Decrease pressure in the left atrium. 5. Closure of the ductus venosus.

1. Decrease in pulmonary vascular resistance. - As blood flows through the lungs and fetal shunts close, increased blood flow dilates pulmonary vessels. This change occurs to maintain blood pressure. 2. Closure of the foramen ovale. - This circulatory system change occurs at or soon after birth, as the result of pressure changes in the lungs, heart, and major vessels. 3. Closure of the ductus arteriosus. - This circulatory system change occurs by the fourth day as the result of pressure changes in the lungs, heart, and major vessels. 5. Closure of the ductus venosus. - This circulatory system change occurs as the result of pressure changes in the lungs, heart, and major vessels. Think like a nurse: At birth, the newborn shifts from a parasitic-type role (i.e., obtaining all needed nutrients, temperature regulation, gas exchange, and waste removal from the umbilical cord, placenta, and mother) to a much more physiologically self-sufficient role. With the newborn's first breath, a series of physiologic changes occur, including drainage or reabsorption of amniotic fluid from the lungs. Fetal circulation ends for the newborn as the ductus arteriosus and foramen ovale close.

The nurse provides care for a client diagnosed with right-sided heart failure. The nurse expects which assessment findings? (Select all that apply.) 1. Dependent edema. 2. Distended jugular veins. 3. Urinating less frequently. 4. Third heart sound (S 3). 5. Intermittent weight gain. 6. Dry, nonproductive cough.

1. Dependent edema CORRECT— Right-sided heart failure is caused by failure of the right ventricle, which causes a backup of circulation. This results in dependent edema. 2. Distended jugular veins CORRECT— Venous jugular distention is caused by the increased venous pressure that occurs with right-sided heart failure. 3. Urinating less frequently INCORRECT - Right-sided heart failure is accompanied by frequent urination, especially at night. 4. Third heart sound (S 3) INCORRECT - A third heart sound is found in left-sided heart failure, the result of a dilated left ventricle. A benign third heart sound is also sometimes heard in pregnancy, childhood, and in trained athletes. 5. Intermittent weight gain CORRECT— Weight gain occurs due to fluid retention. Kidney perfusion is decreased by the weaker pumping of the heart, the kidneys react to the decreased perfusion by retaining sodium to increase fluid volume and pressure to increase perfusion. A weight gain of 2 lbs (0.91 kg) per day or 5 lbs (2.27 kg) in 1 week requires medication adjustments. 6. Dry, nonproductive cough INCORRECT - A dry cough is associated with initial left-sided heart failure. Right-sided heart failure is often the result of prolonged left-sided heart failure.

The nurse assesses a client with a physical health problem. Which finding indicates to the nurse that the client might have a history of alcohol use? 1. Depression, difficulty falling asleep, decreased concentration. 2. Elevated liver enzymes, cirrhosis, decreased platelets. 3. Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms. 4. Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes.

1. Depression, difficulty falling asleep, decreased concentration. INCORRECT - Depression, difficulty falling sleep, and decreased concentration are associated with symptoms of dysphoria or mood disorder. 2. Elevated liver enzymes, cirrhosis, decreased platelets. INCORRECT - Elevated liver enzymes, cirrhosis, and decreased platelet count might warrant further investigation of alcohol use, but these symptoms are not the best indication. 3. Tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms. CORRECT- When a client is admitted for another physical problem to a general medical, surgical, or critical care unit, the nurse many times becomes the case finder and must be alert for subtle symptoms of an alcohol-related problem. The client experiencing tremors, elevated body temperature, nocturnal leg cramps, and complaining of pain are all symptoms associated with an alcohol-related problem. 4. Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes. INCORRECT - Flulike symptoms, night sweats, elevated temperature, and decreased deep tendon reflexes are associated with withdrawal from narcotics or an infectious process, such as tuberculosis.

A client diagnosed with Addison disease comes to the emergency department experiencing nausea, vomiting, diarrhea, and abdominal pain. Which prescription does the nurse expect from the health care provider? 1. Dextrose 5% in normal saline IV solution and high-dose steroids. 2. Adrenocorticotropic hormone (ACTH) IM injection, 0.9% saline infusion, and potassium. 3. Sliding scale insulin asparte subcutaneous injection. 4. Oral administration of sodium chloride, potassium chloride, and steroids.

1. Dextrose 5% in normal saline IV solution and high-dose steroids. — The client is exhibiting symptoms of Addisonian crisis, in which the client is hypotensive and experiences a severe deficiency of glucocorticosteroids. The nurse expects to administer isotonic fluid to increase fluid volume and to provide high-dose steroids to replenish the client.

The home health nurse is visiting a client who was recently diagnosed with T2DM. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply 1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is skipped if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemic episodes. 5. Muscle pain is an expected effect of metformin and may be treated with acetaminophen. 6. Metformin increases hepatic glucose production to prevent hypoglycemic associated with repaglinide.

1. Diarrhea may occur secondary to the metformin. 2. The repaglinide is skipped if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. A simple sugar food item is carried and used to treat mild hypoglycemic episodes. - Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken approximately 30 minutes before meals, and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, thus a simple sugar item should be carried at all times. - Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production.

A client diagnosed with a spinal cord injury is being treated for a neurogenic bladder. Which medication does the nurse expect to be prescribed as part of this client's bladder retraining program? 1. Diphenhydramine. 2. Diazepam. 3. Dicyclomine. 4. Bethanechol.

1. Diphenhydramine INCORRECT - Diphenhydramine is an antihistamine that promotes urinary retention. 2. Diazepam INCORRECT - Diazepam is an anti-anxiety medication that may cause nausea, but it will not affect the urinary system. 3. Dicyclomine INCORRECT - Dicyclomine is an anti-cholinergic medication that promotes urinary retention. 4. Bethanechol CORRECT - Bethanechol is a cholinergic or parasympathomimetic medication used to treat functional urinary retention. It mimics the action of acetylcholine.

A school-age client with eye inflammation tells the school nurse that the parents refuse to take the student to a health care provider for medical attention. Which action will the nurse take first? 1. Discuss the condition of the child's eyes with the parents. 2. Notify the principal of the parents' refusal to seek health care. 3. Notify the child protective division of the department of human resources. 4. Cleanse the drainage from the child's eyes.

1. Discuss the condition of the child's eyes with the parents. - The nurse needs to collect objective data and not just base care upon the child's report. The parents should be contacted first to learn more about the situation, including the possible cause of the condition.

The nurse provides care for a pregnant client. The client comes for a second prenatal visit at 15 weeks' gestation. The client's blood pressure is 120/72 mm Hg. The client's first blood pressure at 12 weeks' gestation was 124/80 mm Hg. Which action does the nurse implement based on this information? 1. Document the blood pressure. 2. Retake the blood pressure with the client in a side-lying position. 3. Review nutrition with the client to determine iron intake. 4. Notify the health care provider.

1. Document the blood pressure. - The client's systolic blood pressure usually remains the same as the pre-pregnancy level, but may decrease slightly as the pregnancy advances. Both of these values are within normal limits. Therefore, the nurse documents the blood pressure. Think like a nurse: The body undergoes major changes during pregnancy. Depending upon the health of the mother, the cardiovascular system may be stressed or need to accommodate the growing fetus. When assessing the pregnant client, the nurse needs to reflect on the physiological changes that occur in pregnancy. Each assessed parameter should be analyzed to determine if the finding is expected or needs to be further studied. In the case of blood pressure, the measurement would be expected and should be documented as such.

The nurse provides care for a client diagnosed with a detached retina. Which post-operative medication prescription does the nurse question? (Select all that apply.) 1. Droperidol. 2. Polyethylene glycol 3350. 3. Morphine sulfate. 4. Benzonatate. 5. Hydromorphone. 6. Clonidine.

1. Droperidol INCORRECT— Droperidol prevents vomiting, and therefore helps prevent increased intraocular pressure. 2. Polyethylene glycol 3350 INCORRECT— Polyethylene glycol 3350 prevents constipation, thus preventing increased intraocular pressure. 3. Morphine sulfate CORRECT — Morphine sulfate can cause constipation, which should be avoided after repair of the retina. Non-narcotic pain relievers are used when possible. 4. Benzonatate INCORRECT— Benzonatate suppresses cough, thus preventing increased intraocular pressure. 5. Hydromorphone CORRECT— Hydromorphone can cause constipation, which should be avoided after detached retina repair. 6. Clonidine. CORRECT— Clonidine can cause constipation, which should be avoided after detached retina repair.

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 (25 g/L), fasting blood sugar is 110 mg/dL (6.1 mmol/L), potassium is 4.2 mEq/L (4.2 mmol/L), and sodium is 140 mEq/L (140 mmol/L). It is most important for the nurse to assess for what finding? 1. Edema. 2. Nausea. 3. Muscle weakness. 4. Blurred vision.

1. Edema. — The client has hypoalbuminemia. The normal albumin range is 3.5-5.5 g/dL Think like a nurse: The nurse reviews the lab values and identifies the client's albumin level as low. The nurse evaluates each assessment finding to identify whether it is associated with hypoalbuminemia. One reason for the development of edema is a low total body protein level. An adequate albumin level is required for fluid to stay in the vasculature. When this level decreases, fluid will shift to body tissues, causing edema. The nurse should assess the client's dietary intake, explore reasons why the client is not eating (if applicable), and collaborate with the dietitian to develop a healthy, balanced meal plan for the client.

The nurse leads group therapy for clients diagnosed with substance abuse. A client diagnosed with alcoholism, and 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 action 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. — The client is probably experiencing some mild level of anxiety. The nurse should reinforce and encourage the client to share feelings and attend the meeting. Think like a nurse: Group therapy for drug addictions is difficult for the client who might feel out of place, not know how to participate, and be generally uncomfortable in this new setting. An invitation to join in the discussion helps to guide the client into the environment and understand what is expected. The nurse works toward easing the client's anxiety and feeling secure in sharing information and thoughts.

A client in a semiprivate room with a roommate is visited by an employee from the hospital business office. The employee discusses the client's inability to pay for services. The client then reports to the nurse that a right to privacy was violated. Which action does the nurse take first? 1. Escort the client to a private setting. 2. Tell the client that his roommate was probably not listening. 3. Inform the client that the business office had to straighten out the client's account. 4. Contact the business office so the client can talk with the employee.

1. Escort the client to a private setting. — This prevents further violation of client privacy while the nurse addresses the concern. Think like a nurse: The nurse has a responsibility to ensure that client privacy is maintained at all times. Certain aspects of the client's care is confidential (such as personal financial information) and should not be discussed where other clients can overhear. Having more than one client in a hospital room presents a challenge with maintaining client privacy. Although the employee from the business office violated client privacy, the nurse should not repeat the offense and must talk with the client in a private setting.

The nurse prepares to assess an infant. Which action is appropriate for the nurse to complete at the end of the assessment? 1. Evaluate genitalia. 2. Assess ears and mouth. 3. Assess deep tendon reflexes. 4. Obtain heart and respiratory rates.

1. Evaluate genitalia. INCORRECT - The nurse should complete the assessment in a head to toe direction. 2. Assess ears and mouth. CORRECT— Assessment of the ears and mouth is more traumatic and invasive and may cause the infant to cry. The nurse should perform auscultation and less aggressive assessments first while the client is calm and quiet. 3. Assess deep tendon reflexes. INCORRECT - Deep tendon reflexes should be assessed as each body part is examined. 4. Obtain heart and respiratory rates. INCORRECT - Heart and respiratory rates should be measured while the infant is calm and quiet. The infant is unlikely to be calm and quiet at the end of the assessment process.

The nurse provides care for the client with a radium implant. Which action is most important for the nurse to take? 1. Evaluate the position of the applicator every 2 hours. 2. Place the client on a low-residue diet to decrease bowel movements. 3. Encourage the use of the bedside commode every 1 to 2 hours. 4. Decrease fluid intake to decrease radiation in the bladder.

1. Evaluate the position of the applicator every 2 hours. INCORRECT - The position of the applicator should be checked every 8 hours, not every 2 hours. 2. Place the client on a low-residue diet to decrease bowel movements. CORRECT — Bowel movements can dislodge the radium implant. This diet will decrease the amount of stool and number of bowel movements. 3. Encourage the use of the bedside commode every 1 to 2 hours. INCORRECT - A client is on strict bedrest to prevent dislodging the radium implant. 4. Decrease fluid intake to decrease radiation in the bladder. INCORRECT - Decreasing fluids will not alter exposure to radiation. A client should have a high fluid intake.

The nurse reviews a list of clients waiting to be seen in the emergency department (ED). Which clients will the nurse select to be seen immediately? (Select all that apply.) 1. Experiencing a tingling sensation in the face and arm. 2. Reporting chest heaviness. 3. Experiencing redness on the lower legs for the past week. 4. Reporting a needle stick while being medicated. 5. Demonstrating drowsiness after taking cyclobenzaprine. 6. Experiencing headache, fever, and neck stiffness.

1. Experiencing a tingling sensation in the face and arm. — Face and arm tingling could indicate a stroke. The client requires immediate evaluation. 2. Reporting chest heaviness. — Chest heaviness requires an immediate electrocardiogram and laboratory tests to rule in or rule out a myocardial infarction. 4. Reporting a needle stick while being medicated. — Receiving a needle stick may require post-exposure prophylaxis if the client is high risk or known to have an infectious disease. 6. Experiencing headache, fever, and neck stiffness. — Headache, fever, and neck stiffness are manifestations of meningitis. The client needs to be assessed immediately. Think like a nurse: When deciding which clients are a priority, the nurse can utilize the ABCs (airway, breathing, circulation) or Maslow's hierarchy of needs. Since the clients all have a range of symptoms, each one should be analyzed individually for acuity and long-term outcome. Symptoms of a stroke include face and arm tingling. This client is at risk for cerebral edema and possible brain herniation. Chest heaviness is a manifestation of an acute myocardial infarction. This client is at risk for sudden cardiac death. The client with a needlestick needs immediate prophylaxis to prevent the development of a blood-borne infection. The client with a headache, stiff neck, and fever is demonstrating signs of meningitis and should be isolated until a definitive diagnosis is obtained.

The nurse provides care for a client before and after electroconvulsive therapy. In which order does the nurse complete the associated nursing interventions? (Please arrange in order. All options must be used.) - Explain the procedure - Orient the client - Administer atropine - Ask the client to void

1. Explain the procedure 2. Ask the client to void 3. Administer atropine 4. Orient the client - Explain the procedure to the client. The client will have convulsions similar to grand mal seizures. Explain about potential temporary memory loss and confusion. Ask the client to void and remove dentures, glasses, and jewelry about 1 hour before the procedure. Administer atropine about 30 minutes before the treatment to decrease secretions. Orient the client after the procedure because the client will be confused after treatment. Stay with the client during this confusion and frequently orient. Obtain the client 's vital signs.

The nurse assesses a client's reflexes. Which finding indicates to the nurse an expected response? 1. Extension of the leg when the patellar tendon is tapped. 2. Spreading of the toes when the lateral part of the sole of the foot is stroked. 3. Flexion of the hips and knees when the neck is quickly flexed. 4. Rapid alternating flex and extension of the ankle after holding the foot in a flexed position.

1. Extension of the leg when the patellar tendon is tapped. - To elicit the patellar reflex, strike the patellar tendon just below the patella. The client can be sitting or lying if the leg being tested hangs freely. The normal response is extension of the leg with contraction of the quadriceps. Think like a nurse: The nurse needs knowledge of assessment skills and the meaning of assessment findings. A complete neurologic examination includes assessment of the cranial nerves, cognition, sensory and motor function, gait, and reflexes. Of these areas to assess, reflexes may be the most challenging. Typically, musculoskeletal reflexes are assessed with the use of a reflex hammer. After positioning, the area being assessed is gently struck with the rubber hammer in order to elicit a musculoskeletal response. The response is outside of conscious control and typically includes some sort of "kick" if the knee is used for this assessment.

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncology emergency? Select all that apply 1. Facial edema in the morning 2. Weight loss of 20lbs in 1 month 3. Serum calcium level of 12 mg/dL 4. Serum sodium level of 136 mg/dL 5. Serum potassium level of 3.4 mg/dL 6. Numbness and tingling of the lower extremities.

1. Facial edema in the morning 3. Serum calcium level of 12 mg/dL 6. Numbness and tingling of the lower extremities. - Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome and tumor lysis syndrome. - Blockage of blood flow to the venous system of the head, resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression.

The nurse provides care for the client who is a strict vegetarian. Which assessment data does the nurse document to support the current diagnosis of vitamin B12 deficiency? (Select all that apply.) 1. Fatigue. 2. Bradycardia. 3. Hypertension. 4. Constipation. 5. Sore tongue. 6. Diarrhea.

1. Fatigue CORRECT — Symptoms of vitamin B12 deficiency include weakness and fatigue. 2. Bradycardia INCORRECT — Bradycardia is not a symptom of vitamin B12 deficiency. 3. Hypertension INCORRECT— Hypotension, not hypertension, is a symptom of vitamin B12 deficiency. 4. Constipation CORRECT — Constipation is seen with vitamin B12 deficiency. 5. Sore tongue CORRECT — A sore tongue is often seen with vitamin B12 deficiency. 6. Diarrhea CORRECT — Clients with vitamin B12 deficiency often report diarrhea.

The nurse provides care for the client diagnosed with heart failure and who takes digoxin 0.25 mg and furosemide 20 mg daily. Which assessment findings indicate the need for the nurse to intervene based on the current diagnosis and treatment regimen? (Select all that apply.) 1. Fatigue. 2. Intestinal colic. 3. Muscle cramps. 4. Cardiac dysrhythmia. 5. Anorexia. 6. Alopecia.

1. Fatigue CORRECT— Furosemide is likely to cause hypokalemia. A symptom of hypokalemia is fatigue. Therefore, this assessment finding causes the nurse to intervene. 2. Intestinal colic INCORRECT— Furosemide is likely to cause hypokalemia. Intestinal colic is seen with hyperkalemia, not hypokalemia. 3. Muscle cramps CORRECT — A symptom of hypokalemia is muscle cramps, so this assessment finding causes the nurse to intervene. 4. Cardiac dysrhythmia CORRECT — A symptom of hypokalemia is cardiac dysrhythmia, so this assessment finding causes the nurse to intervene. 5. Anorexia CORRECT — A symptom of hypokalemia is anorexia, so this assessment finding causes the nurse to intervene. 6. Alopecia INCORRECT— Alopecia is not a concern with furosemide or digoxin.

The nurse provides care to a client with a peripherally inserted central catheter (PICC) for treatment of metastatic cancer. Which findings will the nurse expect 4 days after the catheter placement? (Select all that apply.) 1. Feels no resistance when flushing the catheter with saline. 2. Observes dried blood at the insertion site under the transparent dressing. 3. Notes the insertion site is on the client's left chest. 4. Measures the exposed (nontunneled) portion of the catheter as being 18 cm for the past 2 days. 5. Notes a vesicant medication is prescribed to be administered through the catheter. 6. Learns during hand-off communication that the client showered for morning care.

1. Feels no resistance when flushing the catheter with saline. - Feeling no resistance when flushing the catheter is a normal finding. 4. Measures the exposed (nontunneled) portion of the catheter as being 18 cm for the past 2 days. - A PICC can be up to 60 cm in length, including the tunneled portion. The nurse should measure the exposed length each shift to ensure the catheter has not migrated. 5. Notes a vesicant medication is prescribed to be administered through the catheter. - Irritating and vesicant medications may be infused through a PICC. 6. Learns during hand-off communication that the client showered for morning care. - The insertion site and dressing may be covered with a transparent semipermeable dressing during bathing. If the sterile dressing becomes loose or damp during the shower, a new dressing should be applied. Think like a nurse: A peripherally inserted central catheter (PICC) is a long-term IV access device. PICCs often have multiple lumens, which allow for simultaneous infusion of multiple medications into the fast, voluminous flow of the superior vena cava. Nothing smaller than a 10 mL syringe is used when flushing (unless the syringe is specially designed to generate low pressure) or administering medications through this device, as the pressure will damage the tip, potentially causing a catheter embolism or causing the catheter to collapse. Frequent normal saline flushing is required to maintain patency.

The charge nurse is reviewing medical records. The charge nurse follows up with which documentation entries? (Select all that apply.) 1. Ferrous sulfate 60 mg given orally. Client reported GI discomfort because of medication; calcium carbonate chewable tablets given. 2. Insulin lispro 10 units prescribed before meals. AM dose held because of surgery scheduled at 1000. 3. Furosemide 20 mg IV prescribed. K+ = 5.2 mEq/mL (5.2 mmol/L). Medication administered via IV push. 4. Carvedilol 12.5 mg orally administered as prescribed. T: 99.1 F (37.28 C), HR: 54 bpm, RR: 18 breaths/min, BP: 146/86 mm Hg. 5. Oxycodone IR 10 mg prescribed orally every 4 hours as needed for pain. Medication was administered at 0800, 1200, 1600, and 2000 for the last 4 days.

1. Ferrous sulfate 60 mg given orally. Client reported GI discomfort because of medication; calcium carbonate chewable tablets given. - This documentation entry requires follow up by the charge nurse. Calcium decreases iron absorption and should not be administered with iron replacement. Iron is administered separately from foods and other medications to ensure absorption. 4. Carvedilol 12.5 mg orally administered as prescribed. T: 99.1 F (37.28 C), HR: 54 bpm, RR: 18 breaths/min, BP 146/86 mm Hg. - This documentation entry requires follow up by the charge nurse. The beta-blockers should be held if the client's heart rate is less than 55 to 60 bpm, for this medication will further decrease the heart rate. 5. Oxycodone IR 10 mg prescribed orally every 4 hours as needed for pain. Medication was administered at 0800, 1200, 1600, and 2000 for the last 4 days. - This documentation entry requires follow up by the charge nurse. Breakthrough pain medication should not be given routinely, for this indicates poor pain control. This client needs to have the baseline analgesic increased.

The nurse notes that a client is prescribed to receive fluoxetine. Which herbal supplement will the nurse teach the client to avoid because it interacts adversely with this medication? 1. Feverfew. 2. Echinacea 3. Valerian. 4. St. John's Wort.

1. Feverfew INCORRECT - Clients can use feverfew to prevent migraine headaches. Feverfew can adversely interact with platelet aggregation. Therefore, it interacts adversely with antiplatelet medications, such as aspirin, and anticoagulants, such as heparin and warfarin. 2. Echinacea INCORRECT - Clients can use echinacea to suppress immune function, decrease inflammation, and manage viral infections. Because echinacea can suppress the immune system, it can adversely interact with other immunosuppressant medications, as well as interfere with medications clients take for HIV infection, tuberculosis, or cancer. 3. Valerian INCORRECT - Clients can take valerian to promote sleep. It can adversely interact with medications that can cause central nervous system depression, such as opioids and benzodiazepines. 4. St. John's Wort CORRECT-Clients can use St. John's wort to treat mild to moderate depression. St. John's wort can adversely interact with fluoxetine, causing excessive serotonin transmission that leads to serotonin syndrome.

The nurse provides care to a client who is vomiting brown material that has a fecal odor. Which condition does the nurse suspect is causing this type of vomitus? 1. Gastric outlet obstruction. 2. Obstruction below the pylorus. 3. Intestinal obstruction. 4. Excessive hydrochloric acid in the gastric area.

1. Gastric outlet obstruction INCORRECT - There would be undigested food in the vomitus if gastric outlet obstruction was the problem. 2. Obstruction below the pylorus INCORRECT - The vomitus would be bile-stained green if there was an obstruction below the pylorus. 3. Intestinal obstruction CORRECT— A bowel obstruction is indicated with vomitus that is brown with a fecal odor as described. 4. Excessive hydrochloric acid in the gastric area. INCORRECT - The vomitus would be burning and bitter-tasting if excessive hydrochloric was the issue.

The nurse completes an admission for a client diagnosed with depression to the psychiatric unit. It is important for the nurse to take which action? 1. Give the client a brief orientation to the unit. 2. Explain the activities available 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 client experiencing depression will benefit from a brief orientation to the unit upon admission. A more in depth orientation can occur at a later time. Think like a nurse: Routine admission procedure to the psychiatric unit includes orientation to the unit. However, the nurse should keep information simple and not overwhelm the client. The nurse should be cognizant of possible low self-esteem of the client and changes in self-care behavior. The nurse should be alert for signs of self-destructive behavior, help client to reduce anxiety and decisiveness, and support self-esteem.

The nurse completes dietary teaching with a client diagnosed with chronic kidney failure. The nurse determines further teaching is needed when the client makes which menu selection? (Select all that apply.) 1. Grilled cheese sandwich, canned tomato soup, diet cola. 2. Toast with peanut butter, coffee, orange juice. 3. Turkey sandwich with mustard, tossed salad, lemonade. 4. Macaroni with salt substitute, bread pudding with raisins. 5. Spaghetti with meat sauce, boiled cabbage, apple pie.

1. Grilled cheese sandwich, canned tomato soup, diet cola. — Canned soup is high in sodium, cheese is high in phosphorus, and cola is high in phosphorus. Sodium and phosphorus should be limited for a client diagnosed with chronic kidney disease. 2. Toast with peanut butter, coffee, orange juice. — Peanut butter is high in phosphorus and orange juice is high in potassium. Phosphorus and potassium should be limited for a client diagnosed with chronic kidney disease. 4. Macaroni with salt substitute, bread pudding with raisins. — Salt substitute is high in potassium, as are raisins and other dried fruits. The client diagnosed with chronic kidney disease must limit potassium intake.

The nurse provides care for a client before surgery. Thirty minutes after administering the preoperative medication, the nurse observes the unlicensed assistive personnel (UAP) ambulate the client to the bathroom. Which action should the nurse take first? 1. Have the UAP assist the client back to bed. 2. Ask the UAP if the client had difficulty walking. 3. Determine why the UAP ambulated the client. 4. Ensure that the UAP receives the appropriate training.

1. Have the UAP assist the client back to bed. - The client may be sleepy after receiving preoperative medications and is at risk for falling. The client should not ambulate after receiving preoperative medications. The priority nursing action is to assist the client back to bed. Think like a nurse: The nurse is responsible for supervising and evaluating care provided by the UAP. Usually, preoperative medication includes a sedative. Once this medication is administered, the client is to remain in bed for safety. The UAP needs to return the client to bed immediately. Afterwards, the nurse can counsel the UAP on the importance of maintaining client safety after receiving preoperative medication since the nurse is ultimately accountable for the provision of client care.

The nurse assesses the uterus of a postpartum client who is breast feeding. The nurse notes that the fundus is boggy and deviated to the right side of the client's abdomen. Which action does the nurse take next? 1. Have the client void and reassess the result. 2. Ask if the client has experienced pelvic pain while breastfeeding. 3. Assess when the client last breastfed. 4. Put the baby to breast and reassess uterine muscle tone.

1. Have the client void and reassess the result. - The uterine fundus descends at a predictable rate as the muscle cells contract to control bleeding at the placental insertion site. After the placenta is expelled, the uterine fundus can be felt midline, at, or below the level of the umbilicus as a firm mass. A lateral deviation is related to a distended bladder. Think like a nurse: Prior to implementing a specific action, the nurse should mentally ask, "What does each of the assessment findings mean?" The nurse should recognize a boggy uterus because it will feel soft when palpated. A boggy uterus increases the client's risk of bleeding after delivery, because the blood vessels at the previous site of the placenta are not closed off. A displaced uterus can occur if the bladder is distended, and the nurse should first assess for the last time the client voided. After voiding, the nurse should reassess the status of the uterus. It may return to midline, but it may continue to be boggy, which can be addressed by external massage.

The nurse performs a physical assessment of a newborn who is 4 hours of age. Which finding is appropriate for the nurse to report to the health care provider (HCP)? 1. Head circumference of 40 cm. 2. Chest circumference of 32 cm. 3. Acrocyanosis noted to both feet. 4. An apical pulse rate noted at 160 beats/min.

1. Head circumference of 40 cm. — The average head circumference is 33-35 cm. An increased circumference may indicate hydrocephalus or increased intracranial pressure. Think like a nurse: The nurse who is working in a speciality area needs to be aware of the parameters, which indicates that assessment findings are normal. When abnormal assessment finding are noted, the nurse can reassess for accuracy. The expected head circumference of a newborn is between 32 and 36 cm. When the client's head circumference is 40 cm, the nurse should suspect hydrocephalus may be occurring. This abnormal finding needs to be addressed immediately and the nurse should report the information to the health care provider.

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. 1. Hemodialysis 2. Peritoneal dialysis 3. Kidney transplant 4. Bilateral nephrectomy 5. Intense immunosuppression therapy

1. Hemodialysis 3. Kidney transplant 4. Bilateral nephrectomy - Cysts must be removed to prevent rupture. Peritoneal dialysis is not a treatment option due to the infected cysts and immunosuppression is not effective

A client receives a prescription for clopidogrel. Which laboratory results are important for the nurse to monitor based on this new prescription? (Select all that apply.) 1. Hemoglobin. 2. Hematocrit. 3. Platelet count. 4. International normalized ratio (INR). 5. Activated partial thromboplastin time (aPTT).

1. Hemoglobin. — Clopidogrel is an oral antiplatelet medication that interferes with platelet aggregation. Adverse effects include hemorrhage, bleeding, hematuria, and hemoptysis. A decreased hemoglobin may indicate bleeding. 2. Hematocrit. — A decreased hematocrit may indicate bleeding. Think like a nurse: Hemostasis refers to the cessation of bleeding from a damaged blood vessel. Coagulation, which is one step in the complex process of hemostasis, refers to blood clot formation. The coagulation cascade, which involves a complex series of chemical reactions between clotting factors, results in formation of the fibrin protein. Treatment of the client who experiences hypercoagulation may include administration of medications that (a) affect platelet function or (b) selectively target one or more mechanisms involved in the clotting cascade. Antiplatelet medications, such as clopidogrel, decrease the platelets' tendency to stick to one another and require monitoring of the client's bleeding time. Anticoagulant medications, such as warfarin, heparin, and fondaparinux sodium, alter the function of clotting factors and require monitoring of international normalized ratio (INR), prothrombin time (PT), or activated partial thromboplastin time (aPTT).

The nurse provides care for a client scheduled for an adrenalectomy to treat pheochromocytoma. For which symptom will the nurse monitor the client first? 1. Hypertension. 2. Urine glucose. 3. Intake and output. 4. Urine acetone.

1. Hypertension. - Hypertension is the classic sign of pheochromocytoma. The client's blood pressure should be closely monitored. Think like a nurse. Hypertension has often been characterized as "the silent killer" and there can be a physiologic reason for the development of this health problem. The nurse is aware one reason for secondary hypertension to develop is the presence of a pheochromocytoma, which is a tumor within the adrenal gland. This tumor alters adrenal gland hormone secretion, which causes hypertension. While clients with pheochromocytoma may present with thirst, increased urinary output, and increased blood glucose, these symptoms are unlikely to result in immediate harm to the client. The severe hypertension found in pheochromocytoma may result in stroke or myocardial infarction.

The nurse provides care for a client diagnosed with acute myocardial infarction (MI) due to a blockage in the right coronary artery. Which complication of acute MI most concerns the nurse? 1. Hypertensive crisis. 2. Heart failure. 3. Recurrent MI. 4. Ventricular dysrhythmias.

1. Hypertensive crisis INCORRECT - Hypertensive crisis is not a complication associated with an MI. The client is more likely to experience hypotension related to impaired cardiac pump action. 2. Heart failure INCORRECT - Heart failure is a long-term complication that is more likely to occur when the left anterior descending artery, which supplies the left ventricle, is involved. Because this client is experiencing a blockage in the right coronary artery, the presence of ventricular dysrhythmias would most concern the nurse. 3. Recurrent MI INCORRECT - A recurrent MI is a possibility. However, because ventricular dysrhythmias are the most common cause of death related to MI, their presence would most concern the nurse. 4. Ventricular dysrhythmias CORRECT— Ventricular dysrhythmias are common immediately following an acute MI and are the most common cause of death related to an MI. Ventricular dysrhythmias may happen with any MI but may be more likely when the right coronary artery is involved, as this artery supplies blood to the coronary pacemaker cells.

The nurse provides care to a client with hypercalcemia. Which risk factor will the nurse identify when reviewing the client's medical record? 1. Hypomagnesemia. 2. Renal failure. 3. Malignant neoplasm. 4. Hypoparathyroidism.

1. Hypomagnesemia INCORRECT - Clients with hypomagnesemia are at risk for hypocalcemia. 2. Renal failure INCORRECT - Clients with renal failure are at risk for hypocalcemia because these clients frequently have elevated serum phosphate levels. 3. Malignant neoplasm CORRECT - Most common causes of hypercalcemia are malignancies and hyperparathyroidism. Normal ionized calcium level is 4.25 to 5.1 mg/dL (1.06 to 1.27 mmol/L). Normal total serum calcium is 8.6 to 10.2 mg/dL (2.15 to 2.55 mmol/L). 4. Hypoparathyroidism INCORRECT - Clients with hypoparathyroidism are at risk for hypocalcemia.

A client receiving a blood transfusion experiences a hemolytic reaction. Which finding will the nurse expect when assessing this client? 1. Hypotension, backache, low back pain, fever. 2. Wet breath sounds, severe shortness of breath. 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, headache, backache, and dyspnea. Think like a nurse: The nurse is aware that a client should be closely monitored during a blood transfusion. A hemolytic transfusion reaction is the most severe type of reaction because the immune system breaks down red blood cells in the body due to incompatibility with the transfused blood. Manifestations of this type of reaction include a drop in blood pressure, backache, chills, headache, and a fever. The nurse should stop the transfusion immediately, administer oxygen, monitor vital signs, and contact the health care provider.

The nurse is providing postpartum instructions to a client who will be breastfeeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1. I should wear a bra that provides support. 2. Drinking alcohol can affect my milk supply. 3. The use of caffeine can reduce my milk supply. 4. I will start my estrogen birth control pills again, as soon as I get home. 5. I know if my breasts get engorged, I will limit my breastfeeding and supplement the baby. 6. I plan on having bottled water available in the refrigerator so I can get additional fluids easily.

1. I should wear a bra that provides support. 2. Drinking alcohol can affect my milk supply. 3. The use of caffeine can reduce my milk supply. 6. I plan on having bottled water available in the refrigerator so I can get additional fluids easily.

The nurse determines that the client needs further instruction on cimetidine if which statements were made? Select all that apply. 1. I will take cimetidine with meals. 2. I'll know the medication is working if my diarrhea stops. 3. My episodes of heartburn will decrease if the medication is effective. 4. Taking the cimetidine with an antacid will increase its effectiveness. 5. I will notify my HCP of I become depressed or anxious. 6. Some of my blood levels will need to be monitored closely since I also take Warfarin for atrial fibrillation.

1. I will take cimetidine with meals. 2. I'll know the medication is working if my diarrhea stops. 4. Taking the cimetidine with an antacid will increase its effectiveness. - Since cimetidine crosses the blood-brain barrier, central nervous system side/adverse effects, such as mental confusion, agitation, depression and anxiety can occur. Food and antacids reduces the rate of absorption of cimetidine and should be taken 1 hour apart.

The nurse reviews the prescription for hormone therapy for a client with prostate cancer. Which goal of treatment will the nurse identify as important when planning care for this client? 1. Increase prostaglandin levels. 2. Increase testosterone levels. 3. Increase circulating androgens. 4. Limit the amount of circulating androgens.

1. Increase prostaglandin levels. INCORRECT- Increasing prostaglandin levels would cause the disease to increase. 2. Increase testosterone levels. INCORRECT- The desired outcome is to decrease hormones that would increase the cancer. 3. Increase circulating androgens. INCORRECT- The desired outcome is to decrease hormones that would increase the cancer. 4. Limit the amount of circulating androgens. CORRECT- Limiting the amount of circulating androgens is the desired outcome because prostate cells depend on androgen for cellular maintenance.

The charge nurse meets with the nurse manager and provides a document providing extensive rationales about why the staff has voted not to implement the new care delivery model as instructed. Which action by the nurse manager is most appropriate? 1. Inform the charge nurse that the process was inappropriately initiated. 2. Reprimand the charge nurse in writing for insubordination and place in employee file. 3. Instruct the 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 charge nurse should have informed staff that voting would not negate the process and supported the institution's decisions. Addressing the staff's concern should be done, and probably needed to be done before the care model decision, but this does not deal with the charge nurse's decision.

The nurse is admitting a client who is diagnosed with SIADH and has serum sodium of 118 mEq/L. Which HCP prescriptions should the nurse anticipate receiving? Select all that apply. 1. Initiate an infusion of 3% NaCl 2. Administer IV furosemide 3. Restrict fluids to 800 mL over 24 hours 4. Elevate the head of the bed to high Fowler's 5. Administer a vasopressin antagonist as prescribed

1. Initiate an infusion of 3% NaCl 3. Restrict fluids to 800 mL over 24 hours 5. Administer a vasopressin antagonist as prescribed - Management is directed at correcting hyponatremia and preventing cerebral edema. Hypertonic saline (3% NaCl) is prescribed when hyponatremia is severe; less than 120 mEq/L along with fluid restriction when hyponatremia is due to dilution. Given that Vasopressin is an ADH, a Vasopression antagonist is prescribed. - Furosemide may be used to treat extracellular volume and dilutional hyponatremia in SIADH, but it is only safe if the serum sodium is at least 125 mEq/L and when accompanied by potassium supplementation. To promote venous return in SIADH, the head of the bed should not be raised more than 10 degrees.

The nurse provides care for a client who experienced a severe eye injury related to an acid splash. The nurse administers proparacaine hydrochloride before each eye examination. Which action is most important for the nurse to take? 1. Instruct the client about the action of the medication. 2. Measure the client's intraocular pressure. 3. Instruct the client not to touch the eye. 4. Inform the client that the numbing effect will last 15 minutes.

1. Instruct the client about the action of the medication. INCORRECT - This is an appropriate action, but is not the priority. Proparacaine hydrochloride is a topical anesthetic. 2. Measure the client's intraocular pressure. INCORRECT - Intraocular pressure is used to test for glaucoma. This is not a relevant assessment at this time. 3. Instruct the client not to touch the eye. CORRECT - Rubbing or touching the eye when the eye is anesthetized may cause corneal damage. Instructing the client not to touch the eye ensures client safety and is the highest priority. 4. Inform the client that the numbing effect will last 15 minutes. INCORRECT - This is an appropriate statement, but preventing further damage to the eye takes priority. Think like a nurse:The nurse considers the safety risks inherent in this client situation. Proparacaine hydrochloride is an anesthetic used prior to ophthalmologic examinations. Once the medication is instilled, the nerve endings of the eye are blunted, reducing the ability of the eye to react to pain or pressure. The nurse knows that this places the client at higher risk for eye damage if the eye is touched or rubbed, an action that the client experiencing eye irritation may be more likely to do. The nurse prioritizes teaching the client about not touching the eye to minimize this safety hazard.

The nurse teaches a client who is newly diagnosed with type 1 diabetes mellitus. Which information does the nurse include in the client's discharge teaching? (Select all that apply.) 1. Insulin administration. 2. Symptoms and treatment of hypoglycemia. 3. Reduction of physical activity. 4. The use of a portable blood glucose monitor. 5. Elimination of carbohydrates from diet.

1. Insulin administration - The body does not produce insulin in type 1 diabetes mellitus, so the client needs to learn insulin administration 2. Symptoms and treatment of hypoglycemia - It is critical for the client to learn to recognize the symptoms of hypoglycemia and to understand the ways to manage hypoglycemia. 4. The use of a portable blood glucose monitor - A glucose monitor is needed to check blood glucose frequently. Think like a nurse: Important topics to be included in teaching a client newly diagnosed with type 1 diabetes mellitus (DM) include the disease process, physical activity, diet and menu planning, medication adherence, blood glucose monitoring, risk reduction, and psychosocial trajectories. The client should be familiar in differentiating the signs and symptoms of hypoglycemia and hyperglycemia. Before teaching, the nurse should first assess the client's baseline knowledge. The teach-back method is used to verify the client's understanding. The American Diabetes Association recommends that people with diabetes mellitus who are meeting treatment goals and have stable blood glucose levels have the hemoglobin A1C test twice a year. Health care providers may repeat the hemoglobin A1C test as often as four times a year until blood glucose levels reach recommended levels. The goal is to keep A1C levels below 7% for clients with DM.

The nurse notes that a client diagnosed with acquired immune deficiency syndrome (AIDS) has hyperpigmented skin lesions. Which complication associated with the current diagnosis does the nurse suspect this client is experiencing? 1. Kaposi sarcoma. 2. Varicella-zoster virus infection. 3. Candida albicans. 4. Herpes simplex type 1 infection.

1. Kaposi sarcoma. — Hyperpigmented skin lesions are associated with Kaposi sarcoma. Think like a nurse: The nurse is aware that acquired immune deficiency syndrome (AIDS) is caused by a virus that attacks and causes malfunctioning of the immune system. A client with this disorder is at risk for developing opportunistic infections because the body is unable to fend off microorganisms and disease processes. One disease process commonly seen in clients with AIDS is Karposi sarcoma. This illness is characterized by skin lesions that are darker than the client's skin tone. Definitive diagnosis of this illness occurs after a lesion is biopsied. Treatment will depend upon the findings.

An older adult client with pneumonia has a temperature of 101.2 F (38.4 C), pulse of 112 beats/min, respirations of 22 breaths/min, and BP of 90/50 mm Hg. For which findings will the nurse notify the health care provider? (Select all that apply.) 1. Lactic acid level 5.0 mEq/L (0.555 mmol/L). 2. White blood cell count of 15,000 (15 x 103/microL). 3. Blood pressure of 90/50 mm Hg. 4. Apical heart rate of 112 beats per minute. 5. Oral temperature of 101.9 degrees F (38.8 degrees C).

1. Lactic acid level 5.0 mEq/L (0.555 mmol/L). - A normal lactic acid level is 0.5 to 2.2 mEq/L (0.0555 to 0.2442 mmol/L). Elevated levels indicate inadequate oxygenation in the body or the presence of shock. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 2. White blood cell count of 15,000 (15 x 103/microL). - An elevated white blood count indicates an infection, which is an expected finding for pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 3. Blood pressure of 90/50 mm Hg. - A drop in blood pressure indicates potential shock, which could be life-threatening in the client with pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 4. Apical heart rate of 112 beats per minute. - A rapid apical heart rate occurs with an infection. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. 5. Oral temperature of 101.9 degrees F (38.8 degrees C). - An elevated oral temperature indicates an infection, which is an expected finding with pneumonia. Based on the 2016 Surviving Sepsis Campaign, this client is experiencing severe sepsis; therefore, nurse reports this finding to the health care provider. Think like a nurse: Pneumonia is a bacterial or viral infection in the lungs. Symptoms include elevated temperature and a change in respiration, in addition to upper and lower respiratory congestion. Based on the 2016 Surviving Sepsis Campaign, an elevated lactic acid level in addition to the low blood pressure indicate severe sepsis. Current guidelines indicate that these symptoms, in addition to the elevated WBCs, tachycardia, and elevated temperature are all manifestations the nurse reports to the health care provider.

The nurse provides care for a term neonate born to a client diagnosed with diabetes mellitus (DM). Which manifestation does the nurse monitor the newborn for when conducting the physical examination? 1. Low birth weight. 2. Hypoglycemia. 3. Hypobilirubinemia. 4. Hypercalcemia.

1. Low birth weight INCORRECT- Large birth weight (macrosomia) is expected in an neonate born to a client diagn 2. Hypoglycemia CORRECT- Neonatal hyperinsulinemia occurs after birth. The maternal glucose is no longer available, but insulin production remains high. This results in hypoglycemia. 3. Hypobilirubinemia. INCORRECT- Hyperbilirubinemia (rather than hypobilirubinemia) after birth is expected. The probable cause is breakdown of excessive red blood cells after birth. 4. Hypercalcemia. INCORRECT- Hypocalcemia (rather than hypercalcemia) is expected. The probable cause is transfer of calcium that is abruptly stopped at birth and reduced fetal parathyroid function.

The nurse provides care to a client diagnosed with severe liver disease. Which intervention is appropriate for the nurse to include in this client's plan of care? 1. Low-sodium IV albumin. 2. Sodium polystyrene sulfonate enemas. 3. Sengsteken-Blakemore tube. 4. Low-protein, high-carbohydrate diet.

1. Low-sodium IV albumin INCORRECT - Low-sodium IV albumin is used to balance osmotic pressure. 2. Sodium polystyrene sulfonate enemas INCORRECT - Sodium polystyrene sulfonate enemas are used to treat hyperkalemia 3. Sengsteken-Blakemore tube. INCORRECT - A Sengsteken-Blakemore tube is used to apply pressure against bleeding esophageal varices. 4. Low-protein, high-carbohydrate diet CORRECT - A low-protein, high-carbohydrate diet will help reduce the risks of hepatic coma by reducing the level of ammonia that results from the breakdown of proteins.

A client diagnosed with Crohn disease experiences acute pain. Which action will the nurse teach the client to avoid to reduce the discomfort associated with the health problem? 1. Lying supine with legs straight. 2. Massaging the abdomen. 3. Using relaxation techniques. 4. Taking antispasmodic medication.

1. Lying supine with legs straight. - Lying supine with the legs straight increases muscle tension in the abdomen, which aggravates inflamed intestinal tissues as the abdominal muscles are stretched. Think like a nurse: The nurse is aware that Crohn disease is a small bowel disorder that causes inflammation and pain. The pain related to Crohn disease is referred throughout the abdominal region. The nurse needs to apply the pathophysiologic elements of this disorder, which involves the colon, and recognize actions to help the client with discomfort. One recommendation is to teach the client to avoid lying supine with the legs extended, which places tension on the abdominal muscles, increasing pain and discomfort.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Maintain NPO status. 2. Encourage coughing and deep breathing. 3. Give small, frequent high-calorie feedings. 4. Maintain the client in a supine and flat position. 5. Give hydromorphone intravenously as prescribed for pain. 6. Maintain IV fluids at 10mL/hour to keep the vein open.

1. Maintain NPO status. 2. Encourage coughing and deep breathing. 5. Give hydromorphone intravenously as prescribed for pain.

The nurse plans care for a client receiving peritoneal dialysis. Which intervention is most important for the nurse to include in the plan of care? 1. Maintain strict aseptic technique. 2. Add heparin to dialysate solution. 3. Change the catheter site dressing every day. 4. Monitor the client's level of consciousness.

1. Maintain strict aseptic technique. — A major complication of the procedure, the most common and most serious, is peritonitis. Therefore, precise aseptic technique is required for the client receiving this treatment.

The nurse reviews a clients laboratory report and notes that the client's serum phosphorous level is 1.8 mg/dL. What condition most likely caused the serum phoshporus level? 1. Malnutrition. 2. Renal insufficiency. 3. Hypoparathyroidism. 4. Tumor lysis syndrome.

1. Malnutrition. - Hypophosphosphatemia causative factors relate to malnutrition, starvation, and the use of aluminum hydroxide or magnesium-based antacids. - Hyperphosphosphatemia: Renal insufficiency, Hypoparathyroidism and Tumor lysis syndrome.

The nurse provides care for a client with an ileostomy. For which acid-base disorder does the nurse monitor the client? 1. Metabolic acidosis. 2. Respiratory acidosis. 3. Metabolic alkalosis. 4. Respiratory alkalosis.

1. Metabolic acidosis. — Intestinal secretions are high in bicarbonate that may be lost through enteric drainage tubes, an ileostomy, or diarrhea. This causes metabolic acidosis.

The nurse prepares to administer medications to four clients admitted to a medical-surgical unit. For which prescription does the nurse request clarification by the health care provider? 1. Metoclopramide 10 mg IV prescribed to a client who reports frequent involuntary finger movement. 2. Betaxolol 1 drop in both eyes prescribed to a client diagnosed with glaucoma. 3. Furosemide 40 mg IV prescribed to a client diagnosed with acute kidney injury. 4. Dolasetron 12.5 mg IV prescribed to a client who reports nausea following general anesthesia.

1. Metoclopramide 10 mg IV prescribed to a client who reports frequent involuntary finger movement. CORRECT — Metoclopramide is a prokinetic agent used to increase gastrointestinal motility. The nurse should hold the metoclopramide and notify the health care provider about the client's reported involuntary finger movement. The client may be experiencing tardive dyskinesia (TD), which is a serious side effect associated with long-term metoclopramide use. Signs and symptoms of TD include involuntary movements of the face, arms, and legs. 2. Betaxolol 1 drop in both eyes prescribed to a client diagnosed with glaucoma. INCORRECT— Betaxolol, which is a beta-blocker, is a topical medication used to treat glaucoma. The evidence base for administering this medication is clear and no apparent contraindications exist. 3. Furosemide 40 mg IV prescribed to a client diagnosed with acute kidney injury. INCORRECT— Furosemide is a loop diuretic that promotes diuresis. Clients with renal dysfunction can receive furosemide. The evidence base for administering this medication is clear and no apparent contraindications exist. 4. Dolasetron 12.5 mg IV prescribed to a client who reports nausea following general anesthesia. INCORRECT— Dolasetron is a 5-HT3 histamine antagonist that blocks serotonin receptors in the vagal nerve terminals and the chemoreceptor trigger zones of the central nervous system. Administration of dolasetron is indicated to treat nausea and vomiting during the post-operative period. Dolasetron also may be administered pre-operatively to prevent nausea and vomiting. The evidence base for administering this medication is clear and no apparent contraindications exist.

The nurse provides care for a client receiving lithium carbonate 300 mg orally three times per day. Which clinical manifestations will the nurse identify as early indications of toxicity? (Select all that apply.) 1. Mild thirst. 2. Nausea and vomiting. 3. Coarse hand tremor. 4. Ataxia. 5. Slurred speech. 6. Muscle weakness.

1. Mild thirst. INCORRECT - Lithium is a mood stabilizer used to treat bipolar disorder. Mild thirst is an expected side effect. Other common side effects include fine hand tremor and polyuria. 2. Nausea and vomiting. CORRECT— Nausea and vomiting are early signs of toxicity. The nurse should withhold the medication and obtain a blood lithium level before the dose is re-evaluated. 3. Coarse hand tremor. INCORRECT - A coarse hand tremor is an advanced sign of toxicity. Other indications include persistent GI upset, mental confusion, and poor coordination. 4. Ataxia. INCORRECT - Defective, uncoordinated muscle movements indicate a severe toxicity. 5. Slurred speech. CORRECT— Slurred speech is an early sign of lithium toxicity, along with possible diarrhea, thirst, and polyuria. 6. Muscle weakness. CORRECT— Muscle weakness is an early sign of toxicity, and the nurse should withhold the medication and obtain a blood lithium level.

The nurse plans to teach a group of older adult clients with diabetes mellitus (DM) about ways to maintain glycemic control. Which strategies will the nurse reinforce? (Select all that apply.) 1. Monitor blood glucose levels on a prescribed basis. 2. Participate in a regular exercise program. 3. Lose weight by eating a low carbohydrate diet. 4. Improve self-care through education about diabetes. 5. Limit the total intake of dietary cholesterol.

1. Monitor blood glucose levels on a prescribed basis. 2. Participate in a regular exercise program. 4. Improve self-care through education about diabetes. 5. Limit the total intake of dietary cholesterol.

The nurse provides care to a client diagnosed with hydronephrosis secondary to renal calculi. After surgical removal of the calculi, post-obstructive diuresis occurs. Initial client assessment and monitoring include which nursing action? 1. Monitor daily serum electrolytes. 2. Assess urine output each shift. 3. Measure vital signs every hour. 4. Obtain weekly weight measurements.

1. Monitor daily serum electrolytes CORRECT- Diuresis may cause electrolyte imbalances. Serum electrolytes must be monitored daily, as electrolyte imbalances may lead to serious complications, including cardiovascular events 2. Assess urine output each shift INCORRECT - To allow for effective assessment and monitoring of renal function, urine output should initially be assessed every hour, not each shift 3. Measure vital signs every hour INCORRECT - For the first 4 hours following the procedure, vital signs should measured every 30 minutes. Vital signs should then be measured every 2 hours 4. Obtain weekly weight measurements INCORRECT - Effective assessment and monitoring of the client's fluid volume status requires daily assessment of the client's weight

The nurse provides care for an infant who is six months of age. Which action does the nurse implement when conducting a neonatal reflex assessment? 1. Monitoring for the Moro reflex. 2. Eliciting the Babinski reflex. 3. Monitoring for the tonic neck reflex. 4. Eliciting the stepping reflex.

1. Monitoring for the Moro reflex. INCORRECT - The Moro reflex disappears by 3 to 4 months of age. 2. Eliciting the Babinski reflex. CORRECT- The Babinski reflex is present in the infant who is 6 months of age. It disappears at 12 months of age. 3. Monitoring for the tonic neck reflex. INCORRECT - The tonic neck reflex disappears by 3 to 4 months of age. 4. Eliciting the stepping reflex. INCORRECT - The stepping reflex disappears by 4 to 5 months of age.

The nurse palpates a pregnant client's uterus. The nurse notes that the fetal position is left sacrum anterior (LSA). Which location does the nurse place the Doppler to hear the point of maximum intensity of the fetal heart tone? 1. Mother's left side near the level of mother's umbilicus. 2. Mother's right side below the mother's umbilicus. 3. Mother's left side below the mother's umbilicus. 4. Mother's right side near the level of mother's umbilicus.

1. Mother's left side near the level of mother's umbilicus. CORRECT—This is correct positioning of the Doppler to hear point of maximum intensity of fetal heart tone at LSA. 2. Mother's right side below the mother's umbilicus. INCORRECT - This placement is used for either right occiput anterior or right occiput posterior fetal positions. 3. Mother's left side below the mother's umbilicus. INCORRECT - This placement is used for either left occiput anterior or left occiput posterior positions. 4. Mother's right side near the level of mother's umbilicus. INCORRECT - This placement is used for the right sacrum anterior position.

The nurse receives several telephone messages when performing triage. Which client will the nurse direct to come to the health facility immediately? 1. Multipara client at four weeks' gestation reporting unilateral, dull abdominal pain. 2. Primigravida client at five weeks' gestation having vaginal spotting and some cramping. 3. Multigravida client at six weeks' gestation reporting frank, red vaginal bleeding with moderate cramps. 4. Primipara client at seven weeks' gestation reporting an increase in whitish vaginal secretions.

1. Multipara client at four weeks' gestation reporting unilateral, dull abdominal pain. -The client reporting unilateral dull abdominal pain needs to be evaluated immediately for an ectopic pregnancy. Think like a nurse: The client experiencing dull pain on one side of the abdomen can be experiencing an ectopic pregnancy and should be assessed immediately. Vaginal bleeding during the early weeks of pregnancy could indicate a threatened or spontaneous abortion. These clients need to decrease activity and count the number of pads that are saturated. The nurse recognizes that white vaginal secretions can occur during an early pregnancy. This does not indicate an infection or other disease process.

The nurse assesses a client with a serum sodium level of 138 mEq/dL (138 mmol/L), potassium level of 3.8 mEq/dL (3.8 mmol/L) and calcium level of 7.8 mg/dL (1.95 mmol/L). For which client symptom does the nurse assess? ( Select all that apply.) 1. Muscle cramps. 2. Polyuria. 3. Chvostek sign. 4. Weakness. 5. Nausea.

1. Muscle cramps. CORRECT — The client is experiencing hypocalcemia. Muscle cramps are associated with hypocalcemia. Serum calcium levels should be 8.2 to 10.2 mg/dL (2.05 to 2.55 mmol/L). 2. Polyuria. INCORRECT— Polyuria is associated with hypercalcemia, not hypocalcemia. 3. Chvostek sign. CORRECT — Chvostek sign is associated with hypocalcemia. 4. Weakness. INCORRECT— Weakness is associated with hypercalcemia, not hypocalcemia. 5. Nausea. INCORRECT— Nausea is associated with hypercalcemia, not hypocalcemia.

The nurse provides care for a client in the first trimester of pregnancy. The client experiences nausea. Which information does the nurse provide to the client? (Select all that apply.) 1. Nausea may be linked to the mother 's acceptance of the pregnancy. 2. Nausea should diminish by the 14th week of pregnancy. 3. Eating a dry carbohydrate immediately upon arising is recommended. 4. Decreasing the intake of protein in the evening meal may help. 5. Avoid fried, spicy, and greasy foods.

1. Nausea may be linked to the mother 's acceptance of the pregnancy. CORRECT - Ambivalence about, or rejection of, the pregnant state may cause nausea. 2. Nausea should diminish by the 14th week of pregnancy. CORRECT - Nausea begins about 4 weeks after the last menstrual period, and usually improves by the end of the 14th week of pregnancy. Nausea is associated with an increase of human chorionic gonadotropin (hCG) levels in early pregnancy. 3. Eating a dry carbohydrate immediately upon arising is recommended. CORRECT - Eating a dry carbohydrate upon waking up in the morning may help decrease nausea. 4. Decreasing the intake of protein in the evening meal may help. INCORRECT - Eating more protein at night may help with nausea 5. Avoid fried, spicy, and greasy foods. CORRECT - Avoiding fried, spicy, and greasy foods can help. Think like a nurse: The nausea ( "morning sickness ") that many women experience during the first trimester of pregnancy is the result of hormonal changes. Human chorionic gonadotropin (hCG), is produced at higher levels during the first trimester than at any other time during pregnancy. The nurse explains to the client the difference between typical "morning sickness " and hyperemesis gravidarum, which is a complication of pregnancy that is characterized by severe nausea and vomiting over an extended period. Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify the client 's understanding.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these ABG results. (Select all that apply). 1. Nausea. 2. Confusion. 3. Bradypnea. 4. Tachycardia. 5. Hyperkalemia. 6. Lightheadedness.

1. Nausea. 2. Confusion. 4. Tachycardia. 6. Lightheadedness. - Clinical manifestations of respiratory alkalosis include: lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, N/V, epigastric pain, numbness and tingling of the extremities. To compensate, hyperventilation (tachypnea) occurs. - Note: hyperkalemia is associated with acidosis.

A female client reports that she discovered a lump in her breast about 4 months ago, and the lump seems to be getting larger. Which action is most important for the nurse to take? 1. Notify the health care provider to schedule a mammogram. 2. Ask the client if she is taking oral contraceptives. 3. Ask the client the date of her last period. 4. Instruct the client to discontinue any hormones.

1. Notify the health care provider to schedule a mammogram. — A mammogram is an x-ray of the breast, which screens for breast cancer. It is the first step to determine whether the lump is malignant or benign. This is the priority action. Think like a nurse: Sometimes the nurse needs to ask, "What nursing intervention will address the client's needs best?" Nurses are encouraged to use the nursing process when providing care. However, there are times when the nurse recognizes that any application of the nursing process will not change the client's condition. This client has a breast mass or lump, which needs further examination. The client should first be scheduled for a mammogram. Depending upon the results, the client may need a breast biopsy.

Following the removal of a brain tumor from a child, the nurse observes a colorless drainage on the dressing. Which action does the nurse take first? 1. Notify the health care provider. 2. Document the findings. 3. Continue to monitor for increase in drainage. 4. Outline the drainage on the bandage.

1. Notify the health care provider. — The nurse should report the presence of colorless drainage immediately because it may be cerebrospinal fluid. The nurse will monitor for signs of increased intracranial pressure, hemorrhage, and meningitis. It is an appropriate action to mark the extent of the drainage for future comparison. However, the priority is to contact the health care provider.

The nurse provides care to a client who reports nervousness, hunger, tremors, and sweating. Which action will the nurse take first? 1. Obtain a capillary blood sample for blood glucose testing. 2. Obtain an arterial blood sample for an ABG analysis. 3. Administer glucagon subcutaneously, as prescribed. 4. Administer a rapidly-absorbed oral carbohydrate.

1. Obtain a capillary blood sample for blood glucose testing. - The nurse should first obtain a capillary blood sample for blood glucose testing to confirm that hypoglycemia is the cause of the client's symptoms. Think like a nurse: Before acting, the nurse should think about the client's symptoms and consider reasons for them occurring together. Nervousness, hunger, tremors, and sweating are cardinal manifestations related to some sort of metabolic imbalance. The nurse should recognize that this group of symptoms are likely indicative of a low blood glucose level. The action that the nurse should take first involves use of the nursing process. The nurse would use assessment by determining this client's capillary blood glucose level. Depending upon the result, treatment with food or other oral source of glucose would alleviate the symptoms. If the glucose level is within normal limits, additional assessment would be required to identify the source of the symptoms.

The nurse assesses a client in the outpatient clinic reporting repeated severe headaches. Which action does the nurse take first? 1. Obtain a description of the headache. 2. Determine how the client usually relieves headaches. 3. Ask how long the client has been having headaches. 4. Obtain a list of medication the client is currently taking.

1. Obtain a description of the headache. — The nurse should ask the client to describe the headache in the client's own words. Headache is usually a symptom and not a disease, and can be a result of neurological disease, vasodilation, or skeletal muscle tension. The description of the headache will assist the nurse to determine what course of action is best. Think like a nurse: The first nursing action is always to assess, unless the client is in distress. The nurse should ascertain as much information as possible about the characteristics of the headaches. The information will be subjective and should be as detailed as possible, including a description of the kind and level of pain, along with the duration, frequency, and any preemptive events. This assessment will help determine the potential cause and identification of interventions that will be most appropriate to relieve the pain.

Intravenous potassium chloride is prescribed for a client with hypokalemia. Which actions should the nurse take in preparation and administration of the potassium? Select all that apply 1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 3. Prepare the medication for bolus administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

1. Obtain an intravenous (IV) infusion pump. 2. Monitor urine output during administration. 4. Monitor the IV site for signs of infiltration or phlebitis. 5. Ensure that the medication is diluted in the appropriate volume of fluid. 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution. - Administering potassium via IV push can result in cardiac arrest.

The nurse assigns a client who is receiving a red blood cell transfusion to the unlicensed assistive personnel (UAP). Which actions can be delegated to the UAP? (Select all that apply.) 1. Obtain vital signs prior to the transfusion. 2. Obtain blood products from the blood bank. 3. Verify the client's identity prior to the transfusion. 4. Perform hourly rounding during the transfusion. 5. Assist the client with toileting during the transfusion.

1. Obtain vital signs prior to the transfusion. 2. Obtain blood products from the blood bank. 4. Perform hourly rounding during the transfusion. 5. Assist the client with toileting during the transfusion.

The nurse provides care to an infant client who is diagnosed with heart failure. Which assessment by the nurse best detects fluid retention in the client? 1. Obtaining daily weights. 2. Testing the urine for blood. 3. Measuring abdominal girth. 4. Counting the number of wet diapers.

1. Obtaining daily weights. - The earliest sign of fluid retention is weight gain. Think like a nurse: Infants with heart failure often exhibit subtle signs such as difficulty feeding and tiring easily. The nurse should pay close attention to parents' statements such as, "The baby drinks a small amount of milk and stops, but then wants to eat again very soon after," "The baby seems to perspire a lot during feedings," or "The baby seems to be more comfortable sitting up than lying down." Although the earliest sign of fluid retention is weight gain, the nurse should keep in mind that, in general, weight gain is a late sign of heart failure.

The nurse recognizes that which lifespan consideration may impact the care of older adult clients? 1. Older adults have a decreased sense of thirst. 2. Sensitivity to odors increases with aging. 3. Older adults have decreased total body fat. 4. Gastrointestinal motility increases with aging.

1. Older adults have a decreased sense of thirst. - Sense of thirst is decreased among older adults. With aging, sense of smell becomes less acute and gastrointestinal mobility decreases. Total body fat increases with aging. Think like a nurse: In this scenario, the nurse should mentally review the age-related changes that are considered normal and expected. The older adult client will experience changes in sensory perception, digestion, and body composition. Regarding sensory perception, one primary change that should be addressed is the sense of thirst. Older adult clients will have a decline in the ability to detect thirst, which can lead to dehydration. When planning the care of an older adult client, the nurse should ensure for an adequate oral fluid intake. The nurse will provide client teaching about the importance of maintaining a normal fluid intake and the health issues associated with low fluid intake.

The nurse provides care for a client taking disulfiram. Which medication is important for the nurse to instruct the client to avoid? 1. Over-the-counter cough syrup. 2. Propranolol. 3. Aspirin. 4. Antacids.

1. Over-the-counter cough syrup. - Intake of any form of alcohol with disulfiram will cause a severe reaction, including flushed skin, pounding headache, tachycardia, chest pain, shortness of breath, blurred vision, and hypotension. Most over-the-counter cough/cold preparations contain varying levels of alcohol and will precipitate this reaction. Think like a nurse: The nurse teaches the client to avoid medication interactions. Using Maslow's hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports ingesting over-the-counter (OTC) medications and drugs that may interact. Alcohol is a substance in many products that consumers do not think about, including cough medications. In this case, the client is taking disulfiram, an alcohol deterrent that is prescribed to help clients abstain from alcohol. All forms of alcohol ingestion, direct and indirect, should be avoided for this client. Serious adverse effects such as chest pain may occur if the client takes an unapproved OTC medication and the prescribed medication.

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment finding should the nurse expect to observe? Select all that apply 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids

1. Pallor 2. Edema 3. Anorexia 4. Proteinuria - Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. In addition, the child is likely to gain weight, not lose weight.

As the night nurse makes rounds, an older adult client reports having cold feet. Which action does the nurse take first? 1. Palpate pedal pulses. 2. Elevate the foot of the bed. 3. Place a heating pad on the client's feet. 4. Offer the client a warm drink.

1. Palpate pedal pulses. — Cold feet may be a sign of decreased circulation, especially in the older adult client. The nurse should assess the client's circulation first before taking action. Think like a nurse: The nurse needs to mentally ask, "What would be the cause of a client having cold feet?" The nurse needs to consider specific causes that may be related to the client. Older adult clients typically have alterations is circulation. So, prior to implementing an action to warm the feet, the pulses should be assessed in order to evaluate blood flow. Cold feet could indicate a change in neurovascular integrity, which may be exacerbated by an inappropriate intervention. The nurse should always assess before implementing, unless the client is in distress.

The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply 1. Pathological fracture 2. Urinalysis positive for nitrates 3. Hemoglobin level of 15.5 g/dL 4. Calcium level of 8.6 mg/dL 5. Serum creatinine level of 2.0 mg/dL

1. Pathological fracture 2. Urinalysis positive for nitrates 5. Serum creatinine level of 2.0 mg/dL - Normal (F) hemoglobin levels: 12 - 16 gm/dL - Normal calcium level: 8.5-10.8 mg/dL - Adult creatinine: 0.7-1.4 mg/dL

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the healthcare provider (HCP) and the HCP prescribes dietary restrictions based on sodium level. Which acceptable food items does the nurse instruct the client to consume? (Select all that apply) 1. Peas. 2. Nuts. 3. Cheese. 4. Cauliflower. 5. Processed oat cereals.

1. Peas. 2. Nuts. 4. Cauliflower. - Peas, nuts, and cauliflower are good food sources of phosphorus and are not high is sodium. - Peas and cauliflower are also high in magnesium.

The nurse assumes care for a client from the post-anesthesia care unit (PACU). In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.) - Develop a plan of care based on findings and the individual's risk factors - Review the HCP's postoperative prescriptions - Perform a focused assessment of the client, including vital signs - Observe incision, dressing and/or drainage tubes - Develop and implement individualized client education

1. Perform a focused assessment of the client, including vital signs 2. Observe incision, dressing and/or drainage tubes 3. Review the HCP's postoperative prescriptions 4. Develop a plan of care based on findings and the individual's risk factors 5. Develop and implement individualized client education The nurse first assesses the client and obtains baseline vital signs so any subsequent change in status will be apparent. Second, the nurse continues the assessment by observing for bleeding and marking or reinforcing dressings as needed and ensuring drains are patent. Third, after gathering baseline assessment data, the nurse reviews prescriptions for IV fluids and other medications, prescribed diet, and activity level. Fourth, using assessment data and health care provider prescriptions, the nurse develops the client's plan of care. Fifth, the nurse plans and begins teaching to the client and caregiver. This includes such teaching as the use of incentive spirometry.

A client's cardiac monitor shows a new onset of atrial fibrillation with a ventricular rate of 90 beats/min. Which actions will the nurse implement when providing care for the client? (Select all that apply.) 1. Perform rapid defibrillation. 2. Measure vital signs. 3. Assess for associated signs and symptoms. 4. Notify the health care provider. 5. Administer amiodarone.

1. Perform rapid defibrillation. INCORRECT - Rapid defibrillation is indicated for treatment of ventricular fibrillation, not atrial fibrillation. 2. Measure vital signs CORRECT- The nurse should measure the client's vital signs to determine whether the client is hemodynamically stable and tolerating the arrhythmia. 3. Assess for associated signs and symptoms. CORRECT- The nurse should assess the client to determine whether associated signs and symptoms are present. 4. Notify the health care provider. CORRECT- The nurse should notify the health care provider of the change in the client's condition. 5. Administer amiodarone INCORRECT - Amiodarone should not be administered for a client whose heart rate is less than 150 beats per minute.

The nurse provides care to a toddler-age client who has a laceration to the left hand. Which actions by the child require investigation by the nurse? (Select all that apply.) 1. Persistently disobeys the parent after instructions to sit down. 2. Explores items found within the exam room. 3. Continues to scream after having the hand wrapped with gauze. 4. Hides behind the parent during interactions with the nurse. 5. Smiles when receiving a sticker after the treatment.

1. Persistently disobeys the parent after instructions to sit down. - Disobeying the parent indicates defiance and is a negative outcome of development. 3. Continues to scream after having the hand wrapped with gauze. - Screaming after receiving treatment indicates fearful behavior and is a negative outcome of development. 4. Hides behind the parent during interactions with the nurse. - Hiding behind a parent indicates withdrawal and is a negative outcome of development. Think like a nurse: A toddler should demonstrate specific behaviors that indicate normal development. The child ignoring direction by the parent indicates an issue with expected development and should be investigated further. The child should not scream after treatment has concluded. This demonstrates fearfulness and suggests an adverse developmental finding. A child of this age should not be fearful and hiding when interacting with the nurse. This also requires further developmental assessment.

A school-age client is prescribed phenobarbital 15 mg every 12 hours by mouth and phenytoin 30 mg/5 mL twice a day by mouth. Which information is most important for the nurse to instruct the parents? 1. Phenytoin comes as a suspension and should be shaken. 2. Phenytoin can cause a change in the growth of gums. 3. Phenobarbital can cause a discoloration of the urine. 4. Phenobarbital can affect vitamin D metabolism.

1. Phenytoin comes as a suspension and should be shaken. CORRECT— Teaching the importance of shaking the phenytoin is necessary for client safety. The medication needs to be provided accurately. 2. Phenytoin can cause a change in the growth of gums. INCORRECT - Gingival hyperplasia is a side effect of phenytoin that occurs over a long period. This adverse effect is minimized with frequent dental care 3. Phenobarbital can cause a discoloration of the urine. INCORRECT - Phenobarbital does not change the color of urine, but it may cause nausea, constipation, and epigastric pain. Phenytoin may turn the urine pink, red, or red-brown. 4. Phenobarbital can affect vitamin D metabolism. INCORRECT - Phenobarbital increases vitamin D metabolism, which can lead to sub-therapeutic levels with prolonged therapy. However, this is not the most important information to teach the parents.

The nurse provides cares for a client who sustained a T5 spinal cord injury four weeks ago. The nurse observes that the client is diaphoretic, nauseated, and reports a severe headache. Which action does the nurse take first? 1. Place the client in a sitting position. 2. Assist the client to empty the bladder. 3. Examine the client's rectum. 4. Administer hydralazine as prescribed.

1. Place the client in a sitting position. - These symptoms reflect autonomic dysreflexia, which is a life-threatening condition that can occur with spinal cord injuries above T6. Causes include visceral distension and noxious stimuli, such as skin pressure and temperature extremes. A primary symptom, and of most major concern, is severe and rapid-onset hypertension. Another symptom includes bradycardia. Placing the client in a sitting position should be done immediately to help reduce intracranial pressure and prevent cerebral hemorrhage and seizures.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by RSV. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask at all times when in contact with the infant. 4. Place the infant in a tent that delivers warm, humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

1. Place the infant in a private room. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which abnormal laboratory test results should the nurse report? (Select all that apply) 1. Platelets 35,000 mm 2. Sodium 150 mEq/L 3. Potassium 5.0 mEq/L 4. Segmented neutrophils 40% 5. Serum creatine 1mg/dL 6. White blood cells 3,000 mm

1. Platelets 35,000 mm 2. Sodium 150 mEq/L 4. Segmented neutrophils 40% 6. White blood cells 3,000 mm - Normal values: Platelets: 150,000 - 400,000 mm Sodium: 135-145 mEq/L Potassium: 3.5-5.0 mEq/L Segmented neutrophils: 60-70% Serum Creatine: 0.6-1.3 mg/dL WBC: 5,000-10,000 mm

The nurse is completing an assessment of a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. 1. Polyuria 2. Headache 3. Bone pain 4. Nervousness 5. Weight gain

1. Polyuria 3. Bone pain - Parathyroid hormone (PTH) maintains serum calcium homeostasis, so in hyperparathyroidism, PTH levels are too high, causing bone resorption (calcium pulled from the bones). Elevated serum calcium levels produce osmotic diuresis, thus polyuria.

The home care nurse visits an older adult client living with an adult child. Which observations, if made by the nurse, may indicate elder abuse? 1. Poor nutritional status and hygiene. 2. Difficulty with short-term memory. 3. Dirty laundry found in the client's room. 4. Client is recovering from a fractured hip.

1. Poor nutritional status and hygiene. - Poor nutrition and poor hygiene may indicate elder abuse. Other signs include absence of needed dentures and glasses, dehydration, urine burns, excoriation, and pressure injuries. Think like a nurse: Manifestations of elder abuse may be subtle or overt. The most common symptoms of this type of abuse include poor nutrition and hygiene. The client's daily oral intake and frequency of performing hygiene should be assessed. Alteration in short-term memory can occur with a variety of health problems. Dirty laundry is not an indication of abuse. The most common cause for a fractured hip in an older client is a fall. It is unlikely that a hip fracture occurred from abuse.

The nurse provides care for a client experiencing diabetic ketoacidosis (DKA). Which findings will the nurse expect when assessing this client? (Select all that apply.) 1. Poor skin turgor. 2. Decreased urine output. 3. Elevated blood glucose. 4. Tachycardia. 5. Orthostatic hypotension.

1. Poor skin turgor. 3. Elevated blood glucose. 4. Tachycardia. 5. Orthostatic hypotension.

The nurse provides care to a client in labor who is undergoing augmentation. The nurse notes three consecutive late decelerations on the client's electronic fetal monitor tracing. Which action does the nurse implement first? 1. Position the client on the left side. 2. Turn off the intravenous oxytocin infusion. 3. Administer oxygen by face mask at 10 L per min. 4. Increase the rate of intravenous fluid administration.

1. Position the client on the left side. — Positioning the client on the left side is the priority action to increase placental perfusion for the client who is experiencing late decelerations during augmentation of labor. Think like a nurse: When persistent late decelerations are noted, further assessment is not needed prior to taking action. Interventions include re-positioning the client to the left side or to the knee-chest position to increase uterine blood flow, administering oxygen and fluid to increase oxygenation and cardiac output, and correcting the stimulus of the late decelerations. Late decelerations may stem from excessive contractions or maternal hypotension. Late decelerations are caused by decreases in fetal oxygenation and subsequent fetal hypertension. If allowed to continue, fetal hypoxia results in sustained fetal bradycardia.

The client has a cataract removed from the left eye. Which intervention does the nurse implement in the immediate post-operative period? 1. Position the client on the right side with the head elevated. 2. Place the client on the left side with the head tilted downward. 3. Perform sensory neurological checks every 2 hours. 4. Maintain complete bed rest for the first 2 days.

1. Position the client on the right side with the head elevated. - The client is positioned on the back or unaffected side to prevent trauma to surgical eye. Think like a nurse: Proper client positioning in consideration of illnesses or procedures is an essential and frequent nursing function. For example, after surgery for macular degeneration, the client has to maintain a face-down position. By contrast, after cataract surgery, the client has few restrictions, but is advised to sleep in a position that avoids direct pressure on the operative eye. The client should avoid bending (even to tie shoes) and carrying anything heavy, because these actions increase eye pressure.

The nurse reviews laboratory values for a group of clients. Which results does the nurse report to the health care provider? (Select all that apply.) 1. Positive nitrates in the urinalysis of a client receiving chemotherapy. 2. An activated partial thromboplastin (aPTT) level of 78 seconds in a client receiving an IV heparin infusion. 3. A blood urea nitrogen (BUN) level of 68 mg/dL (24.3 mmol/L) in a client diagnosed with kidney failure receiving hemodialysis. 4. A blood glucose level of 140 mg/dL (7.77 mmol/L) in a client diagnosed with diabetes mellitus receiving IV methylprednisolone. 5. A serum potassium level of 3.3 mEq/dL (3.3 mmol/L) in a client receiving IV antibiotics.

1. Positive nitrates in the urinalysis of a client receiving chemotherapy. CORRECT - The presence of nitrates indicates an infection caused by E. coli. Since the client is receiving chemotherapy, the client is at risk for myelosuppression. 2. An activated partial thromboplastin (aPTT) level of 78 seconds in a client receiving an IV heparin infusion. INCORRECT - The aPTT is normally 25 to 39 seconds. Since the client is receiving an infusion of heparin, the level of 78 seconds is within the therapeutic range. 3. A blood urea nitrogen (BUN) level of 68 mg/dL (24.3 mmol/L) in a client diagnosed with kidney failure receiving hemodialysis. INCORRECT - A BUN level of 68 mg/dL (24.3 mmol/L) is abnormal, but is expected for a client diagnosed with end-stage kidney disease. 4. A blood glucose level of 140 mg/dL (7.77 mmol/L) in a client diagnosed with diabetes mellitus receiving IV methylprednisolone. CORRECT - Corticosteroids may cause hyperglycemia. Special care should be used in treating clients diagnosed with diabetes mellitus. 5. A serum potassium level of 3.3 mEq/dL (3.3 mmol/L) in a client receiving IV antibiotics. CORRECT - Antibiotics can destroy the normal flora of the gastrointestinal tract leading to diarrhea and the excretion of potassium. The level of 3.3 mEq/dL (3.3 mmol/L) is below normal and indicates a potassium loss.

The nurse provides care for a client receiving chemotherapy. The medication is an alkylating agent. Which actions will the nurse implement to minimize adverse effects? (Select all that apply.) 1. Prevent ileus formation by encouraging frequent ambulation. 2. Administer anti-emetics prophylactically and as needed. 3. Offer frequent high fat meals to prevent weight loss. 4. Teach client to use saline mouth rinse before and after meals. 5. Encourage client to increase fluid intake for the next 3 days. 6. Educate client about the benefits of exercise to manage fatigue.

1. Prevent ileus formation by encouraging frequent ambulation. INCORRECT- Ileus formation is not a common side effect of chemotherapeutic medications. 2. Administer anti-emetics prophylactically and as needed. CORRECT - Nausea and vomiting are common and should be prevented if possible. 3. Offer frequent high fat meals to prevent weight loss. INCORRECT- A high protein, nutrient-dense, high calorie diet is recommended to prevent weight loss. Clients should not choose high fat items solely for their fat content, unless the items also contain necessary nutrients, such as the calcium found in ice cream. 4. Teach client to use saline mouth rinse before and after meals. CORRECT - Stomatitis is a common adverse effect of chemotherapy, and it may be prevented or minimized with meticulous oral care. Salt water, usually mixed with baking soda, is used to rinse the mouth after every meal as a way to reduce particles and reduce oral acidity. 5. Encourage client to increase fluid intake for the next 3 days. CORRECT - Cystitis occurs with many chemotherapeutic agents and may be prevented with increased fluid intake. 6. Educate client about the benefits of exercise to manage fatigue. CORRECT - Mild to moderate exercise, along with frequent rest periods, will help to manage the fatigue often experienced during chemotherapy. Think like a nurse: Chemotherapy with alkylating agents can be particularly caustic to the body's mucous membranes. Stomatitis can be minimized by a saline mouthwash. Urinary tract irritation can be reduced by ingesting more fluid. Since chemotherapy can irritate the gastrointestinal tract and cause nausea and vomiting, anti-emetic medications are recommended. Mild to moderate exercise while receiving chemotherapy helps reduce fatigue and enhance general well being.

The employee-health nurse encourages all employees to use a newly opened physical exercise and wellness area in the workplace. Which level of health promotion is the nurse demonstrating in this situation? 1. Primary prevention. 2. Secondary prevention. 3. Tertiary prevention. 4. Passive prevention.

1. Primary prevention. - This type of prevention works to precede disease and alter unhealthy behaviors. Think like a nurse: One role of the nurse is to provide health promotion and disease prevention teaching. Prior to this teaching, the nurse should recall the different levels of prevention. Primary prevention includes activities to prevent the development of disease. This would include making lifestyle adjustments such as increasing daily exercise. Secondary prevention includes activities to detect and then treat disease. Tertiary prevention includes activities to recover from disease. In this scenario, the nurse is endorsing the use of exercise facilities as a primary prevention action.

A neonate is born with a myelomeningocele. In which position will the nurse place this client? 1. Prone with the face turned to one side. 2. Sitting upright in an infant seat. 3. Supine with the head of the crib elevated. 4. Left side-lying with a pillow behind the back.

1. Prone with the face turned to one side. — For a client with a myelomeningocele, the prone position prevents pressure on the sac-like protrusion on the back. Placing pressure on this area would result in increased intracranial pressure or it may rupture the sac, leading to an infection. The area should be covered with a moist sterile dressing. Think like a nurse: The spinal cord is normally protected by surrounding bone, which prevents spinal cord injury. In the case of myelomeningocele, the client is at risk for exposure of the spinal cord, which is protected only by a thin, fragile membrane. For the neonate diagnosed with myelomeningocele, key interventions are aimed at preventing irritation and damage of the sac that contains the spinal cord. Impaired integrity of the sac may lead to cerebrospinal fluid leakage, which requires emergent surgical intervention. Complications related to exposure of the spinal cord to a nonsterile environment include infection and death.

The nurse develops a teaching plan regarding nutrition for a pregnant client. Which information is appropriate for the nurse to include in the plan? 1. Protein requirements will triple during pregnancy. 2. Energy requirements will increase by 1200 calories/day. 3. Iron requirements will double during pregnancy. 4. Sodium should be restricted to 2 g/day.

1. Protein requirements will triple during pregnancy. INCORRECT - Added protein is needed for metabolism and to support the growth and repair of maternal and fetal tissues. An intake of 60 g/day is recommended during pregnancy, which is not a triple increase. 2. Energy requirements will increase by 1200 calories/day. INCORRECT - A calorie increase of about 300 kcal/day is recommended to provide for the growth of the fetus, the placenta, amniotic fluid, and the maternal tissues. 3. Iron requirements will double during pregnancy. CORRECT - The Dietary Reference Intakes (DRI) for iron is 15 mg/day for nonpregnant adult women and 30 mg/day for pregnant women. It is difficult to obtain this much iron from the diet alone, and most health care providers prescribe iron supplements of 30 mg/day beginning in the second trimester, after morning sickness decreases. 4. Sodium should be restricted to 2 g/day. INCORRECT - Sodium intake is essential for maintaining normal sodium levels in plasma, bone, brain, and muscle, because both tissue and fluid expand during the prenatal period. Sodium should not be restricted during pregnancy.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Generalized edema 5. Increased pulse rate 6. Increased respiratory rate.

1. Proteinuria 2. Hypertension - Generalized edema can occur, but is not included as a classic sign because it can occur in many conditions.

The nurse assesses a client with a colostomy. Which stomal appearance indicates a prolapse has occurred? 1. Protruding. 2. Narrowed and flattened. 3. Sunken and inverted. 4. Dark, bluish colored.

1. Protruding. - A prolapsed stoma is protruding and indicates that the bowel is protruding through the stoma. Think like a nurse: When preparing to care for a client with a colostomy, the nurse should mentally ask, "What characteristics are expected when assessing the stoma?" A normal stoma is nearly flush with the abdominal skin and is pink to beefy red in color. The skin around the site should be intact. The nurse identifies evidence of a problem if a portion of the colon can be seen protruding through the stoma. This is called a prolapse and must be immediately reported to the health care provider for evaluation and intervention.

The nurse provides care for the family of a client who died 30 minutes ago. Which action is most important for the nurse to take? 1. Provide a private place for family members. 2. Explain to the family that the client is now in heaven. 3. Notify the family members individually. 4. Prevent the family from spending time with the client.

1. Provide a private place for family members. — This provides a private place to grieve. This shows compassion and understanding by the nurse. Think like a nurse: The nurse needs to recognize the family needs because the client's death just occurred. The family needs a private place to grieve if the client is in a room with another client. The nurse needs to carefully assess the needs of both clients assigned to the room. Being present during a death and family grieving can cause unnecessary stress for a roommate, and the roommate may not be able to safely leave the room. If the client is in a private room or the roommate is out of the room for a diagnostic test or other reason, the family can stay at the bedside to begin the grieving process. This is the best approach to support the family during this difficult time.

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply 1. Provide a soft diet. 2. Position the child on the left side. 3. Administer an antihistamine twice daily. 4. Irrigate the right ear with normal saline every 8 hours. 5. Administer IBU for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

1. Provide a soft diet. 5. Administer IBU for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy. - The child is placed on their effected side to promote draining and their associated fever should be treated with IBU.

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply. 1. Providing a low-fat, well-balanced diet. 2. Teaching the child effective hand-washing techniques. 3. Scheduling playtime in the playroom with other children. 4. Notifying the HCP if jaundice is present. 5. Instructing parents to avoid administering medications unless they are prescribed. 6. Arranging for indefinite home schooling because the child will not be able to return to school.

1. Providing a low-fat, well-balanced diet. 2. Teaching the child effective hand-washing techniques. 5. Instructing parents to avoid administering medications unless they are prescribed. - The child should be discouraged from sharing toys due to the potential viral cause of hepatitis, so playtime in the playroom with other children would not be part of the care plan. A child can return to school 1 week after the onset of jaundice.

The nurse conducts a class for clients in their first trimester of pregnancy. Which information is appropriate for the nurse to include? (Select all that apply.) 1. Quickening should occur around 16 to 20 weeks' gestation. 2. The fundal height is the measurement from the top of the symphysis pubis to the top of the fundus. 3. Toddlers should be informed of the mother's pregnancy early on in the pregnancy. 4. Expected weight gain is 10 to 15 lb (4.5 kg to 6.8 kg) in the first trimester. 5. Nausea usually ends by 14 to 16 weeks.

1. Quickening should occur around 16 to 20 weeks' gestation. CORRECT— Quickening should occur around 16 to 20 weeks' gestation. 2. The fundal height is the measurement from the top of the symphysis pubis to the top of the fundus. CORRECT— The fundal height is measured from the top of the symphysis pubis, over the abdominal curve, to the top of the fundus. 3. Toddlers should be informed of the mother's pregnancy early on in the pregnancy. INCORRECT - Since toddlers have little perception of time, many parents delay telling them that a baby is expected until shortly before the birth. 4. Expected weight gain is 10 to 15 lb (4.5 kg to 6.8 kg) in the first trimester. INCORRECT - Pregnant clients should not gain much weight in the first trimester. The majority of weight gain should occur in the second and third trimesters, at approximately 1 lb (0.4 kg) per week. For a client whose pre-pregnancy body mass index fell within normal limits, the total weight gain in pregnancy should only be 25 to 35 lb (11.3 kg to 15.9 kg). 5. Nausea usually ends by 14 to 16 weeks. CORRECT— Nausea usually ends by 14 to 16 weeks' gestation.

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

1. Radiation 2. Chemotherapy 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone - The syndrome is managed by treating the condition/cause and usually indicates fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonisitic to antidiuretic hormone.

The nurse screens clients at a health fair for vitamin B 12 deficiency. Which clients will the nurse determine as needing vitamin B 12 supplementation? (Select all that apply.) 1. Recently diagnosed with pernicious anemia. 2. Treated for acute lymphocytic leukemia. 3. Follows a strict vegan diet. 4. Takes medication for gastroesophageal reflux disease. 5. Takes metformin (Glumetza) for type 2 diabetes mellitus. 6. Had a gastrectomy 2 years ago.

1. Recently diagnosed with pernicious anemia. 3. Follows a strict vegan diet. 5. Takes metformin (Glumetza) for type 2 diabetes mellitus. 6. Had a gastrectomy 2 years ago.

The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate? Select all that apply. 1. Record: site, date and time if the test 2. Give the client a list of potential allergens if identified 3. Estimate the size of a wheal and document the finding 4. Tell the client to return to have the site inspected only if there is a reaction 5. Have the client remain in the waiting room for at least 1-2 hours after injection

1. Record: site, date and time if the test 2. Give the client a list of potential allergens if identified - Skin testing involves administration of an allergen to the surface of the skin or the dermis. Site, date and time of the test must be recorded, the client must return at a specific date and time for a follow-up evaluation, even if no reaction is suspected; a list of potential allergens is identified, the size of the site being evaluated has to be measured, not estimated and after injection, clients only need to be monitored for 30 minutes to assess for adverse effects.

The nurse provides care to clients in a skilled nursing facility. Which client requires the nurse's immediate attention? 1. Recovering from a cerebral vascular accident whose prescription for warfarin expired two days ago. 2. Experiencing pain after receiving morphine in an acute care facility and was transferred with a prescription for acetaminophen with codeine. 3. Voiding foul-smelling, cloudy, dark amber urine associated with dysuria. 4. Needing influenza immunization because of immunosuppression.

1. Recovering from a cerebral vascular accident whose prescription for warfarin expired two days ago. - The duration of warfarin therapy for the client recovering from a cerebral vascular (CVA) accident is 2 to 5 days. This client is at risk for another CVA and should be assessed first. Think like a nurse: Warfarin is routinely prescribed as a treatment for ischemic/embolic stroke. Failure to take warfarin can result in new clot formation and place the client at risk for experiencing another stroke. This is a circulatory issue and should be assessed first. The client experiencing pain when voiding foul-smelling, cloudy, dark amber urine most likely has a urinary tract infection and should be assessed second. This is a physical need, but not a circulatory need.

The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which actions will the nurse implement when providing care to this client? (Select all that apply.) 1. Remove the newborn's eye patches during feedings. 2. Place the newborn 15 cm (6 in) below the phototherapy lights. 3. Reposition the newborn every 4 hours. 4. Cover the newborn with light cotton clothing. 5. Cluster activities when caring for the newborn.

1. Remove the newborn's eye patches during feedings. CORRECT — The nurse should place eye patches over the newborn's eyes to prevent retinal damage, but should remove them at least every 2 to 3 hours to assess the skin and to promote stimulation and bonding with parents during feedings. 2. Place the newborn 15 cm (6 in) below the phototherapy lights. INCORRECT - The newborn should be placed about 30 to 40 cm (12 to 16 in) below the bank of phototherapy lights to prevent injury to the skin. 3. Reposition the newborn every 4 hours. INCORRECT - The nurse should reposition the newborn at least every 2 hours to provide stimulation, maximize skin exposure to the lights, and prevent skin breakdown. 4. Cover the newborn with light cotton clothing. INCORRECT - The nurse should dress the newborn only in a diaper to maximize skin exposure to the lights. 5. Cluster activities when caring for the newborn. CORRECT — When performing care for the newborn, the nurse should cluster care to ensure the newborn obtains maximum exposure to the lights.

The client reports, "I can't get warm. I'm cold all the time" to the nurse. The client's spouse reports recent behavior changes and forgetfulness. The client is unsure when daily medications were taken last. The nurse notes the client has periorbital edema and a flat affect. Vital signs reveal T 95.6°F (35.3°C); BP 100/60 mm Hg; pulse 58 beats/min; respirations 26 breaths/min. Laboratory data reveal serum pH 7.25; PaCO2 50 mm Hg; HCO3 23 mEq/L; serum T4 is 4.2 mcg/dL; serum TSH 6.3 mcg/dL. Which action does the nurse take when providing client care? (Select all that apply.) 1. Reorient client every 15 minutes. 2. Administer oral levothyroxine sodium. 3. Administer intravenous (IV) hydrocortisone. 4. Obtain a stat 12-lead electrocardiogram (ECG). 5. Place client on continuous cardiopulmonary monitoring.

1. Reorient client every 15 minutes. INCORRECT — The client is conscious and alert, so reorienting doesn't apply at this time. 2. Administer oral levothyroxine sodium. CORRECT— The client has advanced hypothyroidism. The initial and least invasive treatment to prevent myxedema coma is oral T4 replacement therapy. 3. Administer intravenous (IV) hydrocortisone. INCORRECT — IV hydrocortisone is administered when a client is unconscious or unable to swallow. This client is conscious. 4. Obtain a stat 12-lead electrocardiogram (ECG). INCORRECT — A stat 12-lead ECG is obtained immediately after acute cardiac changes or symptoms of acute coronary syndrome are identified (e.g., ST elevation, reports of chest pain), and then typically after pharmacologic treatment is initiated. 5. Place client on continuous cardiopulmonary monitoring. CORRECT— The client is at risk for acute cardiopulmonary changes. The continuous monitoring captures acute changes in cardiac rhythm and oxygenation (O2 sat). Blood pressure can be monitored in time intervals, usually every 5 to 15 minutes, and provides real-time data for emergent response.

The nurse teaches a client who is prescribed prednisone for systemic lupus erythematosus (SLE). Which information related to prednisone does the nurse include in the teaching plan? (Select all that apply.) 1. Report any symptoms of infection. 2. Do not discontinue medication abruptly. 3. Take medication at bedtime. 4. Report unusual weight gain. 5. Get vaccinated for influenza. 6. Avoid salt substitutes.

1. Report any symptoms of infection. CORRECT— Prednisone causes immunosuppression, and symptoms of infection should be reported. 2. Do not discontinue medication abruptly. CORRECT — Discontinuing prednisone abruptly can cause adrenal crisis. 3. Take medication at bedtime. INCORRECT - Prednisone should be taken before 0900 to mimic normal peak of corticosteroid blood levels. It seems to help avoid sleep disturbance that can occur with the drug. 4. Report unusual weight gain. CORRECT — Prednisone is associated with fluid retention and weight gain in most clients. 5. Get vaccinated for influenza. INCORRECT - Vaccinations are to be avoided when taking prednisone because of the decreased ability to mount an inflammatory response. 6. Avoid salt substitutes. INCORRECT - Salt substitutes contain potassium that may help prevent the potential for hypokalemia that may be caused by prednisone.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation. 2. Respiratory alkalosis from anxiety and hyperventilation. 3. Metabolic acidosis from calcium loss due to broken bones. 4. Metabolic alkalosis from taking analgesics containing base products.

1. Respiratory acidosis from inadequate ventilation. - Hypoventilation results in respiratory acidosis.

The nurse is reviewing a health care providers prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Restrict fluid intake. 2. Position for comfort. 3. Avoid strain on painful joints. 4. Apply 2L of oxygen via nasal cannula. 5. Provide a high calorie, high protein diet. 6. Give meperidine, 25 mg intravenously, very 4 hours for pain.

1. Restrict fluid intake. 6. Give meperidine, 25 mg intravenously, very 4 hours for pain. - Oral and IV fluids are important for treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures.

The nurse notes that a prescription for parenteral nutrition, which a client has been receiving for 2 weeks, is discontinued. Which type of intravenous fluid does the nurse expect to be prescribed for this client? 1. Ringer lactate. 2. 0.9% sodium chloride. 3. 10% dextrose in water. 4. 0.45% sodium chloride.

1. Ringer lactate INCORRECT - Ringer lactate is an isotonic solution. It is effective as a volume expander 2. 0.9% sodium chloride INCORRECT - Sodium chloride 0.9% is an isotonic solution. This solution is used for fluid replacement and to increase plasma volume 3. 10% dextrose in water CORRECT— Dextrose 10% in water is a hypertonic solution that is similar to the parenteral nutrition solution. This solution is used to wean the client from parenteral nutrition 4. 0.45% sodium chloride INCORRECT - Sodium chloride 0.45% is a hypotonic solution. This solution is not effective when weaning a client from parenteral nutrition

A client must follow a high-protein, low-sodium, and low-potassium diet. Which menu selections by the client require follow-up teaching by the nurse? (Select all that apply.) 1. Roast beef sandwich, coleslaw, and baked beans. 2. Broiled chicken breast, spinach salad, and green beans. 3. Poached salmon fillet, broiled cabbage, and lemonade. 4. Steel cut oatmeal with brown sugar, fresh blueberries, and black coffee. 5. Grilled chicken Caesar salad and whole grain roll with iced tea.

1. Roast beef sandwich, coleslaw, and baked beans. CORRECT — Although this meal selection is high in protein, the coleslaw and baked beans are high in sodium. 2. Broiled chicken breast, spinach salad, and green beans. CORRECT — Although this meal selection is high in protein, the spinach is high in potassium. 3. Poached salmon fillet, broiled cabbage, and lemonade. CORRECT — The salmon is high in potassium. 4. Steel cut oatmeal with brown sugar, fresh blueberries, and black coffee. INCORRECT— This is appropriate for the dietary restrictions. 5. Grilled chicken Caesar salad and whole grain roll with iced tea. CORRECT — Caesar salad is high in sodium and potassium.

During a home visit, the nurse observes a client self-administer an isophane insulin injection. Which observation indicates to the nurse that the client administered the medication correctly? 1. Rotates the vial between the hands for 1 minute. 2. Shakes each vial for a minimum of 1 minute. 3. Discards a vial of insulin due to cloudiness. 4. Removes vials from the refrigerator for 30 minutes.

1. Rotates the vial between the hands for 1 minute CORRECT— Rotating the medication vials mixes the modified insulin preparations. 2. Shakes each vial for a minimum of 1 minute INCORRECT - Shaking the medication vials causes bubbles and foam, which can alter the dose. 3. Discards a vial of insulin due to cloudiness INCORRECT - Lente, protamine zinc insulin, and isophane insulin are supposed to be cloudy. 4. Removes vials from the refrigerator for 30 minutes INCORRECT - Insulin does not have to be refrigerated. It should be stored in a cool place.

The nurse provides care for a client who underwent a supratentorial craniotomy to remove a brain tumor. In which position can the nurse safely place the client? (Select all that apply.) 1. Semi-Fowler position. 2. Left-lateral position. 3. Head midline. 4. Neck flexed. 5. Minimal hip flexion.

1. Semi-Fowler position. — Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. 3. Head midline. — The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. 5. Minimal hip flexion. — The client is positioned to avoid extreme bending of the hip.

A parent of a 3-year-old tells a clinic nurse that their child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions should the nurse provide to the parent? Select all that apply. 1. Set limits on the child's behavior 2. Ignore the child when the behavior occurs. 3. Allow the behavior, because this is normal at this age period. 4. Provide a simple explanation of why the behavior is unacceptable. 5. Punish the child everytime the child says "no," to change their behavior.

1. Set limits on the child's behavior 4. Provide a simple explanation of why the behavior is unacceptable. - Gaining independence between ages 1-3 years of age means that the child has to rebel against the parents wishes, saying things like "no" and "mine" and having temper tantrums. But, being consistent and setting limits on the child's behavior are necessary elements. Options 2 & 3 do not address the child's behavior. Option 5 is likely to produce a negative response.

The nurse provides care to a client who is being prepared to receive an epidural patch for a postlumbar puncture headache. In which position will the nurse place the client? 1. Side-lying position. 2. Dorsal recumbent position. 3. Lithotomy position. 4. Upright position.

1. Side-lying position. — The client should be in the side-lying position for epidural patch placement. This position allows the health care provider access to the region for the procedure. Think like a nurse: The nurse is responsible for client placement during medical procedures. Placing an epidural patch requires the same positioning as the lumbar puncture because the health care provider has to be able to access the intervertebral spaces adequately and safely. After a lumbar puncture, there may be one or more holes in the dura mater, allowing cerebrospinal fluid (CSF) to leak out of the space. The client 's blood is removed and placed over the hole, sealing it closed, restoring normal CSF pressure, and correcting the headache.

The nurse instructs a client on the newly prescribed medication imipramine. Which symptoms will the nurse teach the client to report immediately to the health care provider? 1. Sore throat, fever, increased fatigue, vomiting, diarrhea. 2. Dry mouth, nasal stuffiness, weight gain. 3. Rapid heartbeat, frequent headaches, yellowing of eyes or skin. 4. Weakness, staggering gait, tremor, feelings of drunkenness.

1. Sore throat, fever, increased fatigue, vomiting, diarrhea. - Sore throat, fever, increased fatigue, vomiting, and diarrhea are possible adverse effects of imipramine, a tricyclic antidepressant medication. These side effects can be resolved by altering the dosage or changing the medication. Think like a nurse: Imipramine is a tricyclic antidepressant that can cause the adverse effects of sore throat, fever, fatigue, vomiting, and diarrhea. A dosage or medication change may be indicated if these effects occur. Dry mouth, nasal stuffiness, and weight gain are side effects of the medication, but do not require a medication or dosage change to manage. The other symptoms are not identified as adverse effects of imipramine.

The nurse provides care to a client with suspected influenza. To promote infection control, the nurse ensures implementation of which precautions? (Select all that apply.) 1. Standard precautions. 2. Neutropenic precautions. 3. Contact precautions. 4. Droplet precautions. 5. Airborne precautions.

1. Standard precautions. - Standard precautions, the first line of infection control, are used during the provision of care to all clients, regardless of the source of infection. Second line precautions (such as airborne, droplet, and contact) are initiated as transmission-based precautions, based on the infectious agent. 4. Droplet precautions. - Droplet precautions are required for clients with infections, such as influenza or meningococcus, to prevent transmission of infected respiratory or pharyngeal secretions. Think like a nurse: One of the nurse's roles is to implement safety and infection control when providing client care. An action to ensure that both client and care provider are protected is the use of standard precautions, these precautions are those used by all care providers for all clients regardless of diagnosis. However, in the event of an illness that can be spread via droplets, the nurse may need to add additional precautions. In this scenario the client has influenza, which is a viral infection spread through respiratory secretions. It is appropriate to implement standard and droplet precautions when caring for this client.

The nurse delegates tasks to an unlicensed assistive personnel (UAP) for the first time. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. State to the UAP how to report task completion. 2. Describe to the UAP which tasks will be delegated. 3. Allow the UAP to decide which client changes to report. 4. Permit the UAP to decide when tasks will be completed. 5. Describe to the UAP the expected task outcomes.

1. State to the UAP how to report task completion. — This is an important step when delegating tasks to the UAP. 2. Describe to the UAP which tasks will be delegated. — This is an important step when delegating tasks to the UAP. 5. Describe to the UAP the expected task outcomes. — This is an important step when delegating tasks to the UAP. Think like a nurse: The five rights of delegation include the right task, right circumstance, right person, right direction/communication, and right supervision. The nurse is expected to provide a hand-off to the unlicensed assistive personnel (UAP) at the beginning of the shift. This is an opportunity for the nurse to verify the UAP's experience with tasks being delegated. It is important for the nurse to be familiar with the local institutional policy and state regulations related to delegation. Matching staff skill to client and family needs highlights the difference between delegation and assignment.

The nurse provides care for a newborn who passed meconium stool in utero. The newborn's respiratory rate is 32 breaths/min, heart rate is 114 beats/min, and good muscle tone is present immediately after delivery. Which action is most important for the nurse to take? 1. Suction newborn's mouth and nose with a bulb syringe. 2. Assist the newborn's respiratory effort with a resuscitation bag. 3. Dry and wrap the newborn in warm blankets. 4. Request the health care provider suction the newborn's trachea.

1. Suction newborn's mouth and nose with a bulb syringe. — Maintaining a patent airway is a priority for the newborn with potential for aspiration. Think like a nurse: Upon delivery, one of the greatest challenges of the newborn is adjusting to extrauterine life. At times though, the fetus may be stressed and begin to make these adjustments before delivery. One indication of in utero stress is the fetus passing the first stool before delivery. Should this occur, the fecal material can easily be aspirated by the fetus. Upon delivery, the primary action is to assure the patency of the newborn's airway by suctioning all material from the nose and mouth. The newborn's respirations should be closely assessed and preparations made for emergency resuscitation if necessary.

A client is placed on NPO status because of an esophageal mass. A family member gives the client juice, which is vomited immediately. Which are appropriate nursing actions? (Select all that apply.) 1. Suction the client 's mouth with an oral suction. 2. Elevate the head of the bed to 45 degrees. 3. Notify the health care provider immediately. 4. Auscultate the client 's breath sounds frequently. 5. Draw blood for arterial blood gas assessments.

1. Suction the client 's mouth with an oral suction. — This is an appropriate nursing action. Suctioning with oral suction can clear secretions and vomitus from the mouth, decreasing the risk of aspiration or reducing the amount of aspirate. 2. Elevate the head of the bed to 45 degrees. — This is an appropriate nursing action. Elevating the head of the bed 30 to 45 degrees or higher can prevent or reduce aspiration that can occur with vomiting. 3. Notify the health care provider immediately. — Once the nurse has implemented bedside interventions and performed a focused assessment, the health care provider should be informed that the client may have aspirated juice, vomitus, or both. 4. Auscultate the client 's breath sounds frequently. — This is an appropriate nursing action. Adventitious sounds may indicate aspiration of food/vomitus. Think like a nurse: Symptoms of esophageal cancer often include dysphagia, which indicates esophageal occlusion. In many cases, by the time of diagnosis, the esophageal tumor is large. Regurgitation of a thin liquid is a sign of a complete esophageal obstruction. The client who experiences any degree of esophageal obstruction is at high risk for aspiration, which may lead to airway obstruction, pneumonia, and other serious consequences. In the event of known or suspected aspiration, priorities of care include ensuring airway patency and adequate breathing. After implementation of priority interventions, the health care provider should be promptly notified of the client 's status. Instruct family and visitors to refrain from offering the client food or drink until further diagnostics can be performed.

An unlicensed assistive personnel (UAP) was injured in an automobile accident. After rehabilitation, the UAP walks with a limp and a slow, unstable gait. The UAP returns to work on an acute care surgical unit. Which action by the nurse manager is best? 1. Survey other units for more suitable positions for the UAP. 2. Recommend the UAP apply for disability benefits. 3. Transfer the UAP to a less demanding shift on the unit. 4. Transfer a portion of the UAP's duties to other staff.

1. Survey other units for more suitable positions for the UAP. - The American Disability Act (ADA) recommends that the UAP be offered a position that is appropriate. The manager could first evaluate the care the UAP is able to provide before offering reassignment. Think like a nurse: The nurse manager should first assess the staff member's abilities and then discuss possible assignments with Human Resources. The the possible assignment changes can then be presented to the UAP for discussion and selection. The nurse manager needs to be aware of safety issues for both the clients and the UAP.

The nurse provides care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) and cutaneous Kaposi sarcoma. Which assessment confirms this new diagnosis? 1. Swelling in the legs. 2. Reddish blue lesions all over the skin. 3. Swelling in the genital area. 4. Punch biopsy of the cutaneous lesions.

1. Swelling in the legs. INCORRECT — The late disease progresses to this enlargement of the lower extremities. 2. Reddish blue lesions all over the skin. INCORRECT — This condition begins as the macules described on the lower legs that then change into plaques that open and drain. 3. Swelling in the genital area. INCORRECT — The late disease can progress to swelling of the penis and scrotum. 4. Punch biopsy of the cutaneous lesions. CORRECT — A punch biopsy is the procedure by which a definitive diagnosis is made. Think like a nurse: The client who is positive for human immunodeficiency virus (HIV) is at risk for developing acquired immune deficiency syndrome (AIDS). The nurse should mentally review the pathophysiological process of AIDS and the types of opportunistic infections that can develop. The nurse is aware the client with AIDS has a compromised immune system that is unable to prevent specific diseases from occurring. One such disease is Kaposi sarcoma, which can only be diagnosed definitively by a biopsy of a lesion. Other symptoms may develop as the disease progresses.

A client who developed acute respiratory distress syndrome (ARDS) after a motor vehicle crash (MVC) is being weaned from the ventilator. Which ventilator mode will the nurse utilize to wean the client? 1. Synchronized intermittent mandatory ventilation (SIMV). 2. Controlled ventilation. 3. Assist-control ventilation. 4. Positive end expiratory pressure (PEEP).

1. Synchronized intermittent mandatory ventilation (SIMV) CORRECT— This ventilator mode allows for spontaneous breaths at the client's own rate and tidal volume between ventilator breaths. This mode facilitates weaning. 2. Controlled ventilation INCORRECT — This mode delivers a set volume at a set rate. It does not allow client-initiated respirations and should not be used for weaning. 3. Assist-control ventilation INCORRECT — Assist-control ventilation allows for a variable rate, but the tidal volume is preset so that each breath is delivered at a set volume regardless of the client's needs. This is not the best mode for weaning. 4. Positive end expiratory pressure (PEEP) INCORRECT — PEEP delivers positive pressure during expiration to keep airways constantly open and used with seriously ill clients. However, it is not the best mode to use while weaning, as it does not allow clients to maintain their own airway.

The nurse assesses a client who had a thyroidectomy eight hours ago. The nurse notes that the client has a weak voice and hoarseness. Which is the best action from the nurse? 1. Tell the client this is likely due to edema. 2. Administer intravenous calcium gluconate. 3. Notify the health care provider immediately. 4. Monitor the client for esophageal bleeding.

1. Tell the client this is likely due to edema. - Initial hoarseness after a thryoidectomy often occurs as a result of edema or use of an endotracheal tube during surgery and will subside. Persistent hoarseness may be indicative of a laryngeal nerve injury. Think like a nurse. The nurse is aware the client having a thyroidectomy will have an incision across the front of the throat in order to have the gland removed. The position of the body during the surgery and the use of a breathing tube can cause the throat to be irritated. The nurse needs to reassure the client recovering from a thyroidectomy that throat soreness is expected and a temporary manifestation. The nurse understands the importance of closely monitoring the client for actual complications, which include bleeding, thyroid storm, and hypocalcemia. During surgery, the parathyroid glands can accidentally be damaged (resulting in hypocalcemia), and after surgery, a thyroid storm can occur if remnants of thyroid tissue are left behind.

The nurse provides care for a client who had a hypophysectomy. The nurse observes clear drainage coming from the client's nostril. Which action does the nurse take immediately? 1. Test the drainage for glucose. 2. Document the drainage. 3. Lower the head of the bed. 4. Obtain a culture of the drainage.

1. Test the drainage for glucose. — A possible complication of a hypophysectomy is a cerebrospinal fluid (CSF) leak. CSF contains glucose. This test will determine if the drainage is CSF. Think like a nurse: If a cerebral spinal fluid (CFS) leak is suspected, the nurse can simply test the drainage for sugar content (CSF has a high glucose content). The nurse should also conduct a thorough neurological assessment. The nurse may also assess for the "halo" sign of the suspected CSF leak. The halo sign is a classic image traditionally taught as a method for determining whether bloody discharge from the ears or nose contains CSF. If there is CSF leak, a "double-ring" appearance on the gauze used to dab the drainage is observed. The nurse anticipates sending the client with CSF leak for a CT of the head. The nurse understands that a CSF leak puts the client at risk for infection, a serious complication following surgery on the brain.

The nurse assists in the care provided by the LPN/LVN for client who had a mastectomy. The client has a wound drainage evacuator in place. Which observation concerns the nurse? 1. The LPN/LVN secures the drainage evacuator to the client's gown without applying tension on the drainage tubing. 2. The LPN/LVN fully compresses the drainage evacuator with one hand, while replacing the spout plug with the other hand. 3. The LPN/LVN uses an alcohol wipe to clean the drainage evacuator's spout and plug prior to reestablishing the vacuum. 4. The LPN/LVN releases manual pressure on the drainage evacuator after the plug is in place, and the unit rapidly inflates.

1. The LPN/LVN secures the drainage evacuator to the client's gown without applying tension on the drainage tubing. INCORRECT - This is an appropriate action. The unit should be fastened to the client's gown. Tension should not be applied to tubing because it can cause dislodgment. 2. The LPN/LVN fully compresses the drainage evacuator with one hand, while replacing the spout plug with the other hand. INCORRECT - This is an appropriate action. After emptying the drain, the goal is to reestablish a negative pressure vacuum that creates suction. 3. The LPN/LVN uses an alcohol wipe to clean the drainage evacuator's spout and plug prior to reestablishing the vacuum. INCORRECT - This is an appropriate action to decrease the risk for infection. 4. The LPN/LVN releases manual pressure on the drainage evacuator after the plug is in place, and the unit rapidly inflates. CORRECT - Rapid reinflation indicates an air leak is present. If this occurs, the nurse should compress the unit again and check the plug for a secure fit. Think like a nurse: The drainage evacuator device should remain deflated after the plug is in place and manual pressure released. Should the device inflate, either the plug was not secure or the device has a leak. The nurse should compress the device again and re-secure the plug. The nurse should periodically assess and document the amount and characteristics of the drainage.

The nurse supervises the care of a client who just had a short leg cast applied. Which observations demonstrate to the nurse that care is appropriate? (Select all that apply.) 1. The cast is covered with a light sheet. 2. The staff handles the cast using the palms of the 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.

1. The cast is covered with a light sheet INCORRECT — The nurse needs to leave the cast uncovered and exposed to the air to dry. 2. The staff handles the cast using the palms of the hands. CORRECT— The use of the palms of hands by caregivers prevents the development of pressure areas under the cast. 3. The affected limb is elevated to the level of the heart. CORRECT— Elevating a cast at or above the heart promotes better circulation and decreased edema in the dependent part. 4. The nurse compares the toes of the casted leg with the opposite leg CORRECT— The nurse assesses for neurovascular functioning in the unaffected leg and compares it to the circulation, motion, and sensation in the casted extremity. 5. The staff places a fan in the client's room CORRECT— A fan increases the circulation of air in a client's room, which facilitates drying of the cast. 6. The staff turns the client every 4 hours INCORRECT — Turn the client every 2 hours (not every 4 hours) to facilitate drying the cast. Support the major joints when turning.

The nurse provides care to a client who is scheduled to undergo a craniotomy the following day. Which client data does the nurse recognize as being an indication for insertion of an indwelling urinary catheter? (Select all that apply.) 1. The client is diagnosed with severe urinary retention. 2. The client requires evaluation of residual urine volume. 3. The client is scheduled for a lengthy surgical procedure. 4. The client is at risk for developing a pressure injury. 5. The client requires strict monitoring of intake and output.

1. The client is diagnosed with severe urinary retention. CORRECT - Indications for insertion of an indwelling urinary catheter include treatment of urinary retention, as urinary retention may cause health alterations including urinary tract infection (UTI) and kidney stones. 2. The client requires evaluation of residual urine volume. INCORRECT- Measurement of residual urine is not a routine indication for insertion of an indwelling urinary catheter. Preferred approaches include using a noninvasive device, such as a bladder scanner, to estimate residual urine. 3. The client is scheduled for a lengthy surgical procedure. CORRECT - Lengthy surgical procedures performed under anesthesia may be an indication for insertion of an indwelling urinary catheter. 4. The client is at risk for developing a pressure injury. INCORRECT- Risk for developing a pressure injury is not an indication for insertion of an indwelling urinary catheter. However, an existing pressure injury that cannot be kept clean may be an indication for indwelling urinary catheter insertion. 5. The client requires strict monitoring of intake and output. CORRECT - Indications for indwelling urinary catheter include when accurate intake and output are necessary to closely monitor fluid volume status.

The nurse provides care for a client who began receiving epoetin alfa injections 10 days ago. It is most important for the nurse to report which information to the health care provider? 1. The client reports walking around the block. 2. The client's blood pressure is 130/80 mm Hg. 3. The client reports flu-like symptoms. 4. The client's hematocrit increases from 28% (0.28) to 34% (0.34).

1. The client reports walking around the block. INCORRECT - Activity tolerance indicates improvement in anemia and a positive medication outcome. Epoetin alfa is a biologic response modifier used to stimulate red blood cell production and is used to treat anemia due to chronic kidney disease, zidovudine (AZT) therapy, or chemotherapy. 2. The client's blood pressure is 130/80 mm Hg. INCORRECT - Epoetin injections are contraindicated if client has uncontrolled hypertension, so it is critical to monitor this borderline blood pressure reading. 3. The client reports flu-like symptoms. INCORRECT - The client may experience flu-like symptoms at the beginning of therapy. Adverse effects of bone marrow stimulation to produce RBCs include arthralgia. Adverse effects of the medication include nausea, edema, and a reaction at injection site. 4. The client's hematocrit increases from 28% (0.28) to 34% (0.34). CORRECT - The likelihood of hypertension and seizures increases if hematocrit increases by more than 4 points in 2 weeks. The nurse contacts the health care provider to decrease the dose or stop medication administration. Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects. The therapeutic effect of epoetin alfa is a rise in hematocrit and hemoglobin levels, indicating red blood cell production and a qualitative increase in energy and quality of life, as evidenced by increased ambulation. Adverse effects such as seizures and hypertension may result from an antigen-antibody interaction caused by epoetin alfa. A dramatic, rather than gradual, rise in hemoglobin and hematocrit levels is a sign of this adverse effect, with the potential to lead to a sentinel event.

The nurse performs an assessment of a 9-month-old client. The nurse expects which findings? (Select all that apply.) 1. The client sits unsupported. 2. The client pulls self to a standing position. 3. The client attempts to build a two-block tower. 4. The client responds to simple verbal commands. 5. The client can say three to five words. 6. The client hugs the parent on request.

1. The client sits unsupported. — This is an expected finding. A 9-month-old client can sit without support for a prolonged period of time. 2. The client pulls self to a standing position. — This is an expected finding. A 9-month-old client can also stand while holding onto furniture. 4. The client responds to simple verbal commands. — This is an expected finding. The client should comprehend "no-no, " for example. Think like a nurse: When preparing to assess a 9-month-old client, the nurse should stop and think, "What is appropriate behavior for a client of this age?" The nurse will need to apply the concepts of growth and development. The nurse should expect musculoskeletal and neurologic systems to be developed so the client can sit unassisted and stand while holding onto a piece of furniture or someone's hands. The client's comprehension of words is still underdeveloped; however, the client should be able to understand the word "no," and other simple commands. A client of this age is egocentric and will expect others to respond to his/her vocalizations.

A pediatric nurse performs a developmental age assessment on a 16-month-old client. Which finding most concerns the nurse? 1. The client stands with minimal support. 2. The client builds a tower of two cubes. 3. The client drinks liquids from a bottle. 4. The client eats by moving food with the fingers.

1. The client stands with minimal support. CORRECT - At 12 months, the client should pull to stand, cruise, and take steps without holding on. Requiring support so close to the 18-month milestone is a problem. By 18 months, the client is expected to walk. This client needs careful observation to ensure the 18-month milestone is met, that there is no neuromuscular disease or impairment, and may benefit from intervention now. 2. The client builds a tower of two cubes INCORRECT - Stacking blocks three to four high occurs around 16 months. The nurse teaches the clients to work with the child on building this skill and reassess at a later date. 3. The client drinks liquids from a bottle INCORRECT - This child should be using a cup. The nurse assesses whether the child cannot use a cup, is choosing not to use a cup, or if the parents need education. 4. The client eats by moving food with the fingers. INCORRECT - This usually occurs around 12 months. By 18 months, the client should be using utensils to attempt to eat. The nurse assesses if the parents are letting the child practice using utensils.

The antepartum nurse is planning care for several clients who are waiting to be seen for a prenatal examination. Which client does the nurse assess first? 1. The client who reports nosebleeds at 8 weeks' gestation. 2. The client who reports vulva and rectal varicosities at 16 weeks' gestation. 3. The client who reports abdominal pain at 24 weeks' gestation. 4. The client who reports leg cramps when reclining at 32 weeks' gestation.

1. The client who reports nosebleeds at 8 weeks' gestation. INCORRECT — The client may have nasal stuffiness, epistaxis (nosebleeds), and changes in the voice due to elevated progesterone levels in pregnancy. These are normal occurrences in pregnancy and not the priority to assess. 2. The client who reports vulva and rectal varicosities at 16 weeks' gestation. INCORRECT — The pressure of the enlarging uterus causes pressure on veins, resulting in development of varicosities in vulva, rectum, and legs. These are normal occurrences in pregnancy and not the priority to assess. 3. The client who reports abdominal pain at 24 weeks' gestation. CORRECT— Persistent or severe abdominal or epigastric pain could indicate ectopic pregnancy (if early), worsening preeclampsia, or abruptio placentae. This client should be assessed first. 4. The client who reports leg cramps when reclining at 32 weeks' gestation. INCORRECT — Leg cramps are common in the third trimester. Painful contraction of the muscles of the lower legs occurs most often during sleep, when the muscles are relaxed. To prevent cramps, the client should elevate the legs often during the day to improve circulation and extend the affected leg, keeping the knee straight. Bend the foot toward the body, or ask someone to assist. If alone, stand and apply pressure on the affected leg with the knee straight. These are normal occurrences in pregnancy and not the priority to assess.

The nurse in the outpatient mental health clinic develops a plan of care for a client diagnosed with bulimia. The nurse determines that which goal is most important? 1. The client will identify symptoms of electrolyte imbalance. 2. The client will maintain dental appointments and oral hygiene. 3. The client will attend appropriate community support groups. 4. The client will abstain from binge-purge behaviors.

1. The client will identify symptoms of electrolyte imbalance. - The client needs to know the life-threatening complications of illness, especially hypokalemia, so that help can be sought immediately for symptoms to prevent death. Abstaining from binging and support group attendance are ultimate long term goals, and these behaviors take time to change. The client needs to be able to seek help for life-threatening metabolic imbalances to live long enough to meet this goal.

An influx of clients arrives at an emergency department. The nurse is correct in triaging which clients as critical? (Select all that apply.) 1. The client with facial asymmetry and pulse 112 beats/min. 2. The client with chest pain and blood pressure 140/100 mm Hg. 3. The client with generalized weakness and dizziness and pulse 30 beats/min. 4. The client with copious amounts of diarrhea and blood pressure 118/72 mm Hg. 5. The client with an oxygen saturation of 79% on room air. 6. The client with confusion and blood glucose 42 mg/dL (2.33 mmol/L).

1. The client with facial asymmetry and pulse 112 beats/min. INCORRECT— This client should be triaged as emergent. The client should receive a head CT scan to rule out stroke. 2. The client with chest pain and blood pressure 140/100 mm Hg. INCORRECT— This client is high risk and should be triaged as emergent. 3. The client with generalized weakness and dizziness and pulse 30 beats/min. CORRECT— This client should be triaged as critical due to the signs and symptoms of hypoperfusion (e.g., weakness, dizziness, and bradycardia). 4. The client with copious amounts of diarrhea and blood pressure 118/72 mm Hg. INCORRECT— This client should be triaged as urgent as the blood pressure is stable and there are no signs of hypoperfusion. 5. The client with an oxygen saturation of 79% on room air. CORRECT— This client should be triaged as critical as the oxygen saturation is critically low. 6. The client with confusion and blood glucose 42 mg/dL (2.33 mmol/L). CORRECT— This client should be triaged as critical due to symptomatic hypoglycemia. This client will progress to death without intervention.

The nurse admits an older adult client who reports fever and chills to the medical unit. Which assessment finding most concerns the nurse? 1. The client's HR 120 beats/min and BP is 90/60 mm Hg. 2. The client's RR is 18 breaths/min and BP is 110/70 mm Hg. 3. The client's white blood cell count is 16000/µL (16.00×109/L). 4. The client's platelet count is 325 ×10 3/µL (325×109/L).

1. The client's HR 120 beats/min and BP is 90/60 mm Hg. — These symptoms indicate that the client is experiencing septic shock, a life-threatening condition. Immediate intervention is necessary. Think like a nurse: It is important for the nurse to assess and evaluate findings for a client who is in distress. The nurse evaluates each assessment finding to determine whether the client is unstable. While multiple assessment findings for this client are consistent with infection, a rapid heart rate and low blood pressure indicates the development of septic shock. This condition can be life-threatening, and the client needs immediate cardiovascular support and treatment to combat the infection.

A client diagnosed with emphysema arrives to the emergency department with family. The nurse notes that the client is short of breath and ashen. The client's respiratory rate is 36 breaths/min. Oxygen is started per nasal cannula at 2 L/min. Which observation most concerns the nurse? 1. The client's skin color is pink within the first 20 minutes of oxygen delivery. 2. The pulse oximetry reading is 94% on 2 L/min per nasal cannula. 3. The spouse begins to cry and says living will be difficult if client dies. 4. Blood work reveals hemoglobin 20 g/dL (200 g/L) and hematocrit 56% (0.56).

1. The client's skin color is pink within the first 20 minutes of oxygen delivery. - The COPD client 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 other 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 apneic or going into respiratory arrest. Think like a nurse: For clients without chronic respiratory illness, turning from ashen to pink is a reassuring finding. In the client with chronic obstructive pulmonary disease (COPD), this quick return of color is followed by lethargy and decreased level of consciousness, followed by significant respiratory difficulties. The nurse considers oxygen as a drug that has the potential to cause adverse effects. Supplemental oxygen for this client is titrated slowly and the nurse looks for small and continued improvement of oxygenation.

An older adult client is admitted to the hospital from a long-term care facility. The nurse establishes a nursing diagnosis of decreased fluid volume related to poor intake and fever. Which symptoms most concern the nurse? 1. The client's temperature is 102°F (38.4°C), pulse is 120 beats per minute, and blood pressure 88/54 mm Hg. 2. The client has difficulty breathing in the supine position or with minimal activity. 3. The client's skin is pale and cool to touch with pitting edema in dependent areas. 4. The client has ascites and prominent veins across the abdomen.

1. The client's temperature is 102°F (38.4°C), pulse is 120 beats per minute, and blood pressure 88/54 mm Hg. — An increased pulse rate with thready quality, decreased blood pressure, and elevated temperature indicate that the client may be experiencing hypovolemic shock related to decreased fluid volume. This is a priority concern. Think like a nurse: The nurse recognizes that a rapid heart rate and dropping blood pressure indicates low fluid volume. The client also has a fever, which is contributing to fluid losses, as well. This client needs immediate fluid replacement and diagnostic testing to determine the cause for the elevated temperature. The nurse should anticipate that the health care provider will likely order a battery of diagnostic tests, including a complete blood count (CBC), basic metabolic panel (BMP), blood cultures, and urinalysis.

The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is important for the nurse to evaluate? 1. The client's use of language. 2. The client's insight into the depression. 3. The client's socialization history and skills. 4. The client's attitude toward medications.

1. The client's use of language. - The cognitive viewpoint of 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 and writing are used to express thoughts, and thereby are indicators of the client's automatic thoughts, their schemata or cognitive structure about themselves and the world, and their cognitive distortions. Think like a nurse. The premise of cognitive therapy centers on the assumption that an individual's mood and thought patterns are directly related. Negative, dysfunctional thinking has an impact on an individual's mood, self-concept, behaviors, and physical well-being. Goals of cognitive therapy include educating an individual about identifying negative thought patterns, evaluating the validity of the thought patterns, and replacing negative thoughts with healthier patterns of thinking.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply 1. The ductus arteriosus allows blood to bypass the fetal lungs. 2. One vein carries oxygenated blood from the placenta to the fetus. 3. The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy. 4. Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta. 5. Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta.

1. The ductus arteriosus allows blood to bypass the fetal lungs. 2. One vein carries oxygenated blood from the placenta to the fetus. 4. Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta.

A 6-month-old infant is brought to the wellness clinic by parents for a routine visit. Which observation requires follow up by the nurse for evaluation of a possible developmental delay? 1. The infant cries and clings to the parent when the nurse is present. 2. The infant's weight has increased from 8 lb (3.6 kg) to 16 lb (7.3 kg) since birth. 3. The infant requires support from the parent in order to sit upright. 4. The infant abducts the extremities and fans the fingers when there is a noise.

1. The infant cries and clings to the parent when the nurse is present. INCORRECT - Crying in the presence of strangers and clinging to a parent or caregiver, which are reflective of stranger anxiety, are normal findings at 5-6 months. Stranger anxiety and associated behaviors peak at approximately 7-8 months. No follow up is needed. 2. The infant's weight has increased from 8 lb (3.6 kg) to 16 lb (7.3 kg) since birth. INCORRECT - The infant's weight typically doubles by 5-6 months. This observation is a normal finding. No follow up is indicated. 3. The infant requires support from the parent in order to sit upright. INCORRECT - To sit upright, the infant typically will require support until 7-8 months of age. Because this observation is a normal finding, follow up is not needed. 4. The infant abducts the extremities and fans the fingers when there is a noise. CORRECT— The Moro reflex, which is an involuntary startle response, is strongest during first 2 months after birth.

The nurse prepares the client for ambulatory surgery. Which procedural information is important for the nurse to provide? (Select all that apply.) 1. The methods of pain control that will be used. 2. The odors and sensations that may be experienced. 3. Explanations of common monitoring equipment. 4. Any fluid and food restrictions that will be required. 5. Technique and practice of deep breathing and coughing.

1. The methods of pain control that will be used. CORRECT - This is appropriate and can help relieve the client 's concerns. 2. The odors and sensations that may be experienced. INCORRECT - This is subjective and may increase the client 's anxiety. 3. Explanations of common monitoring equipment. INCORRECT - This information is unnecessary, unless the client specifically asks a question about it. 4. Any fluid and food restrictions that will be required. CORRECT- This is vital information to help the client avoid any anesthesia complications. 5. Technique and practice of deep breathing and coughing. CORRECT- This information is necessary to help the client prevent postoperative complications.

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1. The nurse encourages the client and family to identify and discuss feelings openly 2. The nurse assists the client and family in carrying out spiritually meaningful practices 3. The nurse removes autonomy from the client to alleviate any unnecessary stress for the client 4. The nurse makes decisions for the client and family to relive them from unnecessary demands 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger

1. The nurse encourages the client and family to identify and discuss feelings openly 2. The nurse assists the client and family in carrying out spiritually meaningful practices 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger

The nurse on the long-term care unit identifies a higher than expected incidence of impaired skin integrity among the clients. The nurse calls a staff meeting to obtain input about the problem. Which suggestion indicates that the staff member feels empowered to solve the problem? 1. The nursing assistive personnel states the facility's sheets are irritating and suggests home sheets be requested or donated by employees. 2. A practical nurse states that incontinence during the night is the main factor and suggests that fluids be restricted after the evening meal. 3. A practical nurse states that shearing force is a factor and suggests that the nursing assistive personnel be more gentle when repositioning clients. 4. The registered nurse states that clients are left sitting for too long and announces that from now on clients will be repositioned every hour.

1. The nursing assistive personnel states the facility's sheets are 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. This staff member highlighted a possible problem and proposed a potential, workable solution. Think like a nurse: The suggestion offered by the staff indicates a willingness to act. Feeling empowered is critical in nursing practice. The lack of empowerment will lead the staff to rely heavily on rigid bureaucratic structures rather than their own professional power to guide, practice, or create a solution. Although most of nursing's effort to enhance professional practice is through structural empowerment, it is also important for staff to value psychological and social empowerment.

The nurse assigns the LPN/LVN to perform a moist-to-dry dressing change on the client's 2-inch incision. Which behavior, if performed by the LPN/LVN, requires an intervention by the nurse? 1. The old dressing is saturated with sterile saline before it is removed. 2. Dry dressings are placed over the saline-moistened gauze in the incision. 3. Wound debris and necrotic tissue are removed with the old dressing. 4. The gauze is moistened with sterile saline before it is packed into the incision.

1. The old dressing is saturated with sterile saline before it is removed. - The old dressing should be removed dry so that wound debris and necrotic tissue are removed with the old dressing. The primary purpose of this dressing is to promote debridement. Think like a nurse: Wound debridement prepares the wound bed for healing by removing debris and necrotic tissue. A moist-to-dry dressing may be used for wound debridement. This method involves placing a saline-moistened dressing on the wound surface and then removing it when it dries. Removal of the dry dressing facilitates removal of the debris and necrotic tissue from the wound. When assigning a task such as wound care to an LPN/LVN, the nurse should provide supervision (as needed), evaluate the performed task, and provide feedback. In this case, the nurse should provide feedback that reinforces the proper method for performing moist-to-dry dressing changes.

The parish nurse observes children at a church picnic. Which observation concerns the nurse? 1. The spine of a 2-month-old is flexed forward and rounded when the child is held in a seated position. 2. The legs of an 18-month-old bend outward at the knees when the child stands and walks. 3. The legs of a 4-year-old touch at the knees when standing with the feet spread apart. 4. The arms of a 14-year-old appear different in length and there is a slight limp during ambulation.

1. The spine of a 2-month-old is flexed forward and rounded when the child is held in a seated position. INCORRECT - This is a normal finding. The spine is rounded or C-shaped in infants younger than 3 months of age due to the thoracic and pelvic curves. During the third and fourth months the cervical curve develops, and by 12 to 18 months the lumbar curve develops. 2. The legs of an 18-month-old bend outward at the knees when the child stands and walks. INCORRECT - This is a normal finding for a toddler. This is called genu varum and is referred to as bowleg. It is caused by lateral bowing of the tibia and lasts until all leg and lower back muscles are well developed, usually by 2 years of age. 3. The legs of a 4-year-old touch at the knees when standing with the feet spread apart. INCORRECT - This is a normal variation for a child of 2 to 7 years of age. It is called genus valgum and referred to as knock-knee. 4. The arms of a 14-year-old appear different in length and there is a slight limp during ambulation. CORRECT - This indicates scoliosis, a spinal curvature deformity that is most noticeable during the growth spurt in preadolescence.

The nurse teaches a class to pregnant clients. The nurse discusses fetal movements and positions during labor that facilitate the birth of the fetus. Which information does the nurse include? (Select all that apply.) 1. The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis. 2. The most common orientation is the transverse lie. 3. The fetal attitude is normally one of flexion. 4. The fetal head is fully flexed in the brow presentation. 5. The fetal occiput is in the left front quadrant of the mother 's pelvis.

1. The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis. - The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis. 3. The fetal attitude is normally one of flexion. - Fetal attitude is normally one of flexion with the head flexed forward and the arms and legs flexed. 5. The fetal occiput is in the left front quadrant of the mother 's pelvis. - The fetal occiput is in the left front quadrant of the mother 's pelvis, in the left occiput anterior (LOA) position. This position facilitates delivery. Think like a nurse: Prenatal classes are essential especially for first-time mothers. In addition to the nurse teaching the mother and spouse or significant other about the birthing process, the mother can be given folic acid, checked for immunity to rubella and blood type, as well as advised about smoking, drinking alcohol, and eating a healthy diet, even before the baby is conceived. Once a woman is pregnant, prenatal visits to a health care provider will include examinations to determine the health of the mother and developing fetus. Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify the client 's understanding.

The nurse provides care for a client after a thoracotomy. The client has a chest tube drainage system in place. Which observation most concerns the nurse? 1. The water in the suction control chamber bubbles constantly. 2. There is 700 mL of drainage in the collection chamber. 3. The level of the fluid in the water-seal chamber does not move. 4. There are air bubbles in the water-seal chamber when the client exhales.

1. The water in the suction control chamber bubbles constantly. INCORRECT— This is an expected finding. There should be continuous, gentle, slow but steady bubbling in the suction control chamber. 2. There is 700 mL of drainage in the collection chamber. INCORRECT— In the first 24 hours after chest surgery, as much as 500 to 1000 mL of drainage can occur. During the first two hours, 100 to 300 mL of drainage may occur followed by a progressive decline in amount. This amount of drainage may concern the nurse depending on the time frame in which is occurs. 3. The level of the fluid in the water-seal chamber does not move. CORRECT — The fluid in the water-seal chamber should fluctuate with the respirations of the client, rising with inspiration and falling with expiration. The absence of fluctuation indicates either that the lung has re-expanded (which is desired) or that there is an obstruction of the chest drainage tubes (which is not desired). The most common cause of tubing obstruction is the client lying on the tubing. Other causes are kinking, dependent loops, clots, or fibrin. 4. There are air bubbles in the water-seal chamber when the client exhales. INCORRECT— There should be bubbles in the water-seal chamber when the client exhales (on expiration phase or respiration cycle) and with coughing or sneezing. These bubbles indicate the system is removing air from the pleural space.

The home health nurse visits the home of a client diagnosed with Alzheimer disease. The client lives with an adult child and that adult child's spouse, who both insist the client stay with them for as long as possible. Which observation concerns the nurse? 1. There are extension cords secured to the walls. 2. There is an analog clock on the wall. 3. There is a blow-dryer on a hook on the bathroom wall. 4. There are door locks at the top of the doors.

1. There are extension cords secured to the walls. INCORRECT - This does not require intervention by the nurse. Secured extension cords prevent a tripping hazard in any home. Telephone and other cords should be put behind furniture and secured to the wall. 2. There is an analog clock on the wall. INCORRECT - The nurse may wish to suggest that the family caregivers install a digital clock to assist with client orientation. However, this does not pose a physical safety risk to the client. 3. There is a blow-dryer on a hook on the bathroom wall. CORRECT - The dryer itself could be hazardous to this client in terms of misperceptions of what it is (e.g., a gun) or in terms of improper use causing burns or other injuries. Having the dryer in the bathroom can increase the potential for electric shock (e.g., the client having contact with water while holding the device when it is turned on). The nurse should instruct the family caregivers to secure any devices that could pose a safety risk to the client. 4. There are door locks at the top of the doors. INCORRECT - This does not require intervention by the nurse. Wandering is a frequent behavior of clients with Alzheimer disease. By the time clients are in the middle to late stages of the disorder, they are unable to look up and reach upward. Door locks that are complex or located at the top of the door are best for these clients.

Following the formation of an ileal conduit, the nurse notes that the client's urinary drainage appliance contains pale yellow urine with large amounts of mucus. How should the nurse interpret these data? 1. These findings are normal for a client with an ileal conduit. 2. The mucus is caused by elevated levels of glucose in the urine. 3. There is irritation of the stoma. 4. The client is developing an infection of the urinary tract.

1. These findings are normal for a client with an ileal conduit. A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane. Mucus production is not a result of infection or stomal irritation. Mucus production is not a result of glycosuria. There is no reason to expect to find glucose in the client's urine.

The nurse provides care for a client diagnosed with chronic venous insufficiency. Which findings does the nurse note as being consistent with this diagnosis? (Select all that apply.) 1. Thick, dark skin on bilateral lower extremities. 2. Varicose veins in the right leg. 3. Pain in the lower extremities while sitting. 4. A tender, red area on one lower extremity. 5. Crater-like lesions on the lower extremities.

1. Thick, dark skin on bilateral lower extremities. CORRECT— Thick, dark skin on the lower extremities is consistent with the diagnosis of chronic venous insufficiency. Chronic edema causes changes in consistency and color of the skin. 2. Varicose veins in the right leg. CORRECT— Varicose veins are consistent with the diagnosis of chronic venous insufficiency. 3. Pain in the lower extremities while sitting. CORRECT— Pain in the lower extremities while sitting is consistent with the diagnosis of chronic venous insufficiency. Venous insufficiency may cause pain in dependent positions. 5. Crater-like lesions on the lower extremities. CORRECT — This finding is consistent with the diagnosis of chronic venous insufficiency. Crater-like lesions on the lower legs describes venous stasis ulcers.

The nurse provides care for a client who has a pulmonary injury. Which clinical manifestation indicates to the nurse that the client is experiencing a tension pneumothorax? 1. Tracheal deviation. 2. Hypertension. 3. Flattened neck veins. 4. Bradycardia.

1. Tracheal deviation. CORRECT - Tracheal deviation toward the unaffected (i.e. uninjured) side is a late sign of tension pneumothorax. Breath sounds may be diminished or absent over the affected lung. Shifting of the heart and great vessels will cause decreased cardiac output and hypotension. Additional manifestations of tension pneumothorax include tachycardia and distended neck veins. Tension pneumothorax is a life-threatening medical emergency that requires immediate treatment. Interventions may include needle decompression to release air trapped in the pleural space and chest tube insertion. 2. Hypertension. INCORRECT - Manifestations of tension pneumothorax include hypotension, not hypertension. 3. Flattened neck veins. INCORRECT - Distended neck veins, not flattened neck veins, are a sign of tension pneumothorax. 4. Bradycardia. INCORRECT - Tension pneumothorax causes tachycardia, not bradycardia. Think like a nurse: The nurse needs to recall the pathophysiology of a tension pneumothorax and mentally ask, "What is occurring in the thorax when this problem develops?" The nurse recognizes that a pneumothorax develops when the pressure inside of the lung is the same as the pressure outside of the lung. The lung collapses and can no longer support body tissue oxygenation. In a tension pneumothorax, the structures within the thorax are shifted towards the inflated lung, or away from the collapsed lung. This is because free air in the thoracic cavity increases the pressure in the thorax and moves the organs away from the collapsed lung. One structure that shifts is the trachea.

After insertion of a central venous catheter (CVC), a client suddenly starts coughing. The nurse observes that the client is pale and dyspneic, and has tachycardia. Which action does the nurse take first? 1. Turn the client to the left side and lower the head of the bed. 2. Notify the health care provider. 3. Administer oxygen. 4. Instruct the client to do the Valsalva maneuver.

1. Turn the client to the left side and lower the head of the bed. — The client's symptoms are consistent with an air embolism, which can occur with CVC insertion. Placing the client in the left lateral position prevents the air embolism from entering the right atrium and pulmonary artery, which would create a right ventricular outflow obstruction (air lock) and stop the heart. The client should be kept in this position for 20-30 minutes. Think like a nurse: During the insertion of a central venous catheter, there is a risk that an air embolism may be introduced into the circulation. The client's symptoms indicate an air embolism has occurred in this situation. Because the pulmonary arteries are located on the right side of the heart and the nurse wants to minimize the air occluding the pulmonary arteries, the client should be turned onto the left side with the head lowered. Supplemental oxygen should be provided until the symptoms subside.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client. 1. Twitching 2. Hypoactive bowel sounds. 3. Negative Trousseau's sign. 4. Hypoactive deep tendon reflexes.

1. Twitching (normal serum calcium level: 8.5-10.8 mg/dL) - Signs of hypocalcemia: paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's and Chvostek's sign, increased neuromuscular excitability, muscle cramps, switching, tetany, seizures, irritability, and anxiety. - Gastrointestinal symptoms include: increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse assesses the records of an infant scheduled to see the health care provider for the 6-month checkup. Which immunization records are required for the nurse to determine that the infant is up to date on immunizations? 1. Two doses of diptheria, tetanus, and acellular pertussis (DTaP) and two doses of inactivated polio vaccine (IPV). 2. One dose of measles, mumps, and rubella (MMR). 3. A tuberculin skin test and one dose of diptheria, tetanus, and acellular pertussis (DTaP). 4. One dose of smallpox vaccine and one dose of measles, mumps, and rubella (MMR).

1. Two doses of diptheria, tetanus, and acellular pertussis (DTaP) and two doses of inactivated polio vaccine (IPV). — The infant should receive doses of diphtheria, tetanus, and acellular pertussis (DTaP) at 2 months and 4 months, and will receive a third dose at the 6-month appointment. The inactivated polio is given at 2 months and 4 months.

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

1. U waves. 3. Inverted T waves. 4. Depressed ST segment. - Absent P Waves may be noted in atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

The client tells the nurse that the health care provider stated that the client has a thyroid problem. Which diagnostic study does the nurse expect to be prescribed to determine the size and composition of the thyroid gland? 1. Ultrasonography. 2. Electrocardiography. 3. Thyroid scan with radioactive iodine - 123. 4. Parathyroid function test.

1. Ultrasonography. - Ultrasonography can be used early in the evaluation process to rule out Graves' disease, nodular goiter, or other thyroid dysfunction. Think like a nurse: The nurse is aware that the choice of a diagnostic test is determined by the location of the target organ and body system. When assessing for a thyroid problem, the nurse is aware that the health care provider is likely to initially prescribe an ultrasound of the gland. The ultrasound is a non-invasive scan that provides information about the size and other characteristics, which could indicate the presence of disease. If abnormalities are found with the ultrasound, the health care provider is likely to prescribe an MRI, a radiographic uptake study, or biopsy.

The nurse provides care to the client who is at 40-weeks' gestation and in labor. The nurse notes the client is having persistent late decelerations. The nurse recognizes which condition as a potential cause of persistent late decelerations? 1. Umbilical cord compression. 2. Impending delivery. 3. Fetal head compression. 4. Uteroplacental insufficiency.

1. Umbilical cord compression. INCORRECT - Umbilical cord compression typically causes variable decelerations. Late decelerations are associated with uteroplacental insufficiency. 2. Impending delivery. INCORRECT - Impending delivery is indicated by crowning of the fetal head. 3. Fetal head compression. INCORRECT - Fetal head compression causes early decelerations. Uteroplacental insufficiency causes late decelerations. 4. Uteroplacental insufficiency. CORRECT— Persistent late decelerations are a manifestation of uteroplacental insufficiency. Think like a nurse: Late decelerations are the result of fetal hypoxia and subsequent fetal hypertension. Late decelerations may stem from excessive contractions, maternal hypotension or hypoxia, or poor perfusion across the placenta (placental exchange). If allowed to continue, fetal hypoxia results in sustained fetal bradycardia. The fetus cannot maintain this pattern of poor oxygenation and cardiac perfusion. Initial nursing interventions aim to increase the mother's cardiac output and oxygenation, but if these measures are not quickly successful, the fetus is delivered surgically.

The nurse provides care for a client with a history of chronic urinary tract infections who is experiencing urolithiasis. Which type of urinary stone does the nurse suspect the client has developed? 1. Uric acid. 2. Calcium oxalate. 3. Struvite. 4. Cystine.

1. Uric acid. INCORRECT - Uric acid stones occur in clients with gout. 2. Calcium oxalate. INCORRECT - Calcium oxalate stones result from increased calcium intake or conditions that raise serum calcium concentrations. 3. Struvite. CORRECT - Struvite stones are referred to as infection stones because they form in urine that is alkaline and rich in ammonia. 4. Cystine. INCORRECT - Cystine stones are rare and occur in clients with a genetic defect that results in decreased renal absorption of the amino acid cysteine.

The nurse provides care to a client experiencing the oliguric phase of acute kidney injury (AKI). Which assessment finding will the nurse expect to observe in the client? 1. Urine output 0.8 mL/kg/hr. 2. Serum potassium 5.7 mEq/L (5.7 mmol/L). 3. Serum creatinine 1.0 mg/dL (88.4 µmol/L). 4. Blood urea nitrogen 8.0 mg/dL (2.86 mmol/L).

1. Urine output 0.8 mL/kg/hr. INCORRECT - Decreased urinary output (< 0.5 mL/kg/hr) is expected with AKI. 2. Serum potassium 5.7 mEq/L (5.7 mmol/L). CORRECT- Hyperkalemia is expected with AKI. Normal potassium level is 3.5 to 5.0 mEq/L (3.5 mmol/L to 5.0 mmol/L). 3. Serum creatinine 1.0 mg/dL (88.4 µmol/L). INCORRECT - An elevated serum creatinine is expected with AKI. A normal serum creatinine level is 0.7 to 1.4 mg/dL (61.88 to 123.76 µmol/L). Widely accepted criterion for AKI is 50% or greater increase in serum creatinine above the baseline. 4. Blood urea nitrogen 8.0 mg/dL (2.86 mmol/L). INCORRECT - Elevated blood urea nitrogen is expected with AKI. Normal blood urea nitrogen level is 10 to 20 mg/dL (3.57 mmol/L to 7.14 mmol/L).

The nurse provides care to a client diagnosed with a hearing impairment. Which approach will the nurse use to facilitate communication with the client? 1. Use a normal tone. 2. Speak directly into the impaired ear. 3. Talk louder. 4. Talk faster.

1. Use a normal tone. — Using a normal voice tone is important, as is talking directly to the client while facing the client and speaking clearly Think like a nurse: Clients with hearing impairments often will not tell the nurse, feeling that it is embarrassing or unimportant. If an individual's response to verbal communication is not appropriate, hearing assessment may be indicated. Hearing impairment, not deafness, usually occurs over a prolonged period and the client gradually adjusts to accommodate those around them. Clients who experience gradual hearing loss learn to read lips, so speaking in normal tones while directly facing the client is very useful.

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply 1. Use non-latex gloves 2. Use medications from glass ampules 3. Place the client in a private room only 4. Keep a latex-safe supply cart available in the client's area 5. Avoid the use of medication vials that have rubber stoppers 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure

1. Use non-latex gloves 2. Use medications from glass ampules 4. Keep a latex-safe supply cart available in the client's area 5. Avoid the use of medication vials that have rubber stoppers - While it is not necessary to place the client on a private room, care should be made to avoid any supplies or materials that contain latex, such as blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle.

The nurse provides care to a client receiving packed RBCs to treat anemia. Which action does the nurse take? (Select all that apply.) 1. Uses a 22 gauge needle for the transfusion. 2. Selects standard IV tubing used with an IV pump. 3. Checks client name and blood product with second licensed nurse. 4. Administers 0.9% sodium chloride solution after the transfusion. 5. Ensures the transfusion completes within 5 hours. 6. Monitors for signs of transfusion reaction or fluid volume overload.

1. Uses a 22 gauge needle for the transfusion INCORRECT - An 18- or 20-gauge needle is used for a blood transfusion. This size is required to ensure that the cells are not damaged 2. Selects standard IV tubing used with an IV pump INCORRECT - Tubing with a blood filter is to be used when transfusing packed red blood cells. 3. Checks client name and blood product with second licensed nurse CORRECT - Blood products are to be checked by two licensed care providers to ensure that the correct blood product is being provided to the correct client. 4. Administers 0.9% sodium chloride solution after the transfusion. CORRECT - Intravenous normal saline is used during a blood transfusion. This solution is to flush the IV line after the transfusion is completed. 5. Ensures the transfusion completes within 5 hours INCORRECT - Blood products should be transfused within 2 to 4 hours. 6. Monitors for signs of transfusion reaction or fluid volume overload CORRECT - Clients receiving a blood product should be monitored for the first 15 minutes and then periodically thereafter. Since the client is being treated for anemia and may receive several units of red blood cells, there is a risk for fluid volume overload. The client should be monitored frequently.

The nurse provides care for a client diagnosed with hypocalcemia. The nurse teaches the client about calcium supplements. Which vitamin is essential for the absorption of calcium in the gastrointestinal tract and should be included in the teaching? 1. Vitamin D. 2. Vitamin K. 3. Vitamin A. 4. Vitamin C.

1. Vitamin D. - Vitamin D stimulates absorption of calcium from the gastrointestinal tract. Think like a nurse: Individuals learn at an early age that an adequate intake of calcium is essential for the development of strong bones and teeth. What many people are not aware of is the role of other vitamins required to potentiate the effects of calcium. Vitamin D is one such vitamin. This vitamin works synergistically with calcium to increase the absorption of the mineral into body tissues and structures. When taken with vitamin D, calcium is readily absorbed from the gastrointestinal tract. The nurse is aware that clients who live in sunshine deficient environments are in greatest need of a vitamin D supplement. Sunshine is the catalyst for vitamin D production by the body.

The nurse provides care for toddlers in the pediatric clinic. In which order does the nurse present the information to the toddler's parents? (Arrange the developmental milestones in the proper order. All options must be used.) - Builds a tower of three to four blocks - Use two- to three- word phrases - Jumps with both feet - Walks without help

1. Walks without help 2. Builds a tower of three to four blocks 3. Use two- to three- word phrases 4. Jumps with both feet - One of the first milestones for a toddler is to walk without help or holding onto furniture, beginning at 13 to 15 months. Then the toddler can build a tower of three to four blocks at 18 months. The toddler uses two- to three-word phrases at 24 months. Lastly, jumping with both feet occurs at 30 months.

The nurse is preparing a list of self-care instructions for a postpartum client with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast feeding or breast pump.

1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast feed if the breasts are not too sore.

The nurse receives a report from the laboratory that a client 's sputum culture grew acid fast bacillus. Which transmission-based measures are appropriate for the nurse to implement? (Select all that apply.) 1. Wearing a surgical mask to enter the client 's room. 2. Placing the client in an airborne infection isolation room (AIIR). 3. Putting an N95 respirator mask on the client during transport. 4. Adjusting the mask edge to fit under eyeglasses, if needed. 5. Wearing an impermeable gown to enter the client 's room.

1. Wearing a surgical mask to enter the client 's room. INCORRECT - A fitted N95 respirator or powered air purifying respirator is worn to enter the client 's room. 2. Placing the client in an airborne infection isolation room (AIIR). CORRECT— Acid fast bacillus indicates the client may have pulmonary tuberculosis. The client is put in an AIIR appropriate for airborne transmission-based precautions with 6 to 12 air exchanges per hour. 3. Putting an N95 respirator mask on the client during transport. INCORRECT - The client wears a surgical mask when transport is required. 4. Adjusting the mask edge to fit under eyeglasses, if needed. CORRECT— If the nurse wears glasses, the mask edge is seated under the glasses to prevent airborne contamination. The N95 mask must always fit snugly against the face without gaps. 5. Wearing an impermeable gown to enter the client 's room. INCORRECT - A gown is not required to enter the room of a client who requires airborne transmission-based precautions. A gown is required to prevent infection spread through direct contact or if spraying with blood and body fluids is likely.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in the client with this condition? 1. Weight loss and poor skin tugor. 2. Lung congestion and increased heart rate. 3. Decreased hematocrit and increased urine output. 4. Increased respirations and increase blood pressure.

1. Weight loss and poor skin tugor. - Fluid volume deficit: increased respirations and heart rate, decreased central venous pressure (CVP), weigh loss, poor skin tugor, dry mucous membranes, decreased urine volume, increased urine specific gravity, increased hematocrit, and altered level of consciousness. - Fluid volume excess: lung congestion, increased urinary output, and increased blood pressure.

A client with a serum potassium level of 2.4 mEq/L (2.4 mmol/L) is to receive 40 mEq of potassium chloride (KCl) intravenously. The available supply is 10 mEq KCl in 100 mL sodium chloride in each premixed bag. After hanging the first bag, the nurse sets the pump to infuse at how many milliliters per hour? (Do not round. Record your answer using a whole number.)

100 mL/hr - KCl administration must not exceed the rate of 10 mEq per hour. Because the 10 mEq bag holds 100 mL, 40 mEq will need to be administered at 100 mL per hour over 4 hours. Think like a nurse: Standard potassium chloride (KCl) IV infusion must not exceed the rate of 10 mEq per hour. This is done to prevent rapid correction that might lead to hyperkalemia, or phlebitis if the KCL is infused via a peripheral line. The nurse should also check the client's magnesium level. Magnesium and potassium have a direct relationship. When one is low, it is likely that the other also will be low. The nurse should assess the client for signs and symptoms of hypokalemia, such as muscle weakness, muscle cramps, nausea and vomiting, abdominal cramping, and dysrhythmia.

The nurse documents the following intake and output for a client over an 8-hour period (0700 to 1500): I & O Documentation - IV D 5W infusing; 900 mL remaining in bag. - 150 mL urine voided. - 16 oz of ice chips consumed. 200 mL gastric tube formula and 50 mL water administered. - 200 mL gastric tube formula and 50 mL water administered. - 220 mL urine voided. - 230 mL urine voided. - IV D 5W infusing; 550 mL remaining in bag. 200 mL gastric tube formula and 50 mL water administered. Calculate the client's total fluid intake for the 8-hour shift. (Record your answer using a whole number. Do not round.)

1340 mL The client's input includes intravenous fluid (IVF): 900 mL at start of shift minus 550 mL remaining = 350 mL. Ice chips: half of frozen volume is 8 oz = 240 mL (1 oz = 30 mL). Enteral formula plus water: 250 mL at 0900, 1200, and 1500 = 750 mL. Total fluid intake = 1340 mL.

The home care nurse visits a client undergoing continuous ambulatory peritoneal dialysis (CAPD) for chronic kidney disease. Which instruction does the nurse reinforce with the client? 1. "Drink distilled water." 2. "Cap the catheter during dwell time." 3. "Boil the dialysate 1 hour before an infusion." 4. "Clean the arteriovenous fistula site with hydrogen peroxide daily."

2. "Cap the catheter during dwell time." - The most common complication is peritonitis. Use aseptic technique when caring for catheter, fluid, or tubing. Cap the catheter during the dwell time. Think like a nurse: Prior to teaching a client a specific treatment, the nurse should mentally ask, "What is the most important information that this client needs?" and "What concerns exist regarding the client's safety?" The nurse needs to consider that peritoneal dialysis is the introduction of dialysis fluid directly into the peritoneal cavity. There is a significant risk of infection during the preparation for the procedure, the introduction of the fluid, and when the fluid is drained. The nurse should emphasize practices to reduce the likelihood of the client developing an infection when performing this procedure in the home.

The nurse prepares a client for a computed tomography (CT) scan with contrast enhancement. Which question is most important for the nurse to ask? 1. "Do you have a history of respiratory disease?" 2. "Do you have any allergies to food or medication?" 3. "Have you ever smoked?" 4. "What x-ray tests have you had before?"

2. "Do you have any allergies to food or medication?" - The contrast enhancement is performed with iodine contrast media. The nurse should ask about allergies to seafood, iodine, and other contrast dyes. Think like a nurse. The nurse needs to be aware the contrast medium used for diagnosed tests contains iodine. Individuals with an allergy to iodine, seafood, or other contrast dyes may need another diagnostic test approach or receive medication to prevent an allergic response. It is important for the nurse to understand the process and procedures for diagnostic tests in order to prevent adverse effects or complications for the client.

The nurse admits a client to the surgical unit for a mastoidectomy due to chronic otitis media. Which question should the nurse first ask the client? 1. "When did you begin having problems with your ears? " 2. "Do you have problems with vertigo? " 3. "Do you have any questions about the procedure? " 4. "What are your concerns about the post-operative period? "

2. "Do you have problems with vertigo? " — The nurse needs to anticipate that the client may be experiencing vertigo. This is the question that the nurse needs to ask first to ensure client safety. Think like a nurse: Chronic tympanic membrane perforation will not heal with conservative treatment, and surgery is necessary. A mastoidectomy is often performed with a tympanoplasty to remove the infected portion of the mastoid bone. Post-operative discharge teaching includes informing the client to avoid sudden head movements; change position slowly; report fever, uncontrolled pain, wound drainage, and hearing loss; and, if the client needs to cough or sneeze, the client should keep the mouth open to help reduce pressure.

While working at a local food processing plant, a flying object penetrates an employee's right eye. The employee is admitted to an emergency department. After administering pain medication, which question is most important for the nurse to ask? 1. "Does the company provide worker's compensation?" 2. "Do you wear glasses?" 3. "Did you have visual problems before the injury?" 4. "Are you afraid?"

2. "Do you wear glasses?" — This question helps determine whether material other than the known object penetrated the eye. If the client wears glasses, pieces of glass may have also penetrated the eye along with the flying object.

The nurse conducts an education program for a client who is diagnosed with acute pancreatitis. The nurse includes which statement when teaching about the common causes of this type of pancreatitis? 1. "Autoimmune disorders and cystic fibrosis cause acute pancreatitis." 2. "Gallstone migration and alcohol abuse cause acute pancreatitis." 3. "Liver cirrhosis and pancreatic tumors cause acute pancreatitis." 4. "Wheat products and high-fiber intake cause acute pancreatitis."

2. "Gallstone migration and alcohol abuse cause acute pancreatitis." — Gallstone migration and alcohol abuse are two of the most common causes of acute pancreatitis. Think like a nurse: From the study of anatomy, physiology, and pathophysiology, the nurse is aware the risk for pancreatitis is multifactorial. Gallstone migration and alcohol abuse are two of the most common causes of pancreatitis. With appropriate treatment, most clients diagnosed with acute pancreatitis will make a complete recovery. Severe, acute cases of pancreatitis, however, can lead to bleeding into the gland, cyst formation, infection, and serious tissue damage. In acute pancreatitis, the nurse should monitor the client for signs of acute respiratory distress syndrome (ARDS) and pleural effusion. The nurse monitors the trend in serum amylase and lipase.

The nurse provides care for a client who is human immunodeficiency virus (HIV) positive and has been taking anti-retroviral therapy (ART) for 15 years. Which health maintenance activity does the nurse teach this client related to the adverse effects of long term ART? 1. "Obtain an annual flu immunization." 2. "Have your lipid profile checked." 3. "Use a latex condom during sex." 4. "Monitor your viral load periodically."

2. "Have your lipid profile checked." - Long-term ART leads to hyperlipidemia and cardiovascular disease, possibly due to chronic stress.

The nurse makes a follow-up telephone call to a client 3 days after an extracapsular cataract extraction with intraocular lens implantation. Which client statement most concerns the nurse? 1. "I am going to the beauty shop to get my hair done tomorrow. It will be a celebration—getting my whole head back in shape!" 2. "I am feeling really good. When I get off the phone I am going to do the vacuuming and then play a round of golf." 3. "My eye is itching a little, especially at night. There is also a dry, crusty white drainage on the eyelids and lashes." 4. "It may be hard for me to get a ride to my follow-up visit next week because all my friends are busy that day."

2. "I am feeling really good. When I get off the phone I am going to do the vacuuming and then play a round of golf." — For the first several weeks postoperation, light housekeeping is acceptable, but vacuuming involves too much forward flexion and jerky, rapid movement. Golf also involves too much flexion, potential for strained rapid movement, and possibly excessive lifting related to equipment. These can increase IOP and cause tissue damage at the operative site. Mild itching is caused by the stitches that are in place to close the incision and is expected postoperatively. Crusty white or clear drainage is also expected for the first 1 to 2 weeks after surgery.

The nurse provides discharge teaching to a client recovering from an appendectomy. Which client statement indicates that teaching is effective? 1. "I shall eat a diet low in protein, high in carbohydrates, and low in fats. " 2. "I shall eat a diet high in protein, high in calories, and high in vitamin C. " 3. "I shall eat a diet high in protein, low in calories, and low in fat. " 4. "I shall eat a diet low in protein, low in carbohydrates, and high in vitamin D. "

2. "I shall eat a diet high in protein, high in calories, and high in vitamin C. " - Supplemental vitamin C, iron, and multivitamins aid in wound healing and formation of red blood cells.

The nurse instructs a client diagnosed with genital herpes about acyclovir. Which client statement indicates that teaching has been effective? 1. "If I miss a dose of medication, I can double up the next dose." 2. "I should avoid sexual contact while I have lesions." 3. "I'm glad this medication will cure me." 4. "I must take this medication with food."

2. "I should avoid sexual contact while I have lesions." - This statement indicates correct understanding of the information presented. Acyclovir is an antiviral medication that is used to treat recurrent genital herpes and localized cutaneous herpes zoster. The client is considered contagious and should refrain from sexual contact while the lesions are present. Think like a nurse: Prior to administering a newly prescribed medication, the nurse instructs the client on the mechanism of action, expected effects, any precautions, and possible adverse effects. Acyclovir (Zovirax) is an antiviral, used to treat the genital herpes virus, and does not cure the virus, but helps reduce the symptoms and promotes the healing of lesions. The nurse should emphasize the importance of refraining from sexual contact while the lesions are present to prevent the transmission of the virus to the client's sexual partner. The nurse uses the art of listening to determine if the client has a correct understanding about the prescribed medication and treatment regimen.

The nurse instructs a client about trimethoprim/sulfamethoxazole. The nurse needs to intervene if the client makes which statements? (Select all that apply.) 1. "I am being prescribed this medication because I have a bacterial infection." 2. "I should take the medication with food." 3. "This medication is safe during pregnancy." 4. "I should notify my health care provider if I develop nausea or abdominal pain." 5. "I should wear sunscreen while taking this medication."

2. "I should take the medication with food." — This statement requires intervention by the nurse. Trimethoprim/sulfamethoxazole should be taken on an empty stomach 1 hour before, or 2 hours after, meals. 3. "This medication is safe during pregnancy." — This statement requires intervention by the nurse. Trimethoprim/sulfamethoxazole is a pregnancy category C medication and may pose a risk to a fetus.

The nurse instructs a client with a necrotizing spider bite how to perform dressing changes at home. Which statement indicates the client understands aseptic technique? 1. "I should 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 use an over-the-counter antimicrobial ointment."

2. "I should wash my hands before redressing my wound." — Washing hands before changing the dressing indicates an understanding of aseptic technique as hand washing is a hallmark strategy. Think like a nurse: Aseptic technique is another term for clean technique. Preparation for changing this type of dressing is to perform hand hygiene to remove microorganisms from the surface of the hands. Sterile gloves are not used when performing a dressing change using aseptic technique. The wound does not need to be covered at all times. The client should use the prescribed medications on the wound.

The nurse plans care for a client with toxic shock syndrome. Which client statement causes the nurse the most concern? 1. "I am very frightened of doctors and hospitals. " 2. "I vomited 12 times in the past 24 hours. " 3. "I have abdominal pain and pressure. " 4. "I use extra-absorbent tampons. "

2. "I vomited 12 times in the past 24 hours. " — Vomiting 12 times during the last 24 hours addresses the client's physical status. This amount of vomiting could lead to fluid volume deficit. Symptoms of toxic shock syndrome include a sudden onset of fever, hypotension, and rash. Think like a nurse: Toxic shock syndrome (TSS) is a toxin-mediated acute life-threatening illness, usually precipitated by infection with either staphylococcusaureus or group A s treptococcus (GAS), also called streptococcus pyogenes. It is characterized by high fever, rash, hypotension, multiorgan failure, and desquamation, typically of the palms and soles, 1 to 2 weeks after the onset of acute illness. Due to risk for hemodynamic compromise, the nurse should anticipate close monitoring of the client's hemodynamic parameters such as central venous pressure. The nurse should also assess for the potential cause of the client's TSS.

The nurse instructs a primigravida woman during the third trimester about the signs and symptoms of impending labor. Which statement by the client indicates to the nurse that the teaching was effective? 1."I will call the health care provider when I see pink-tinged secretions from my vagina." 2. "I will call the health care provider when my contractions occur every 5 minutes for an hour." 3. "I will call the health care provider when I pass my mucus plug." 4. "I will call the health care provider when I feel increased pelvic pressure."

2. "I will call the health care provider when my contractions occur every 5 minutes for an hour." — Contractions that last continuously for an hour generally indicate labor. In true labor, contractions are regular with decreasing intervals between contractions. Contractions will increase in intensity and duration. This statement by the client indicates client understanding. Think like a nurse: Braxton Hicks contractions (e.g. abdomen and groin), which the client may have been experiencing throughout pregnancy, may become stronger and more frequent as impending labor begins. In true labor, contractions are felt in the lower back. The nurse should inform the client about the differences between true and false labor.

The nurse provides teaching to a client who is prescribed amitriptyline hydrochloride. Which client statements require additional teaching by the nurse? (Select all that apply.) 1. "I will take this medication at bedtime. " 2. "I will drive short distances initially after starting this medication. " 3. "I will stop eating cheese and yogurt. " 4. "I should feel better in 3 to 4 weeks." 5. "I can adjust the dosage of my medication when I start to feel better. " 6. "I will skip a dose of this medication if I experience a dry mouth. "

2. "I will drive short distances initially after starting this medication. " — When starting amitriptyline hydrochloride, no driving is allowed until it is determined how the client will respond to the medication. This statement would require additional teaching by the nurse. 3. "I will stop eating cheese and yogurt. " — Amitriptyline hydrochloridetrue is a tricyclic antidepressant and does not require the client to avoid cheese and yogurt. Foods such as these are high in tyramine. They are avoided for clients who are prescribed MAOIs. This statement would require additional teaching by the nurse. 5. "I can adjust the dosage of my medication when I start to feel better. " — The client should never adjust the dose of the medication without consulting a health care provider. This statement would require additional teaching by the nurse. 6. "I will skip a dose of this medication if I experience a dry mouth. " — The client should never skip a dose of medication. This statement would require additional teaching by the nurse.

The nurse provides dietary teaching to a client with advanced stage liver cirrhosis. Which client statements require intervention by the nurse? (Select all that apply.) 1. "I will increase the number of calories in my diet. " 2. "I will increase the amount of fat in my diet. " 3. "I will increase the amount of sodium in my diet. " 4. "I will increase the number of B complex vitamins in my diet. " 5. "I will increase the amount of fluids in my diet. "

2. "I will increase the amount of fat in my diet. " - A client with liver cirrhosis should decrease the amount of fat, and increase the amount of carbohydrates, in the diet. 3. "I will increase the amount of sodium in my diet. " - The client with liver cirrhosis should decrease the amount of sodium in the diet to prevent or manage ascites. 5. "I will increase the amount of fluids in my diet. " - A client with liver cirrhosis should decrease the amount of fluids in the diet to help prevent or manage ascites.

The nurse working on an organ transplant unit provides discharge teaching for a client who is prescribed cyclosporine. Which client statements indicate to the nurse a correct understanding of the instructions? (Select all that apply.) 1. "This medication will help my body fight infection." 2. "I will need to take this medication for the rest of my life." 3. "I will check my pulse before taking this medication." 4. "My health care provider will evaluate my blood work regularly." 5. "It is important to take this medication at the same time every day." 6. "I should stop this medication prior to having any dental work."

2. "I will need to take this medication for the rest of my life." CORRECT— Cyclosporine is an anti-rejection medication. In most cases, anti-rejection therapy is lifelong. 4. "My health care provider will evaluate my blood work regularly." CORRECT— Due to nephrotoxicity associated with this anti-rejection medication, blood work will be monitored during therapy. 5. "It is important to take this medication at the same time every day." CORRECT— Taking this anti-rejection medication at the same time helps to maintain therapeutic blood levels and decreases risk of nephrotoxicity.

A client is admitted to the psychiatric unit with a diagnosis of major depression. The client describes to the nurse suicidal thoughts that have occurred for the past 3 days. Which client statement causes the nurse to institute a one-to-one observation of the client? 1. "This is not the first time I felt this way." 2. "I will not sign a no-suicide contract." 3. "This is my fifth hospitalization for depression." 4. "My mother attempted suicide at age 40."

2. "I will not sign a no-suicide contract." - Place the client on one-to-one observation and stay with client to help control self-destructive impulses. The client is never out of sight of a supervisory health care staff member. One-to-one observation is required for clients currently verbalizing a clear intent to harm self, unwilling to sign a no-suicide contract, with poor impulse control, and who have already attempted suicide in the past by a lethal method (hanging, gun). Think like a nurse: Refusing to sign a no-suicide contract is a red-flag to the nurse. The client is at risk for suicide and should be constantly observed. The client may be at risk for suicide because of a family history of the behavior.

The client takes beclomethasone by metered dose inhaler (MDI). Which statement made by the client indicates that teaching is successful? 1. "I know it is time to have the prescription refilled when the canister floats in water." 2. "I will rinse my mouth and throat with water after each dose." 3. "I will be sure not to shake the canister before I use it." 4. "If the dose does not help, I will take extra and let the health care provider know the results."

2. "I will rinse my mouth and throat with water after each dose." - Beclomethasone is a corticosteroid. Inhaled corticosteroids can predispose the client to fungal oropharynx infection (candidiasis). Rinsing the mouth and gargling with warm water when each treatment is completed is imperative to remove residual medication and prevent the onset of infection. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. This client has a few misconceptions about using the inhaler but is correct that rinsing after its use is essential, as this prevents infection. The nurse will assess the source of the client 's other statements and provide corrected information.

The nurse counsels a client diagnosed with glaucoma. Which client statement demonstrates to the nurse that teaching is successful? 1. "Because of glaucoma, the correction in my eyeglasses needs to be changed. " 2. "I will schedule appointments with my physician early in the morning. " 3. "I 'm glad that surgery can reverse the damage caused by the glaucoma. " 4. "I will be happy when I don 't have to use the eye drops anymore. "

2. "I will schedule appointments with my physician early in the morning." — Intraocular pressure (IOP) tends to be higher in the early morning hours. An early morning assessment is likely to be more accurate. Think like a nurse: The nurse needs to understand that glaucoma causes an increase in intraocular pressure. A client with this health problem will need frequent ophthalmologic examinations to measure eye pressure. Depending upon the pressure, medications will be prescribed to reduce the pressure in efforts to maintain the integrity and function of the optic nerve and preserve vision. Since intraocular pressure peaks in the morning, the client should schedule ophthalmologic appointments early in the day so that appropriate treatment can be planned.

Alendronate sodium is prescribed for an older adult client. Which statement by the client to the nurse indicates that teaching about the medication is successful? 1. "I will take it with a full glass of milk as soon as I wake up." 2. "I will sit and read a book for half an hour after I take it." 3. "I will wait about 10 minutes after I take it and then do my yoga exercises." 4. "I will take it as soon as I finish breakfast and my stomach is full."

2. "I will sit and read a book for half an hour after I take it." — Alendronate is an oral biphosphate that inhibits bone resorption. It can be highly irritating to the gastrointestinal tract, particularly the esophagus. It can cause irritation and ulcerations or erosions. After taking the medication, the client should sit for at least 30 minutes in order to facilitate delivery to the stomach and prevent acid regurgitation and esophageal reflux.

The nurse counsels a client newly diagnosed with hypertension. Which statement by the client indicates to the nurse that teaching is successful? 1. "If I feel dizzy when I wake up, I will skip my morning blood pressure pill." 2. "I will switch from lifting weights at the health club to doing aerobics." 3. "I will be sure to take chlorothiazide every night before I go to bed." 4. "I will take hot baths or go to the sauna to relax if I feel tension coming on."

2. "I will switch from lifting weights at the health club to doing aerobics." - Regular aerobic exercises are usually recommended. Isometric exercises, such as heavy weight lifting, are contraindicated due to a potential vasovagal response during intense isometric muscle contraction. Also, aerobic activity benefits the vascular system and reduces blood pressure readings over time. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client's understanding. The client's verbalized plan to choose aerobic exercise instead of lifting weights indicates accurate understanding of the teaching. The nurse reinforces the safety concerns associated with lifting weights, including a potential vasovagal response. The nurse should also reinforce the client's understanding of benefits associated with aerobic exercise, including promoting cardiovascular health and reducing blood pressure.

The nurse reviews proper application of the condom catheter with the unlicensed assistive personnel (UAP). Which statement by the UAP indicates to the nurse that further teaching is required? 1. "I will clip the hair at the base of the penis before I apply the condom." 2. "I will wrap an adhesive strip around the penis in a circular, overlapping pattern." 3. "I will leave 2 inches between the tip of the penis and the end of the catheter." 4. "I will secure the urinary drainage collection bag to the bed frame."

2. "I will wrap an adhesive strip around the penis in a circular, overlapping pattern." - An elastic adhesive strip should be wrapped in a spiral pattern without overlapping on itself to ensure circulation to the penis is not impaired. The tape should be snug to hold the condom catheter in place, but not so tight that it causes discomfort.

The nurse prepares an injection of glargine insulin at a client's bedside. Which client statements indicate a need for further teaching by the nurse? (Select all that apply.) 1. "I usually give myself this insulin in my stomach." 2. "I'd like you to mix this with my regular insulin, so I only have to have one shot." 3. "I always take this insulin just before I take my sleeping pill when I am at home." 4. "I will need a snack in about a half hour to prevent my blood glucose from going too low." 5. "My sister told me that I can get an insulin pump that will automatically inject this insulin throughout the day and night." 6. "My health care provider said when my infection heals, we may be able to decrease the amount of insulin I take."

2. "I'd like you to mix this with my regular insulin, so I only have to have one shot." - Glargine should not be mixed in a syringe with any other insulin. 4. "I will need a snack in about a half hour to prevent my blood glucose from going too low." - Glargine has no peak action. The onset of glargine is 3 to 4 hours, and it lasts 24 hours. 5. "My sister told me that I can get an insulin pump that will automatically inject this insulin throughout the day and night." - Glargine is given once daily, not continuously, as it is a long-action insulin. Insulin pumps use short- acting or rapid-acting insulins.

A client is discharged from the emergency department after evaluation for a concussion with loss of consciousness. Which statement by the client's spouse indicates to the nurse that further teaching is necessary? 1. "I will wake my spouse up every 3 hours when he is sleeping and ask him his name, my name, and where he is." 2. "If my spouse reports a headache and needs aspirin, I will give it to him no more than every 4 hours." 3. "If my spouse complains of blurry vision or has difficulty walking, I will bring him to the emergency department." 4. "I will talk to my spouse's friend about doing the coaching for the soccer team tomorrow."

2. "If my spouse reports a headache and needs aspirin, I will give it to him no more than every 4 hours." - The client should not receive aspirin, as it can prolong any bleeding that might occur. Acetaminophen every 4 hours as needed is what should be given for pain. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client's understanding. In the client with a head injury, any statements about taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) require the nurse to evaluate the client's understanding and reteach the information. Small amounts of intracranial bleeding often are self-limiting; however, the addition of medications that make platelets less sticky increases the chance that any bleeding will result in continued bleeding and brain injury.

The nurse provides care for a client diagnosed with Guillain-Barré syndrome. Which statement indicates to the nurse that the client's family member understands the diagnosis? (Select all that apply.) 1. "The syndrome only lasts 1 or 2 weeks." 2. "Intravenous immunoglobulins are often used for treatment." 3. "The cause of the syndrome may be a virus." 4. "This illness doesn't cause shortness of breath." 5. "My loved one's ability to walk will be affected." 6. "A feeding tube may be required for treatment."

2. "Intravenous immunoglobulins are often used for treatment." — Intravenous immunoglobulins decrease circulating antibody levels and reduce the amount of time the client is immobilized and can prevent the need for mechanical ventilation. This statement indicates correct understanding of the information presented. 3. "The cause of the syndrome may be a virus." — A viral infection precipitates clinical presentation in approximately 60% to 70% of cases. This statement indicates correct understanding of the information presented. 5. "My loved one's ability to walk will be affected." — Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin. This statement indicates correct understanding of the information presented. 6. "A feeding tube may be required for treatment." — If the client cannot swallow because of bulbar paralysis, a gastrostomy tube may be placed to administer nutrients. This statement indicates correct understanding of the information presented. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. Given that Guillain-Barré syndrome is a serious condition, the nurse should offer the client and family emotional support along with information.

As the nurse administers medications to a group of clients, an unlicensed assistive personnel (UAP) approaches the nurse to report that a client has a large amount of thick, dry mucus on one side of the tracheostomy tube. Which response does the nurse provide the UAP in this situation? 1. "Please take these medications into the medication room for me. " 2. "Is the client having difficulty breathing or appear different? " 3. "Take a sterile cotton swab and remove the mucus, please. " 4. "Please find another nurse to take care of the client. "

2. "Is the client having difficulty breathing or appear different? " - The UAP can observe whether a client is in distress. If the client is not in distress, the nurse can complete the current task prior to assessing the client with sputum. Clients with tracheostomies often cough large amounts of sputum through the stoma. As long as there is not an additional plug of mucus, indicated by client distress, this is a normal occurrence. Think like a nurse: The unlicensed assistive personnel (UAP) can report to the nurse any acute changes in a client 's condition. It is essential for the nurse to follow through and examine the client thoroughly. The nurse cannot leave the medication cart with the UAP. It is important to determine whether the client is in distress before taking action. In some institutions, the UAP may activate the rapid response team (RRT) as needed.

The nurse teaches the parent of an infant who is two months of age about the Haemophilus influenzae type B (Hib) vaccine. The parent asks the nurse why the vaccine is necessary. Which response by the nurse is accurate? 1. "It prevents hepatitis B, which can cause liver failure." 2. "It prevents Hib disease, which can cause meningitis, brain damage, and deafness." 3. "It prevents Hib disease, which can cause sickle cell disease." 4. "It reduces the risk for human immunodeficiency virus."

2. "It prevents Hib disease, which can cause meningitis, brain damage, and deafness." —Before the Hib vaccine, Hib disease was the leading cause of bacterial meningitis in children younger than age 5 years. Hib disease can also cause pneumonia, sepsis, and death. Think like a nurse: The nurse is aware that upon birth, a newborn's immune system is immature. Even though the client may be protected somewhat by the mother's immunity, there is at risk for developing an infection or illness. Because of this, the baby should receive vaccinations according to an identified schedule. One such vaccination, the Haemophilus influenzae type B (Hib) vaccine, prevents the development of bacterial meningitis, which can lead to death. The nurse should review the purpose of the vaccination with the parent and encourage the parent to be sure the infant receives all immunizations as recommended.

The school nurse teaches high school students about safe practices when it comes to loud noises and hearing. A student reports, "My parents are always yelling at me about my loud music and that I will go deaf. I tell them that when I get old, if I need a hearing aid, I will just get one. I already wear glasses." What is the best response by the nurse? 1. "It sounds as though your parents really care about you." 2. "Let me explain about the two main kinds of hearing loss." 3. "It is not that simple. Hearing aids are quite different from glasses." 4. "You seem really upset about this issue with your parents."

2. "Let me explain about the two main kinds of hearing loss." — Adolescents can think abstractly and logically, and this response provides important information from an adult outside the family. Hearing loss includes conductive and sensorineural types. The sensorineural type of hearing loss can be caused by prolonged exposure to noise, such as loud music. This type is usually permanent and is not helped with medical or surgical treatment (such as hearing aid use). Think like a nurse: The student's response about treatment for hearing loss indicates the need for teaching. The nurse should explain the types of hearing loss and which can be aided by a hearing device. Addressing the student's comment about eyeglasses does not focus on the most important issue, which is that the student does not understand the types of hearing loss, how they occur, and the methods available to treat them.

The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and frustration. Which statement is best for the nurse to make to the parents at this time? 1. "You should focus on your baby's personality, not appearance." 2. "Let me show you pictures of some babies before and after surgery." 3. "There are other problems with this condition that go beyond surgical correction." 4. "Has anyone else in either of your families had cleft lip or palate?"

2. "Let me show you pictures of some babies before and after surgery." — This addresses the immediate fears and concerns of the parents, who are in a state of crisis. It offers concrete pictorial evidence of a brighter future for their child than they might otherwise have expected.

The nurse performs discharge teaching for an older adult client diagnosed with peripheral artery disease. It is important for the nurse to include which instruction? 1. "Soak in a tub of warm water twice per day or perform foot soaks." 2. "Maintain a warm environment by using blankets or loose, layered clothing." 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. "Maintain a warm environment by using blankets or loose, layered clothing." — Keeping warm, to the client's comfort level, will cause vasodilation of the extremities and is safer than placing direct heat on the extremities. Think like a nurse: Peripheral artery disease (PAD) is characterized by decreased blood flow to the limbs due to narrowing or occlusion of peripheral blood vessels. The client diagnosed with PAD experiences muscle pain with activity, as impaired blood flow limits the delivery of oxygen to muscles and prevents adequate exchange of glucose and lactate. Additional effects of PAD may include delayed wound healing and cool extremities due to impaired circulation. Interventions emphasize maximizing blood flow to and from the extremities by engaging in mild to moderate exercise. To promote capillary dilatation and blood circulation, the client is advised to stay warm by dressing in non-constricting layers of clothing.

The nurse provides care to an adult client with newly-diagnosed rheumatoid arthritis (RA). Which information does the nurse include in the client's discharge instructions? 1. "Avoid taking naps during daylight hours. " 2. "Move your joints as much as you can each day. " 3. "To move an object, lift it instead of sliding it. " 4. "Install doorknobs that are turned instead of pushed. "

2. "Move your joints as much as you can each day. " - With RA, pain often decreases with joint use. By contrast, with osteoarthritis (OA), joint use typically causes joint pain to worsen in intensity. Think like a nurse. Goals of rheumatoid arthritis (RA) treatment include reducing or eliminating pain, decreasing inflammation around the joints, stopping joint damage, and maintaining a desired quality of life. Surgery, medications, and complimentary therapies such as diets, vitamins, or acupuncture may be used, but the client should be aware of the limits of each therapy's effectiveness. For example, acupuncture does not affect the joint condition, but may reduce pain, and, therefore, be of use. The nurse encourages exercise promoting flexibility, range of motion, and general strengthening to best help this client.

The nurse instructs parents on ways to decrease the incidence of sudden infant death syndrome (SIDS). Which statements require the nurse to intervene? (Select all that apply.) 1. "I position my baby on the back for sleep. " 2. "My baby takes naps in the car seat. " 3. "My baby sleeps covered with one blanket from chest to feet. " 4. "My baby sleeps with one pillow under the head. " 5. "My baby sleeps best on the sofa. "

2. "My baby takes naps in the car seat. " —This statement requires immediate intervention. Infants should not routinely take naps in car seats, strollers, or swings. They may slump enough to obstruct the airway. 3. "My baby sleeps covered with one blanket from chest to feet. " —This statement requires immediate intervention. Infants should ideally be dressed warmly in pajamas, sleepers, or sleep sack instead of using blankets. If a blanket is used, it should be placed no higher than infant 's waist. The edges of the blanket should be tucked under the mattress to prevent blankets from covering the infant 's face. 4. "My baby sleeps with one pillow under the head. " —This statement requires immediate intervention. Use of a pillow increases the risk for suffocation. 5. "My baby sleeps best on the sofa. " —This statement requires immediate intervention. Infants should not sleep on soft surfaces like a sofa, armchair, soft mattress, or waterbed.

The nurse prepares a client for an intravenous pyelogram. Which client statement causes the nurse the most concern? 1. "I really cleaned out my bowels last night. " 2. "My face flushes when I eat shrimp. " 3. "I missed my morning cup of coffee. " 4. "They are going to be taking x-rays at multiple intervals. "

2. "My face flushes when I eat shrimp. " — Facial flushing when eating shrimp can indicate a sensitivity to iodine. The contrast medium used for an intravenous pyelogram contains iodine. If used, the client may develop anaphylaxis. The nurse should assess for an allergy to shellfish, iodine, chocolate, eggs, and milk. Think like a nurse: Clients with allergies to shellfish may potentially develop an adverse reaction to iodine-based contrast media. The client should be screened thoroughly for risk factors for adverse effects. Clients at risk for adverse effects include client with diabetes mellitus who are prescribed metformin. Typically, metformin has to be held 2 days before and 2 days after a procedure that involves an iodine-based dye. The client should be informed that he or she might feel warm during the dye infusion, as this is an expected finding.

The nurse provides care for a client diagnosed with a fractured left femur. The client describes how to walk with crutches. Which statement by the client indicates that further teaching is necessary? 1. "The crutches and my weak leg will go forward first when I walk on flat surfaces. " 2. "My strong leg will lead the way going up and down stairs. " 3. "I will use a backpack instead of a briefcase when I go to work " 4. "I will look at the crutch tips and feel them every day. "

2. "My strong leg will lead the way going up and down stairs. " — The nurse should reteach the client that the strong leg leads the way going up stairs, but not when going down stairs. When going down stairs, the crutches are advanced to the lower step, the weaker leg is then advanced, and finally the stronger leg follows. Think like a nurse: For the client who requires crutches for ambulation, discharge teaching includes crutch walking. In an urgent care or emergency department setting, the nurse typically teaches the client how to use crutches. In some cases, the physical therapist will provide crutch walking instructions. Remind the client not to lean on crutches to support body weight. The client is reminded that the basic crutch stance is the tripod position, formed by placing the crutches 6 inches (15 cm) in front of and 6 inches to the side of each foot. This position improves the client 's balance by providing a wide base of support.

The nurse instructs a group of high school parents at a local health fair. Which statements by the parents during the discussion period require follow up by the nurse? (Select all that apply.) 1. "My teenager is very independent and doesn't need constant supervision after school." 2. "My teenager can be impulsive at times, but is improving on problem solving skills." 3. "Although I've made some mistakes in my life, I feel that I am a good role model for my teenager." 4. "My child is moody and requires some guidance when frustrated with homework." 5. "It is important to consistently tell my teenager what to do every day."

2. "My teenager can be impulsive at times, but is improving on problem solving skills." - Impulsiveness in an adolescent should be explored in greater detail and requires follow up. 5. "It is important to consistently tell my teenager what to do every day." - Needing constant direction does not contribute to an ideal level of development with this age group. Think like a nurse: The nurse should focus teaching to the parents of adolescents on reducing high risk behavior and encouraging healthy behaviors. Impulsiveness can lead to high risk behavior and should be followed up by the nurse. Parents are the ideal role models for an adolescent, and positive behaviors should be encouraged. Evidence of an expected level of development includes independence, which reduces the need for constant supervision, so the need for constant direction should be further analyzed.

The nurse instructs a group of mothers of young children about how to prevent upper respiratory infections (URIs). It is most important for the nurse to include which statement? 1. "Avoid crowds, such as large shopping centers, during the flu season." 2. "Promote frequent hand washing with soap and warm water or antibacterial gel." 3. "Ensure that your child gets 8 to 10 hours of rest each night." 4. "Keep your child home during infectious outbreaks at daycare."

2. "Promote frequent hand washing with soap and warm water or antibacterial gel." - Frequent hand washing is the most effective measure to prevent transmission of pathogens. The hands are the most common source of infection. Think like a nurse: The most effective way to reduce the risk of infection is by thorough and frequent hand washing with warm water and soap or by using an antibacterial cleansing gel. Although all of the options are appropriate, the highest priority is hand hygiene as the most effective means of reducing the risk of infection.

The nurse overhears the unlicensed assistive personnel (UAP) discussing a client's medical condition and test results with other clients. Which response by the nurse is appropriate? (Select all that apply.) 1. "Don't worry others yet. The tests will be repeated tomorrow." 2. "Stop discussing the client's condition." 3. "I think the client will improve with this new medication." 4. "Read the medical record silently, please." 5. "Only those with a 'need to know' should be informed of the client's test results."

2. "Stop discussing the client's condition." - This response immediately stops the violation of client privacy. Medical information is used only for the purpose of diagnosis and treatment. Other clients are not involved in a client's treatment plan. 5. "Only those with a 'need to know' should be informed of the client's test results." - This response provides an explanation to the UAP as to why the action is wrong. It also provides further instruction of maintaining a client's privacy. Think like a nurse: The privacy and confidentiality of protected health information (PHI) is federally mandated by the Health Insurance Portability and Accountability Act (HIPAA). All members of the health care team are required to protect client privacy and confidentiality. Given that the UAP works under the nurse's supervision, if a breach of privacy and confidentiality is observed, the nurse intervenes to correct the breach and reinforce understanding of the requirement to protected health information data. Additional action may be indicated based on the organization's disciplinary guidelines. As a rule, staff members should have access only to confidential or sensitive information that is necessary to perform their jobs. This means staff should not review electronic files or paper records of clients for whom they are not assigned to provide care.

The industrial nurse supervises the health care needs at a local plant. It is announced on the news that a device has exploded in a heavily populated area away from the plant and that individuals near the site have become ill. Several hours later, workers at the plant come to the nurse and demand antibiotics to protect them against potential effects of the device. Which is the best response by the nurse? 1. "I cannot administer medication without a prescription. " 2. "Tell me about how you are feeling. " 3. "The cause of the illness has not been identified. " 4. "Do you have any allergies to medications? "

2. "Tell me about how you are feeling. " - This assessment helps the nurse to identify specific concerns. The nurse needs to find out more information before determining the appropriate course of action. Think like a nurse: Several hours after an explosion, people in a populated area near the explosion site become ill. As a result, workers come to the industrial health nurse demanding antibiotics, even though the explosion occurred a distance from the plant. The nurse should think, "How can I best address the worker's demands?" The nurse should first assess the workers to determine whether they have signs and symptoms of illness. If present, the nurse should report such signs and symptoms to the health care provider. The health care provider may prescribe antibiotics depending on the suspected cause of illness.

An older adult client is prescribed ambulation with a walker after total hip arthroplasty surgery. Which statement is the best for the nurse to make to this client? 1. "Sit in a low chair for ease in getting up to use the walker." 2. "Tennis balls with a cross cut can be applied over the walker tips." 3. "You should store items in cabinets that are knee high during the post-operative period." 4. "Practice tying your own shoes before you begin ambulating."

2. "Tennis balls with a cross cut can be applied over the walker tips." — Cross-cut tennis balls are applied over the walker tips to make sliding easier. This statement is appropriate for the nurse to make to the client. Think like a nurse: The nurse needs to ensure that the client can safely use the walker to ambulate. Cross-cut tennis balls have been found effective to make sliding the legs of the walker easier. Hip flexion should be restricted to a 90-degree angle to prevent accidental dislocation of the hip prosthesis. Frequently used items should be placed at waist-height to prevent bending.

The nurse provides care for a client diagnosed with paranoid schizophrenia. The client tells the nurse, "There are really strange people in the corner laughing and saying bad things about me." Which response by the nurse is best? 1. "You have no reason to be ashamed." 2. "That sounds frightening. There is no one in the corner." 3. "What are they saying to you?" 4. "Your imagination is playing tricks on you because you are upset."

2. "That sounds frightening. There is no one in the corner." CORRECT— This response acknowledges the client's feelings, but also presents reality.

The home health nurse conducts a home visit with a client who is the first-time parent of a newborn. Which client statements require further assessment by the nurse? (Select all that apply.) 1. "My baby nurses about every other hour. Is that normal?" 2. "The baby's just so quiet and sleeps almost through the night!" 3. "I sleep when the baby sleeps, and I can't get anything done." 4. "I'm afraid of hurting my baby, and I can't keep my baby happy." 5. "Why does my baby throw out arms and legs when startled?"

2. "The baby's just so quiet and sleeps almost through the night!" - Lethargy and decreased activity are potential signs of neonatal hyperbilirubinemia or other problems and require further assessment. 4. "I'm afraid of hurting my baby, and I can't keep my baby happy." - Feelings of anxiety and despair may indicate postpartum depression. This statement requires further assessment.

The nurse teaches the spouse of a client about changing the dressing on a central venous catheter (CVC). The spouse asks, "What is that round foam disc for?" Which response by the nurse is accurate? 1. "The disc ensures that the insertion site stays clean and dry." 2. "The disc has anti-microbial properties to help prevent infection." 3. "The disc serves as an anchor to hold the catheter in place." 4. "The disc helps to keep the line from clotting."

2. "The disc has anti-microbial properties to help prevent infection." - The disc is impregnated with an anti-microbial product intended to help prevent infections at the insertion site. Think like a nurse: The nurse is aware that a central venous catheter is inserted using a sterile procedure, and all care of this site is done using the same approach. Because the access site provides a direct line into the client's vascular system, extra effort should be taken to reduce the risk of an infection. In this scenario, the client's spouse is asking about part of the existing dressing. The nurse will explain that the central line wound care kit includes a gauze sponge impregnated with an anti-microbial substance to help prevent infection of the site and subsequent infection in the client's body. This sponge is placed over the site and changed according to the manufacturer's recommendations.

The home health nurse visits a client who was hospitalized with chronic kidney disease and sent home on continuous ambulatory peritoneal dialysis (CAPD). Which statement made by the client most concerns the nurse? 1. "I still get constipated, even though I eat the high-fiber diet they told me to eat." 2. "The fluid draining out has looked cloudy the last couple of days." 3. "Sometimes I forget and carry the groceries in my left arm." 4. "I am worried about getting fat. I am gaining weight even though I am not eating more than usual."

2. "The fluid draining out has looked cloudy the last couple of days." - Cloudy or opaque dialysate output is the earliest sign of peritonitis, which is a major complication of peritoneal dialysis. The normal outflow drainage (effluent) is relatively clear and light yellow. This poses an immediate risk of harm to the client and is the highest priority concern to address. There is a high concentration of dextrose in the dialysate solution, which adds calories to daily intake. This may result in some weight gain. The nurse should provide counseling about dietary changes that may be needed. However, there is another answer choice that poses an immediate risk of harm to the client and is the priority concern.

The nurse receives a call from a client who is 37 weeks' gestation and reports that, "The baby has not moved much in the past 24 hours." The health care provider prescribes a nonstress test (NST). Which client statement indicates that client teaching about the nonstress test was successful? 1. "My blood will be checked one hour after drinking a glucose solution." 2. "The test is looking for the baby's heart beat to increase with activity." 3. "An infusion of oxytocin will start contractions to see how the baby's heart beat reacts to the stress." 4. "A good score for the nonstress test is at least a 7 out of 10."

2. "The test is looking for the baby's heart beat to increase with activity." — A nonstress test looks for an acceleration of the fetal heart rate (FHR) in relation to fetal activity. A favorable result is 2 or more FHR accelerations of 15 bpm lasting 15 seconds over a 20-minute interval. This statement indicates that client teaching about the nonstress test was successful. Think like a nurse: A non-stress test (NST) provides an indirect measurement of uteroplacental function. The NST is currently recommended twice weekly, after 28 weeks' gestation for clients with diabetes and other high-risk conditions, such as preeclampsia. The nurse should explain the procedure to the client, using the teach-back method. The nurse should also be ready to explain or reinforce the client's understanding of the NST result.

The nurse in the outpatient clinic counsels a client diagnosed with genital herpes. The client states, "I do not know how I keep getting reinfected because I am really careful." Which response by the nurse is best? 1. "What do you mean, 'I am really careful'?" 2. "The virus remains in your body in a dormant state." 3. "Are you sure that you protect yourself adequately?" 4. "Have you notified all of your sexual contacts?"

2. "The virus remains in your body in a dormant state." — This response provides the client with objective information to directly respond to the concern raised. The client should not engage in sexual activity while the lesions are present. To prevent spread, the client should either abstain from sex or use a condom. Think like a nurse: Therapeutic communication is a process where the nurse consciously influences, or helps, the client to an understanding through verbal communication. The nurse employs specific strategies encouraging the client to express feelings and ideas and strives to convey acceptance and respect during the interaction. It is essential that the nurse provide accurate information, in a non-judgmental manner, to this client regarding the herpes simplex virus. This client is not being reinfected, but the virus is being reactivated within the body. The nurse must determine if there are specific triggers occurring and provide education regarding decreasing these triggers to reduce the incidence of symptoms. The nurse should also provide education to this client related to safer sex practices to decrease the risk of infecting the client's sexual partner(s).

An older adult client who appears alert, oriented, and well-groomed shares with the nurse, "Lately, I am seeing things that are not there. It is always people. I am awake and sitting down and I know they are not there, but I see them." Which response by the nurse is appropriate? 1. "Has anyone in your family ever been diagnosed with schizophrenia?" 2. "What medications have you been taking recently?" 3. "Don't worry. You may actually have been asleep and dreaming." 4. "The Alzheimer organization offers some tests you may want to take."

2. "What medications have you been taking recently?" - This response is an open-ended question. Some medications can cause confusion and hallucinations. Older adult clients are more prone to experiencing these manifestations as the renal function declines with age, decreasing the rate at which medications are eliminated from the body. Think like a nurse: The nurse should mentally ask, "What factor can be assessed first that will provide important information without a jump to conclusions or disregard of client's concerns?" Older adult clients are at risk for medication toxicity due to a variety of age-related physiologic changes, including decreased renal clearance. Adverse drug reactions among older adult clients may manifest as altered mental status, delirium, orthostatic hypotension, incontinence, and gastrointestinal manifestations such as anorexia and nausea. Depending on the prescribed medication, monitoring the client's serum medication level may be indicated.

The nurse assesses a client who gave birth to a neonate 18 hours ago. The client has a temperature of 100.3°F (37.9°C). Which explanation does the nurse give the client regarding the cause of the temperature elevation? 1. "You have an infection of the endometrium." 2. "You are experiencing dehydration and fatigue." 3. "You are experiencing the onset of breast engorgement." 4. "You may have pyelonephritis."

2. "You are experiencing dehydration and fatigue." - During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of dehydrating effects of labor. Think like a nurse: Delivering a baby is an exciting time for the client. After delivery though the body knows that the fetus is no longer in the uterus and begins to change in order to accommodate a non-pregnant state. Excess fluid in the vascular system is eliminated, which can lead to temporary dehydration. Evidence of postpartum dehydration includes a low-grade fever, which can be quickly corrected by the client increasing oral fluid intake.

The nurse prepares a client diagnosed with epilepsy for a positron emission tomography (PET) scan. Which direction to the client is most important for the nurse to include? 1. "Be prepared to feel a warm sensation when the dye is injected." 2. "You will want to empty your bladder before the test." 3. "Be sure to remove all your jewelry before you enter the testing area." 4. "You will be asked to think in different ways during the test."

2. "You will want to empty your bladder before the test." — This ensures that the client will be comfortable and able to lie still throughout the procedure, which may last as long as 2 hours. After radioisotope administration, the client waits 30 to 45 minutes on stretcher or table so the substance can circulate to the brain. After this waiting period, the scan is performed.

The nurse notes that a toddler has honey-colored crusts, vesicles, and reddish macules around the mouth. Which statement is accurate when providing education to the client's parent? 1. "Your child has developed an irritation because of using a pacifier." 2. "Your child has an infection that can be treated with antibiotics." 3. "Your child has a food allergy and needs a restricted diet." 4. "Your child has been exposed to a sick child and should be isolated for a few days."

2. "Your child has an infection that can be treated with antibiotics." — The client is experiencing the skin eruptions found with impetigo. Symptoms of impetigo include reddish macules that become vesicles and then develop crusts. This infection is caused by bacteria Think like a nurse: Impetigo is caused by either streptococcus or staphylococcus. Often these bacteria enter the body when the skin has already been irritated or injured because of other skin problems such as eczema, poison ivy, insect bites, burns, or cuts. Raw skin that develops under the nose (due to a cold or allergies) also increases the child's risk for developing impetigo. However, impetigo also can develop in completely healthy skin. The parents should be taught about strict adherence with antibiotic treatment and preventing the spread of infection among the child's contacts at home or in the community.

The nurse prepares to obtain vital signs on a client. The client's previous blood pressure reading was 138/76 mm Hg and the client's pulse rate was 68 beats/minute. How long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? 1. 45 to 60 seconds. 2. 30 to 45 seconds. 3. 10 to 20 seconds. 4. 15 to 20 seconds.

2. 30 to 45 seconds. - To ensure that the diastolic has been determined, the cuff shouldbe released slowly until the mid-60s mmHg for someone with the client'sprevious reading. Since the cuff should be deflated at a rate of 2 to 3 mm persecond, a range of 90 mmHg will require 30 to 45 seconds. MATH: 138-76 = 62 62 + 30 mmHg (standard measurement to go above systolic) 92/3 = 30.7 and 92/2 = 46 30-45 seconds Think like a nurse: The American Heart Association states that the cuff should be deflated at a rate of about 2 to 3 mm Hg per second to obtain an accurate blood pressure measurement. The systolic pressure is the blood's force against the artery walls in order to pump blood to peripheral organs. The first sound the nurse hears means the systolic pressure is now greater than the pressure exerted on the artery by the inflated blood pressure cuff. The diastolic pressure is reflective of the pressure on the artery walls as the heart relaxes between forceful beats. Blood pressure readings are altered by cardiac output and arterial stiffness.

The nurse presents a program at the community center about risk factors for colorectal cancer. Which client does the nurse identify as being at risk for colorectal cancer? 1. An 18-year-old client who exercises five times weekly. 2. A 54-year-old client who eats a diet high in fat. 3. A 35-year-old client whose cousin was diagnosed with colorectal cancer at age 32. 4. A 45-year-old client who had an appendectomy during the teen years.

2. A 54-year-old client who eats a diet high in fat. — This client has two risk factors. Those include age (over 50 years) and a high-fat diet. A diet high in fat or low in fiber is a risk for colorectal cancer. Think like a nurse: The nurse evaluates each client for the risk factors for colorectal cancer. Risk factors for the development of colorectal cancer include being over 50 years of age and ingesting a diet high in fat. The nurse should counsel this client on ways to decrease the dietary impact of the risk factor. The nurse should teach the client specific foods to limit in the diet (e.g. whole milk products, fried foods, meats with fat, regular salad dressing). Assist the client in learning how to read food labels to identify the fat content of foods. Assist the client in finding appropriate substitutes to foods that are high in fat. Schedule the client to meet with the dietitian, if needed.

The nurse makes rounds on clients on the medical-surgical unit. It is important for the nurse to intervene for which observation? 1. A client 10 hours post-tonsillectomy sits in a bedside recliner watching television. 2. A client admitted 4 hours ago with a closed head injury lies flat in bed with legs elevated. 3. A client 3 days post-below knee amputation (BKA) lies prone in bed. 4. A client admitted yesterday with COPD sits with the head of the bed elevated 45 degrees.

2. A client admitted 4 hours ago with a closed head injury lies flat in bed with legs elevated. - Clients with closed head injuries are prone to increased intracranial pressure. A modified Trendelenburg is dangerous for the client. Elevate head of bed 30 to 45 degrees to promote venous drainage. Think like a nurse. Proper client positioning in consideration of illnesses or procedures is an essential and frequent nursing function. For the client with the potential for increased intracranial pressure, reducing pressure from venous return and arterial blood pressure is partially accomplished by positioning the client with the head and upper body raised into the semi-Fowler position, which promotes blood drainage. Standard Fowler may be considered, but high-Fowler position is avoided unless autonomic dysreflexia is suspected.

The nurse provides care to several hospitalized clients. Which clients does the nurse monitor closely for the development of pneumonia? (Select all that apply.) 1. A client who has experimented with cigarettes. 2. A client diagnosed with cystic fibrosis. 3. A client diagnosed with Addison disease. 4. An adult client diagnosed with hypertension. 5. A client with a fractured rib due to an auto accident. 6. A client in Buck traction due to a fractured hip.

2. A client diagnosed with cystic fibrosis. - Underlying lung disease is a risk factor for pneumonia. Cystic fibrosis causes chronic obstructive pulmonary disease and excess mucous production, as well as pancreatic exocrine deficiency. 5. A client with a fractured rib due to an auto accident. - The pain of a fractured rib causes shallow breathing and easily leads to pneumonia due to lack of lung expansion. 6. A client in Buck traction due to a fractured hip. - This client in Buck traction will be on bed rest, which decreases lung expansion. Therefore, the nurse should monitor this client closely for the development of pneumonia. Think like a nurse: Certain health problems increase the risk of developing pneumonia. The client with cystic fibrosis is at risk because the disease causes a chronic lung disorder. Pain of a fractured rib would be exacerbated by deep breathing and coughing. Shallow breathing with this disorder increases the risk for the development of pneumonia. Being in musculoskeletal traction reduces lung expansion and promotes stasis of pulmonary secretions, increasing the risk for pneumonia.

The nurse plans care for four antepartum clients who have Rh negative blood. To which client does the nurse plan to administer Rh O (D) immune globulin? 1. A client who is at 35 weeks' gestation and tests positive for human immunodeficiency virus (HIV) infection. 2. A client who is at 10 weeks' gestation and has an ectopic pregnancy. 3. A client who is at 28 weeks' gestation and has a nonreactive non-stress test. 4. A client who is at 20 weeks' gestation and has proteinuria.

2. A client who is at 10 weeks' gestation and has an ectopic pregnancy. - Clients who have Rh negative blood are at risk for developing antibodies against Rh positive blood if the fetus has Rh positive blood. Therefore, a client who is Rh negative within the first 12 weeks' of pregnancy should receive a 300 mcg dose following exposure to 30 mL of fetal blood, which can occur during miscarriage, elective abortion, or ectopic pregnancy.

The nurse at a community health center is notified that a group of clients has been exposed to a hazardous chemical. Which client does the nurse see first? 1. A client who says the chemical spilled onto the legs. 2. A client who reports inhaling the chemical. 3. A client who reports being diagnosed with hypertension and type 2 diabetes. 4. A client who reports swallowing the chemical.

2. A client who reports inhaling the chemical. - Inhalation of the chemical results in immediate absorption and can impair oxygen exchange. This client should be assessed first to ensure airway patency and adequacy of breathing. Think like a nurse: The nurse should think, "Which client has life-threatening injuries that require immediate attention?" While a client with skin exposure needs decontamination, a treatment delay is not life-threatening. Injuries that affect circulation, airway, and breathing always take priority. Chemical inhalation can cause chemical burns in the airway. Edema caused by the burns can cause airway obstruction. Additionally, damage sustained from chemical inhalation can also interfere with gas exchange. A client with hypertension and type 2 diabetes shows no signs of complications, so treatment can be delayed. Chemical ingestion poses a serious health risk, but does not require emergent intervention to preserve the client's circulation, breathing, or airway.

The nurse supervises care on the medical-surgical unit. Which situation does the nurse attend to first? 1. The unlicensed assistive personnel (UAP) enters the room of the client diagnosed with Pneumocystis jiroveci pneumonia while wearing gown, N95 mask, and gloves. 2. A client who returned to the unit after a right pneumonectomy is placed in a room with a client diagnosed with emphysema who is receiving IV antibiotics. 3. The family of a client reports that the toilet in the client's bathroom is overflowing. 4. A client diagnosed with tuberculosis is ready for discharge and waiting for discharge instructions.

2. A client who returned to the unit after a right pneumonectomy is placed in a room with a client diagnosed with emphysema who is receiving IV antibiotics - Post-operative clients are considered "clean" or uncontaminated and should not be placed with the client who is considered contaminated. The client who is diagnosed with emphysema and receiving IV antibiotics is considered contaminated. Therefore, this situation requires immediate intervention by the nurse. Think like a nurse: In determining which client to see first, the nurse thinks about who is most unstable or at highest risk for injury. Infection control should be the priority for the client recovering from surgery. The client with a pneumonectomy is at risk for contracting an infection very easily and should not be roomed with a client who has the potential for an infection. While several of the other clients have needs, none of them are at current risk for injury.

The nurse reviews the medical record of a client who is 24 hours post-operative. Which assessment documented in the client's record requires an intervention by the nurse? 1. A client has requested pain medicine every 6 hours since returning from surgery. 2. A client's urine output is 240 mL during the previous 12-hour shift. 3. A client has ambulated twice in the room. 4. A client has not had a bowel movement since surgery.

2. A client's urine output is 240 mL during the previous 12-hour shift. — A urine output of less than 30 mL per hour requires further evaluation by the nurse. Once the nurse assesses the situation, the next action is to notify the health care provider. Think like a nurse: The nurse needs knowledge regarding the normal functioning of the body, and of the conditions that can alter normal functioning. Anesthesia can interrupt normal bodily functions. For the client recovering from surgery, these bodily functions may return slowly. However, renal function is rarely negatively impacted by anesthesia and should be monitored for routine function. The kidneys normally produce 30 mL of urine per hour. If the client had a urine output of 240 mL of urine over the last 12 hours, the kidneys are producing 20 mL/hour, which is less than optimal. This finding should be reported to the health care provider for the prescription of interventions.

The pediatric nurse conducts a parent education class related to disciplinary measures for young children. Which information is appropriate for the nurse to emphasize? 1. Explain to the child why an act is wrong, especially if it relates to moral issues. 2. A good rule of thumb for time-outs is 1 minute for each year of the child's age. 3. If a child cries and refuses a time-out, add another time-out period to the initial one. 4. Once the child has calmed down after disciplinary measures, review what occurred.

2. A good rule of thumb for time-outs is 1 minute for each year of the child's age. - One minute for each year of the child's age is the recommended practice for time-outs. For toddlers, the conception of time is limited and 1 minute can seem like hours. For preschoolers, time is still not fully understood and is interpreted within their own frame of reference. A kitchen timer with an audible bell can be useful so the child knows, and the parent does not forget, when the time-out is over. Think like a nurse: The nurse should mentally ask, "What is a realistic expectation for a young child to comply with time-out discipline?" Disciplining young children can be challenging. An effective suggestion is for the parent to use a time-out. This is where the child is not permitted to play or interact with anyone for a predetermined period of time. A time-out stops the undesirable behavior and reinforces the concept of consequences. However, the parent does not need to over discipline the child by expecting a time out longer than the child can realistically tolerate. The length of time for the time-out is determined by the child's age, which is 1 minute for every year of age.

The nurse performs a physical assessment on a client diagnosed with bulimia nervosa. Which finding warrants an immediate referral to the health care provider? 1. Bilateral parotid gland enlargement. 2. A hoarse voice that is barely audible. 3. Grey to black eroded teeth with foul odor. 4. Multiple papulopustular skin eruptions.

2. A hoarse voice that is barely audible. - The client with a hoarse voice is at high risk for tracheoesophageal fistula from esophageal tear secondary to forceful vomiting. Laryngitis is a danger sign. Think like a nurse. Bulimia nervosa is a type of feeding disorder that starts in adolescence and presents a variety of symptoms from recurrent vomiting that begins in the oral cavity and may reach down to the larynx, causing laryngeal and voice disorder alterations. Nurses should consider bulimia as one of the causes of clinical pictures similar to gastroesophageal reflux disease (GERD). Although not all voice changes in clients with bulimia nervosa are life-threatening, the nurse should refer the client for further evaluation for tracheoesophageal fistula.

The nurse reviews the health care needs for a group of clients. Which client does the nurse identify as being at the highest risk for developing a Dupuytren contracture? 1. An older adult female client from Russia diagnosed with osteoarthritis. 2. A middle-age adult male client from Norway diagnosed with diabetes. 3. An adult female client from Haiti who has a fractured femur. 4. A school-age male client from Poland diagnosed with Duchenne muscular dystrophy.

2. A middle-age adult male client from Norway diagnosed with diabetes. — A Dupuytren contracture is a slow progressive contracture of the palmar fascia causing flexion of the fourth and fifth fingers. This results from an inherited autosomal dominant trait. It occurs most often in men over 50 years of age (middle-age) of Scandinavian or Celtic descent, and is associated with diabetes, gout, arthritis, and alcoholism. The client's age and diagnosis are risk factors. Think like a nurse: Dupuytren contracture is a contracture of the fourth and fifth fingers of the hand. This condition is associated with diabetes mellitus, gout, arthritis, and alcoholism, and is believed to have a genetic link. Other risk factors include male gender, middle-age, and being of Scandinavian descent. Female gender, Haitian descent, and muscular dystrophy are not risk factors for the development of this contracture.

The nurse is admitting a client diagnosed with chronic adrenal insufficiency. Which roommate assignment will cause the nurse to intervene? 1. An older adult client diagnosed with a cerebrovascular accident. 2. A middle-aged adult client diagnosed with pneumonia. 3. A young adult diagnosed with type 1 diabetes mellitus. 4. An adult client diagnosed with a fractured femur.

2. A middle-aged adult client diagnosed with pneumonia. — A client with adrenal insufficiency is at high risk for infection, and any infection can cause circulatory collapse due to lack of corticosteroid production. The client with pneumonia poses a high risk of infection. This roommate assignment should be immediately changed. Think like a nurse: Before making the room assignment, the nurse should consider the pathophysiological process causing the disease process. In adrenal insufficiency, there is an inadequate amount of glucocorticoids in the system. This deficiency increases the risk for the client to develop an infection. Any client with an infection should be immediately removed as a potential roommate for the client. Any client without an active infection would be an appropriate roommate for the client with adrenal insufficiency.

The psychiatric inpatient unit has four new admissions. Which client does the nurse see first? 1. A salesperson diagnosed with depression after the baby was born with Down syndrome and the spouse threatened to file for divorce. 2. A police officer with a history of post-traumatic stress disorder (PTSD) who was admitted with agoraphobia after two of his co-officers were killed. 3. A computer programmer admitted with a diagnosis of generalized anxiety disorder who has extensive debt and just filed for bankruptcy. 4. A college student admitted for depression and anxiety after a sibling committed suicide and a parent was recently diagnosed with lung cancer.

2. A police officer with a history of post-traumatic stress disorder (PTSD) who was admitted with agoraphobia after two of his co-officers were killed. — This client has a high potential for violence to self and/or others. There is easy access to weapons and knowledge of how to use them. Agoraphobia particularly causes this client to be uneasy in the new surroundings and potentiates acting out in fear. Think like a nurse: To be diagnosed with post-traumatic stress disorder (PTSD), an adult must have all the following for at least 1 month: at least one re-experiencing symptom; at least one avoidance symptom; at least two arousal and reactivity symptoms; and at least two cognition and mood symptoms. The nurse should scan the room for objects that may be used as a potential weapon. Agoraphobia is the fear of being helpless in a situation from which escape may be difficult or embarrassing and is often characterized by anxiety, panic, and avoidance of the situation (e.g., public places). Agoraphobia treatment usually includes both psychotherapy and medication. The nurse should follow up with the mental health provider on these interventions, keeping in mind that it takes time to resolve agoraphobia.

A nurse in a rural community assesses residents for risk factors for heart disease. The nurse determines that which resident is at greatest risk to develop heart disease? 1. A resident who participates in a competitive weight lifting program. 2. A resident diagnosed with type 1 diabetes that is poorly controlled. 3. A resident whose grandfather died of heart failure at age 72. 4.A resident who drinks a glass of beer every night.

2. A resident diagnosed with type 1 diabetes that is poorly controlled. — An elevated blood glucose level places a client at risk for heart disease. Diabetes is considered a cardiovascular risk equivalent. Think like a nurse: The nurse needs to consider the connection between heart disease and other presenting factors. Which of the presenting factors have a known negative effect on the cardiovascular system? The nurse needs to remember that the complications of diabetes mellitus are divided into macro-vascular or micro-vascular changes. Both of these types of complications adversely effect the heart's function in the client with diabetes mellitus. The client with diabetes mellitus who is poorly controlled is at the greatest risk for a cardiovascular event.

The nurse provides care for clients on an acute pulmonary unit. The nurse prepares a written report for the next shift. Which information is most critical to communicate to the next shift? 1. Abnormal laboratory work, arterial blood gas reports, nutritional intake, and vital signs for the shift. 2. Abnormal assessment findings, activity tolerance, and variances in vital signs during the shift. 3. Name of each client 's health care provider, the date each client was admitted, dietary intake for each client, and each client's general condition. 4. Urinary output, fluid intake, visits by the attending health care provider, vital signs, and any respiratory problems encountered.

2. Abnormal assessment findings, activity tolerance, and variances in vital signs during the shift. — This information is documented, but because it may reflect variances in the client's status, it should be included in the hand-off report. The nurse on the next shift may not be able to review all client records immediately. Think like a nurse: Hand-off communication should include information that is the most critical for the oncoming nurse to know in order to provide safe effective care. Abnormal assessment findings, activity tolerance, and changes in vital signs would be the most pertinent for the clients on this care area. Items that can be found in the medical record are not necessarily reported, unless there is a change such as an abnormal laboratory value, change in urine output, or exacerbation of the health problem.

The nurse supports the leg as a client bends and flexes the knee. Which type of therapeutic exercise is the nurse assisting the client to perform? 1. Passive. 2. Active-assistive. 3. Active. 4. Resistive.

2. Active-assistive. — In active-assistive exercise, the distal part of the limb is supported when the client actively takes the joint through range-of-motion. Think like a nurse: There are a variety of reasons why a client would need to perform exercises that target a specific joint. A client who is on bed rest would need to perform range-of-motion exercises to maintain adequate joint functioning and to promote circulation. However, in the event that the joint is injured, the nurse may need to assist with the movements. One approach is to support below the level of the joint being exercised. This action reduces strain on the muscles surrounding the joint while ensuring the joint is taken through complete range of motion.

The nurse provides care to a client reporting a cluster headache. Which nursing action is appropriate when providing care for this client? 1. Prepare for a head CT scan. 2. Administer 100% oxygen via facemask. 3. Measure erythrocyte sedimentation rate. 4. Withhold prescribed sublingual sumatriptan.

2. Administer 100% oxygen via facemask. - Acute treatment of a cluster headache includes the provision of 100% oxygen delivered at a rate of 6 to 8 liters per minute for 10 minutes. This may be repeated after a 5-minute rest. Oxygen relieves the headache by causing vasoconstriction and increasing the synthesis of serotonin in the central nervous system. Think like a nurse: There are a variety of types and reasons for the development of a headache. Prior to determining the best intervention for this client, the nurse should review the pathophysiology related to a cluster headache. A cluster headache can occur anywhere within the head and cause sudden and acute pain. The application of 100% oxygen is the identified treatment to reduce the symptoms. Oxygen causes the blood vessels to constrict and helps reduce the throbbing pain. Other interventions include specific medication, which should be provided after oxygen prescribed oxygen therapy.

A client who received an intravenous dose of penicillin G develops restlessness, wheezing, and swelling of the lips and tongue. After applying oxygen via nonrebreather face mask, which action will the nurse take next? 1. Initiate an intravenous infusion of warmed 0.9% sodium chloride. 2. Administer epinephrine 1:1000 subcutaneously. 3. Give subcutaneous diphenhydramine. 4. Insert an indwelling urinary catheter.

2. Administer epinephrine 1:1000 subcutaneously. - The client is exhibiting symptoms of an anaphylactic reaction. While the subcutaneous route is preferred, epinephrine can also be administered by the IV and IM routes. Epinephrine is the medication of choice for anaphylaxis as it can activate three types of adrenergic receptors and thus reverse the reaction to the antigen. This leads to increased blood pressure, decreased epiglottal edema, and decreased bronchoconstriction. The nurse can give subcutaneous diphenhydramine, an antihistamine, to relieve itching and discomfort. However, airway issues are of greater priority.

The nurse is considered professionally negligent by delegating which task to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1. Measure a client's temperature rectally. 2. Administer eye drops stored in the client's room. 3. Increase a client's intravenous fluid flow rate. 4. Insert a straight, intermittent urinary catheter. 5. Change a peripheral intravenous site dressing. 6. Administer a cleansing tap water enema.

2. Administer eye drops stored in the client's room. - Medication administration cannot be delegated to an UAP. Even multidose medications stored in the client's room, whether at bedside or locked in the client's personal medication drawer, cannot be given by the UAP. 3. Increase a client's intravenous fluid flow rate. - Regulation of IV flow rate cannot be delegated to UAP. 4. Insert a straight, intermittent urinary catheter. - Invasive procedures require knowledge of asepsis and cannot be delegated to the UAP. 5. Change a peripheral intravenous site dressing. - Changing a peripheral IV site dressing requires knowledge of asepsis and assessment of peripheral IV site, and cannot be delegated to the UAP. Think like a nurse: When delegating tasks to the unlicensed assistive personnel (UAP), the nurse must recall the scope of practice for the UAP. The nurse is responsible for medication administration, monitoring IV fluid infusions, performing invasive procedures (e.g., intermittent urinary catheterization), and changing dressings on areas that need to be assessed. Therefore, these procedures cannot be delegated. The UAP can safely measure vital signs and administer a cleansing enema after the nurse validates that the skill can be safely performed. Therefore, it is appropriate to delegate these tasks to the UAP.

The nurse provides care to a client who is admitted to the emergency department (ED) with a serum glucose level of 32 mg/dL (1.8 mmol/L). The client is drowsy and has cold, clammy skin. The nurse anticipates implementation of which priority intervention? 1. Recheck the client's serum glucose level. 2. Administer glucagon IM. 3. Provide the client with orange juice. 4.Obtain an EKG on the client.

2. Administer glucagon IM. - For the hypoglycemic client who demonstrates decreased level of consciousness, the priority intervention is administration of glucagon. If an IV access device is in place, dextrose 50% (D50) may be administered intravenously instead of glucagon IM. Administration of oral fluid is contraindicated due to the client's decreased level of consciousness. Rechecking the client's serum glucose level and obtaining an EKG are appropriate actions. However, administration of glucagon is the priority for this client. Think like a nurse: The nurse must recognize assessment findings that indicate hypoglycemia and be prepared to implemented preferred treatment. Hypoglycemia affects level of consciousness and all body functions. The client literally has no fuel in the form of glucose to perform any actions. Because the client is lethargic, oral intake is avoided due to the risk for aspiration. Glucagon, which stimulates the release of glucose by the liver, is administered by IM injection. As the client's condition improves, the nurse conducts additional assessments, which will determine implementation of additional treatment measures.

The nurse provides care for a client diagnosed with tuberculosis. Which transmission-based precautions will the nurse implement? 1. Standard. 2. Airborne. 3. Droplet. 4. Contact.

2. Airborne. — Tuberculosis is transmitted by airborne droplets. The nurse implements airborne precautions. Think like a nurse: Clients with pulmonary or laryngeal tuberculosis (TB) are placed on airborne precautions, in addition to standard precautions. The nurse and all staff members should wear an N95 mask (fit-tested size). Ideally, the client should have a private room with a negative pressure. Discontinue precautions only when the likelihood of infectious TB disease is deemed negligible and either there is another diagnosis that explains the clinical syndrome or the results of three sputum smears for acid-fast bacillus (AFB) are negative. Each of the three sputum specimens should be collected 8 to 24 hours apart, and at least one should be an early morning specimen.

The charge nurse in the emergency department receives a call from paramedics who are en route with four patients involved in a motor vehicle accident (MVA). Which client does the nurse plan to see first based on paramedic report? 1. An adult with an obvious deformity to the left knee, weak pedal pulses bilaterally, and reports of pain. 2. An adult with a decreased level of consciousness, a heart rate of 126 beats/min, and no obvious injuries. 3. A child with an obvious deformity to the right forearm, a strong radial pulse, and reports of pain. 4. A child, crying uncontrollably, with an abrasion on the forehead and a heart rate of 112 beats/min.

2. An adult with a decreased level of consciousness, a heart rate of 126 beats/min, and no obvious injuries. — This client may be experiencing hypovolemic shock related to an unknown hemorrhagic injury and therefore takes priority. Think like a nurse: When deciding which client to assess first, the nurse utilizes the integrated processes that enhance critical thinking and clinical judgement. The nurse first initiates the concepts of airway-breathing-circulation (ABCs), which are key to survival. The clients with obvious deformities, reporting pain, or crying have an adequate airway. They may have issues with bleeding and circulation; however, at this time, seeing these clients can be delayed. The client with decreased level of consciousness, a rapid heart rate, and no obvious signs of injuries is demonstrating hypovolemic shock possibly caused by internal bleeding injuries. The change in level of consciousness could be from inadequate oxygenation caused by a low circulating blood volume. The rapid heart rate is caused by insufficient amount of blood to support organ function.

The nurse supervises the unlicensed assistive personnel (UAP). Which tasks can the nurse safely delegate to the UAP? (Select all that apply.) 1.Determine a client's risk for pressure injury development. 2. Anchor a nasogastric tube to a client's gown. 3. Provide nasal hygiene to a client with a nasogastric tube. 4. Answer questions about a patient-controlled analgesia (PCA) pump. 5. Change a client's peripheral intravenous (IV) site dressing.

2. Anchor a nasogastric tube to a client's gown. - This action can be delegated to the UAP. At this point, the nasogastric tube has already been secured to the bridge of the client's nose by the nurse. 3. Provide nasal hygiene to a client with a nasogastric tube. - This action can be delegated to the UAP. Think like a nurse: Unlicensed assistive personnel (UAP) do not perform assessment and evaluation of nursing care or conduct client education, as these are the responsibilities of the nurse. The UAP can take vital signs, provide comfort measures, document intake and output, assist clients with activities of daily living (e.g., bathing). In some institutions, they can draw blood and perform a 12-lead ECG. It is essential for the nurse to provide a proper hand-off to the UAP and to verify the UAP's knowledge and experience doing certain tasks. The nurse should be familiar with the UAP's job description.

The nurse provides care for clients in a long-term care facility. A client is diagnosed with Legionnaire disease. Which action by the nurse is appropriate? 1. Place the client on droplet precautions. 2. Ask for 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 for maintenance on the institution's hot water tank. — Legionnaire disease is caused by Legionella pneumophila, which is found in warm, stagnant water such as hot water tanks and is spread by the aerosolized route from the environmental source to the client. Maintenance on the hot water heater is required to eliminate the source. Think like a nurse: The nurse assesses the environment of clients and evaluates for any safety risks present. Legionnaire disease is caused by a microorganism that proliferates in warm, standing water. Since this disease was diagnosed in a client who resides in a long-term care facility, all the hot water tanks need to be cleaned and flushed to clear the microorganism out of the facility's water system. This prevents other clients from becoming infected. Clients should be monitored for symptoms of Legionnaire disease, such as fever, body aches, and cough. Clients who are 50 years of age and older, clients who smoke, clients with chronic lung disease, clients with immunodeficiency, and clients with underlying diseases (e.g., diabetes, renal disease, hepatic disease) are at highest risk for infection with Legionnaire disease.

The health care provider prescribes acetaminophen 650 mg PO for a client with an allergy to codeine. The nurse administers acetaminophen with codeine PO. The nurse then notifies the health care provider and administers diphenhydramine 50 mg IM as prescribed. After informing the client of the error, which action is most important for the nurse to take? 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 symptoms of a reaction to codeine. 4. Clarify why the nurse administered the diphenhydramine.

2. Ask the client to remain in bed for 3-4 hours. — The combination of acetaminophen with codeine and diphenhydramine can cause drowsiness and increase the client's risk for falls. The nurse should request that the client stay in bed for several hours to reduce this risk. Think like a nurse: The nurse needs an understanding of the effects of medications. In addition, the nurse's primary concern is always client safety. Recognition of the expected effects of the medications given to the client indicates an increased risk for falls. The incorrectly provided medication includes an opioid, which can cause sedation. The diphenhydramine can cause drowsiness. The client's risk for falling is increased because of the adverse effects of both of these medications.

The nurse provides care to a client diagnosed with acute renal failure secondary to severe kidney infection. During the oliguric phase, which assessment finding does the nurse expect to observe? (Select all that apply. ) 1. Urine specific gravity is 1.039. 2. Azotemia. 3. Pruritus. 4. Nausea. 5. Serum potassium (K+) is 6 mEq/L (6 mmol/L).

2. Azotemia. - Azotemia, which is a classic sign of acute renal failure, refers to the buildup of nitrogenous waste products in the bloodstream. Hallmarks of azotemia include increased serum BUN and increased serum creatinine. 3. Pruritus. - With acute renal failure, pruritus (itching) may occur. Although some scientists believe a buildup of urea in the bloodstream contributes to this condition, research has not yet conclusively identified the cause of pruritus in relationship to kidney dysfunction. 4. Nausea. - With acute renal failure, the buildup of metabolic waste products in the bloodstream may cause nausea and vomiting. 5. Serum potassium (K+) is 6 mEq/L (6 mmol/L). - Normal potassium ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Acute renal failure causes impaired filtration of fluid and electrolytes. During the oliguric phase, an increase in serum potassium (hyperkalemia) is typically seen. Think like a nurse: The kidneys remove body wastes and regulate fluid and electrolyte balance in the body. When the kidneys fail, normal functioning is effected. Azotemia, itching, and nausea occur because nitrogenous waste products and urea cannot be removed from the body. The potassium level can reach dangerously high levels because the injured kidney is unable to remove excess potassium from the body.

The nurse notes an increase in the number of families seeking care for infants with bronchiolitis and respiratory syncytial virus (RSV). Which item is most important for the nurse to have available to provide to the parents of these infants? 1. Antibacterial soap. 2. Bulb syringe. 3. Stool sample kit. 4. Thermometer.

2. Bulb syringe. - A bulb syringe is required for airway management. Infants with these infections can have nasopharyngeal secretions that block airway passages. Young infants are obligatory nose breathers. Parents should be instructed on how to use the syringe before feedings and as necessary. Think like a nurse: An infant is unable to clear the airway and would need to have secretions removed through the use of a bulb syringe. This is the item that the nurse should provide to the parents of infants with an upper respiratory or respiratory syncytial virus (RSV) infection. Thorough and frequent hand washing with warm water and soap should also be emphasized with the parents. Fever is not an issue with an RSV infection.

A client with heart failure and type 1 diabetes mellitus is found unresponsive. Which action will the nurse take first? 1. Open four packets of sugar and empty them on the client's tongue. 2. Call for help. 3. Begin chest compressions. 4. Administer glucagon subcutaneously, as prescribed.

2. Call for help. - After establishing unresponsiveness, the nurse should call for help, check for breathing, and assess for a pulse. - The nurse should begin chest compressions immediately, if the client is not breathing (or only gasping) and does not have a pulse. - The nurse needs to further assess the client instead of assuming that hypoglycemia is the cause of unresponsiveness. After determining that hypoglycemia is the cause, the nurse should administer glucagon by subcutaneous or intramuscular injection, as prescribed. Think Like A Nurse: The nurse can implement different interventions when finding a client unresponsive. The first action would be to implement the airway, breathing, and circulation (ABCs) of emergency care and assess for an airway. Since an airway is not an identified issue in this scenario, the nurse should proceed to call for help. Even though the client has a history of heart failure and type 1 diabetes mellitus, there is not enough information to determine if the client is demonstrating a hypoglycemic reaction or an acute cardiovascular event. Without further assessment information, the best action is to first call for help.

When providing care to a group of postoperative clients, which interventions does the charge nurse delegate to the LPN/LVN? (Select all that apply.) 1. Palpating the suprapubic area of a client who has not voided in 6 hours. 2. Changing the gauze dressing for a client who had a hip pinning yesterday. 3. Teaching the client how to self- administer enoxaparin injections. 4. Titrating oxygen administration according to prescribed parameters. 5. Following up on a report of a 100.6 F (38.1 C) temperature in a client after an appendectomy. 6. Auscultating the abdomen of a client who is nauseated after eating broth.

2. Changing the gauze dressing for a client who had a hip pinning yesterday. - The LPN/LVN may change dressings, so the nurse can delegate this task. 4. Titrating oxygen administration according to prescribed parameters. - An LPN/LVN may titrate O2 within specified parameters. Therefore, the nurse can delegate this task. Think like a nurse: When delegating to the LPN/LVN, the nurse recalls the scope of practice for this member of the health care team. The LPN/LVN can safely collect data, implement the plan of care, and report changes in client conditions to the nurse. Changing a dressing and adjusting oxygen flow according to a prescribed plan of care fall within the LPN/LVN's scope of practice. The nurse will not delegate tasks or skills that include assessment and teaching.

The nurse in the emergency department assesses a client diagnosed with burns. Which observation most concerns the nurse? 1. Redness and swelling with fluid-filled vesicles noted on right arm. 2. Charred, waxy, white appearance of skin on the left leg. 3. Reddened blotchy painful areas noted on the trunk. 4. Blistering and blanching of the skin noted on the back.

2. Charred, waxy, white appearance of skin on the left leg. — This describes a full-thickness burn. All the skin is destroyed and the muscle and bone may be involved. The substance that remains is called eschar and is dry to the touch. Full-thickness burns do not heal spontaneously and require grafting. All functions of the skin are lost. Think like a nurse: Clients who sustain burn injuries often exhibit varying degrees of burns, each of which is associated with unique nursing and medical considerations. A full-thickness burn, sometimes referred to as a third-degree burn, affects multiple skin layers and underlying structures, including muscle and nerves. Third-degree burns allow for loss of fluid and hematological components, are more prone to infection, present a more difficult recovery process, and are generally more complex compared to other classifications of burns.

The nurse provides care for a client diagnosed with laryngeal cancer who is scheduled for a laryngectomy. Which action does the nurse implement to assess the client's laryngeal nerve function? 1. Observe for excessive salivating. 2. Check the ability to swallow. 3. Assess the amount of neck edema. 4. Tap the neck and observe for facial twitching.

2. Check the ability to swallow. - This effectively demonstrates the ability of the nerve to support the esophageal functions. Think like a nurse. The nurse applies knowledge of anatomy and physiology and evaluates laryngeal nerve function by assessing the client's ability to swallow. A laryngoscopy or bronchoscopy may be required for definite diagnosis. Concurrent injury to the laryngeal nerves may cause difficulty breathing. Laryngeal cancer can damage the laryngeal nerve. However, laryngeal nerve damage has also been seen in thyroidectomies, endotracheal intubation, and viral infection affecting the laryngeal nerves.

A client in early labor reports having urinary incontinence. Which action will the nurse take first? 1. Instruct client to void more frequently. 2. Check the pH of the fluid. 3. Assess for dilatation and effacement. 4. Change the bed linens.

2. Check the pH of the fluid. — The nurse needs to determine if the fluid is amniotic fluid (alkaline) or urine (acidic). The pH of the fluid needs to be assessed before making any recommendations or changes to care.

A client experiences a flail chest from a motor vehicle crash. Which finding does the nurse expect when assessing this client? 1. Chest on the affected side expands outward during inspiration and is pulled inward during expiration. 2. Chest on the affected side is pulled inward during inspiration and bulges outward during expiration. 3. A sucking sound is heard on inspiration and expiration. 4. Absent or restricted movement noted on the affected side.

2. Chest on the affected side is pulled inward during inspiration and bulges outward during expiration. — A flail chest is caused by fractures of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically. The chest then pulls in during inspiration and bulges outward during expiration. Think like a nurse: Flail chest requires immediate intervention to ensure adequate oxygenation, as the segment of the chest wall that is flail is unable to contribute to lung expansion. If the flail segment involves a great proportion of the chest and sternum, mechanical ventilation may be necessary to ensure adequate ventilation and oxygenation. The nurse should obtain a baseline ABG and assess the client for other sources of respiratory compromise.

A nurse with postpartum care experience is reassigned to a medical-surgical care area. Which client will the charge nurse assign to the postpartum care nurse? 1. Client receiving tissue plasminogen activator. 2. Client recovering from a sympathectomy as treatment for Raynaud disease. 3. Client receiving treatment for sickle cell crisis. 4. Client recovering from pacemaker insertion surgery to treat a dysrhythmia.

2. Client recovering from a sympathectomy as treatment for Raynaud disease. — Raynaud disease is a form of intermittent arteriolar vasoconstriction. A sympathectomy interrupts the sympathetic nerves. This client is stable and can be assigned to the nurse with postpartum care experience.

The nurse reviews laboratory values on assigned clients. Which clients require further assessment? (Select all that apply.) 1. Client with pyelonephritis whose white blood count has decreased from 17,000 microliter (17 × 109/L) to 10,500 microliter (10.5 × 109/L). 2. Client with an acute kidney injury whose serum creatinine has increased from 1.8 to 2.6 mg/dL (159.12 to 229.84 µmol/L). 3. Client with chronic kidney disease whose glomerular filtration rate has increased from 45 to 60. 4. Client being treated for dehydration whose urine specific gravity has increased from 1.02 to 1.04. 5. Client with benign prostatic hypertrophy whose urine pH has decreased from 7 to 5.1. 6. Pregnant client whose urinary protein has increased from 0 to trace.

2. Client with an acute kidney injury whose serum creatinine has increased from 1.8 to 2.6 mg/dL (159.12 to 229.84 µmol/L). - An increase in creatinine requires follow up. The client's acute kidney injury may progress to kidney failure. 4. Client being treated for dehydration whose urine specific gravity has increased from 1.02 to 1.04. - An increase in specific gravity does not indicate an improvement in the client's hydration. An increase means that urine is becoming more concentrated.

The nurse receives hand-off communication from the previous shift about assigned clients with mental health disorders. Which client will the nurse see first? 1. Client with mania and bipolar disease threatening to sue the primary nurse for negligence. 2. Client with depression stating that things are better and that he will be leaving soon. 3. Client with delusions stating a plan to kill the spouse after being discharged. 4. Client with schizophrenia denying hearing voices.

2. Client with depression stating that things are better and that he will be leaving soon. - The client with depression who states that things are better and will be leaving soon may be an indirect suicide threat with a plan. The nurse must clarify the client's statement, as this client can be in immediate danger. Think like a nurse: A client with depression is at risk for suicide and may feel "better" once a plan to commit suicide is made. This client should be assessed immediately for suicide ideation and placed on suicide precautions.

The nurse provides health promotion for several clients. Which data from the client's genogram indicates to the nurse to follow-up with additional assessment questions? 1. A sibling was born with one kidney. 2. Client's mother has breast cancer. 3. Client's father was treated for tuberculosis. 4. A sibling has bilateral cataracts.

2. Client's mother has breast cancer. - Family history of breast cancer is an important risk factor, especially if the involved family member is a first-degree relative (e.g., mother, sister, daughter). Having any first-degree relative with breast cancer increases a woman's risk of breast cancer 1.5 to 3 times, depending on age.

A nurse prepares to perform blood pressure screenings at a health fair in the local community center. Which part of the preparation receives the most attention? 1. Ensure that there will be several quiet rooms near the main gathering area. 2. Collect blood pressure cuffs of varied sizes. 3. Arrange low-cholesterol snacks for participants. 4. Procure booklets that explain hypertension in simple language.

2. Collect blood pressure cuffs of varied sizes. — Having blood pressure cuffs of varied sizes is essential to ensure accurate blood pressure readings. People attending the fair almost certainly will vary in arm size. A cuff that is too small will produce a falsely high reading, while a cuff that is too large will produce a falsely low reading. The nurse will ensure the ability to obtain accurate readings. Think like a nurse: Since the blood pressure screening is being held for a variety of people, the nurse should prepare to have different blood pressure cuff sizes so that the measurements will be accurate. Some people may enjoy having written material about blood pressure. However, this will not ensure that the measurements are accurate.

The nurse provides care for a client with an abdominal abscess draining into a bulb suction device. Which is the most important data for the nurse to assess when monitoring the drainage? 1. Amount. 2. Color. 3. Consistency. 4. Site leakage.

2. Color - Assessing whether the drainage is purulent, sanguinous, serosanguineous, etc. is the most important characteristic to document. Dark green or yellow drainage may indicate the client has not improved. Pale yellow serous drainage may indicate clearing of the infection.

The nurse provides care for a client 24 hours after admission. The client's spouse reports that the client drinks a fifth of vodka daily. The nurse notifies the health care provider that the client is restless, agitated, and irritable. The health care provider prescribes chlorpromazine 25 mg intramuscularly. Which action does the nurse take first? 1. Administer the medication as prescribed. 2. Contact the health care provider. 3. Continue to monitor the client. 4. Ensure that the lights are on in the client's room.

2. Contact the health care provider. — The client has symptoms of alcohol withdrawal. Chlorpromazine is not appropriate for this client. The nurse should contact the health care provider for a benzodiazepine to sedate the client and calm the neurological irritability.

The nurse is monitoring a client who is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply 1. Tremors 2. Diarrhea 3. Irritability 4. Blurred vision 5. N/V

2. Diarrhea 4. Blurred vision 5. N/V - Early S/S of toxicity: gastrointestinal manifestations such as anorexia. N/V/D, later leading to headache, visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia, drowsiness, fatigue, weakness and cardiac rhythm abnormalities. - Therapeutic digoxin levels: 0.5-0.8 ng/mL

A client is tested for suspected amyotrophic lateral sclerosis (ALS). Which early symptom will the nurse expect the client to exhibit? 1. Incontinence of bowel and bladder. 2. Difficulty swallowing. 3. Paresthesia of the face. 4. Disorientation to time and place.

2. Difficulty swallowing. — ALS affects the muscles of the throat and upper respiratory tract. The client will demonstrate dysphagia, which can cause aspiration. Other early symptoms include fatigue while talking, tongue atrophy, and weakness of the hands and arms. Think like a nurse: Many of the early manifestations of amyotrophic lateral sclerosis (ALS) are related to impaired muscular coordination. Speech or swallowing difficulties, failure to accurately grasp a writing or eating utensil, gait impairments, or clumsiness may be initial symptoms. These symptoms progress rapidly over the course of less than five years, resulting in loss of all muscle control, including the muscles that control respiration. The nurse promotes client safety by offering anticipatory guidance and coping strategies to help compensate for declining muscular coordination.

The nurse provides care for a client at 14 weeks ' gestation and who is diagnosed with a UTI. The client reports that her usual daily intake of fluid is 1 cup of decaffeinated coffee and a 4-ounce glass of orange juice in the morning, a 12-ounce glass of skim milk with lunch and dinner, and a 12-ounce can of caffeine-free diet cola in the midafternoon. It is most important for the nurse to make which suggestion? 1. Drink one 16-ounce glass of water at bedtime. 2. Drink two 8-ounce glasses of water before 5 p.m. 3. Add six 12-ounce cans of caffeine-free diet cola each day. 4. Stop the 1 cup of decaffeinated coffee per day.

2. Drink two 8-ounce glasses of water before 5 p.m. — The recommended fluid intake is 1500 to 2000 mL/day. This client 's fluid intake is approximately 1440 mL/day. Adding water, which is preferable to juices and sodas to manage weight gain in pregnancy, would increase the client 's fluid intake to 1920 mL/day.

The nurse provides care to a client who is prescribed chlordiazepoxide. Which client observation is of most concern to the nurse? 1. Shuffling gait and rigidity. 2. Drowsiness and blurred vision. 3. Photosensitivity and jerky movements. 4. Hypertension and slurred speech.

2. Drowsiness and blurred vision. - Chlordiazepoxide is an antianxiety drug. Drowsiness and blurred vision are adverse reactions and should be reported to the health care provider. Additional side effects include constipation, slurred speech, dermatitis, anorexia, polyuria, pancytopenia, and thrombocytopenia. Administer after meals or with milk to decrease the GI irritation. Think like a nurse: Drowsiness and blurred vision are adverse effects of chlordiazepoxide, an anti-anxiety medication, and should be reported to the health care provider. Parkinsonism effects, jerky movements, and photosensitivity are frequently seen in those taking anti-psychotic medication. Hypertension and slurred speech may indicate a reaction to monoamine oxidase (MOA) inhibitor medication.

The nurse provides care to a prenatal client who is 2 months pregnant. The client reports experiencing nausea each morning. Which recommendation does the nurse provide to the client? 1. Consume only soft foods and fruit until evening. 2. Eat pretzels before getting out of bed in the morning. 3. Avoiding drinking carbonated beverages. 4. Limit food intake to three full meals each day.

2. Eat pretzels before getting out of bed in the morning. - Strategies to prevent or decrease pregnancy-related nausea include eating dry carbohydrate foods (such as pretzels) 30 minutes to 1 hour prior to getting out of bed in the morning. Think like a nurse: Pregnancy-induced nausea is a miserable experience and may require trial and error to determine what helps the mother most. Eating a dry carbohydrate, like crackers or pretzels, prior to getting out of bed is a tried and true method. Frequent, small, nutrient dense meals are encouraged. Suckers, lemon or ginger drops, and sucking on other hard candies may be useful. The goal during this period is to prevent dehydration, ensure proper nutrition, and to maintain current maternal weight or minimize weight loss.

The nurse provides care to infant and toddler clients in a day care facility that has experienced an outbreak of hepatitis A. To control disease transmission and prevent a future outbreak of hepatitis A, the nurse prioritizes the implementation of which intervention? 1. Restricting contact with children who have symptoms of hepatitis A. 2. Educating staff and clients about proper hand hygiene protocols. 3. Advising staff and clients to request administration of immune globulin (IG) from their health care providers. 4. Recommending mandatory hepatitis A screening of all potential staff members.

2. Educating staff and clients about proper hand hygiene protocols. - Following proper hand hygiene protocols is the most effective measure to prevent or control an outbreak of hepatitis A. Restricting contact with individuals who have symptoms of hepatitis A is not an effective strategy for controlling disease transmission, as the disease may be transmitted before symptoms appear. Immune globulin (IG) is effective against hepatitis if administered within 2 weeks of exposure. Because of the cost of blood tests used to screen for hepatitis A, routine screening is not recommended. Think like a nurse: Hepatitis A is a fecal-oral disease, and as such, it flourishes in areas with poor sanitation. Teaching hand hygiene and providing ways in which to make hand hygiene part of the daily routine are important interventions in stopping the spread of hepatitis A. In a day care setting, workers need to perform hand hygiene after diaper changes or assisting with toileting in addition to helping children clean their hands.

The nurse prepares a solution of parenteral nutrition (PN) to infuse through a client's central line. Which piece of equipment is most important for the nurse to obtain before starting the infusion? 1. Glucose monitor. 2. Electronic infusion pump. 3. Pulse oximeter. 4. Urine glucose strips.

2. Electronic infusion pump. - Because of the high glucose content, use of an infusion pump is necessary to ensure that the solution does not infuse too rapidly or fall behind. Think like a nurse: Nutritional support is a major function of nursing care. For some clients though, this support needs to be provided using an alternative approach. Parenteral nutrition is the administration of a highly concentrated glucose solution mixed with additives to provide the nutrients required for body functioning. Because the client receiving this type of nutrition is most likely physically challenged, the nurse needs to ensure this solution is delivered safely and within expected parameters. An infusion pump is to be used when providing this nutritional support. After the infusion is started, the nurse will need to obtain a glucose meter to check the blood glucose every 6 hours.

The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action? 1. Extend the client's left arm flat along the affected side. 2. Elevate the client's left arm on a pillow. 3. Rest the client's left arm across her chest. 4. Place the client's left arm below the level of her torso.

2. Elevate the client's left arm on a pillow. - Following modified radical mastectomy, the client should be placed in semi-Fowler position. To promote lymphatic drainage without compromising circulation, the arm on the affected side should be elevated on a pillow. Elbow flexion or dependent positioning of the arm may impede lymphatic drainage and compromise circulation. Think like a nurse: The nurse needs to mentally ask, "What is a likely manifestation for a client following a mastectomy?" Reviewing the surgical procedure for a modified radical mastectomy, the nurse recalls it is likely that many, if not all, of the lymph nodes and glands surrounding the breast tissue were removed. The nurse can now conclude the removal of lymph tissue increases the client's risk of developing lymphedema in the extremity that is on the same side of the surgery. Lymphedema can increase pain and complicate healing. To reduce the risk of lymphedema, the nurse should make sure that the limb on the same side of the surgery is elevated on a pillow.

The nurse provides care for a client in the second trimester of pregnancy. Which assessment finding does the nurse attribute to the normal blood volume increase in pregnancy? 1. Increase in the client's respiratory rate. 2. Elevation in client's heart rate of 10 to 15 beats. 3. Increase in the client's blood pressure. 4. Decrease in the client's mean arterial pressure (MAP).

2. Elevation in client's heart rate of 10 to 15 beats. — Cardiac output increases in pregnancy because more blood is pumped from the heart with each contraction. The pulse rate increases by 10 to 15 beats per minute to accommodate the additional blood volume. Think like a nurse: The nurse is aware that the body undergoes major changes during pregnancy. When caring for a client who is pregnant, the nurse needs to recall the physiologic processes that are occurring, both within the client and with the fetus. As the fetus grows, the client's body needs to accommodate the fetal metabolic processes. One of these processes is fetal blood flow. The client's total blood volume increases over the course of the pregnancy, which is reflected in the client's heart rate. An increase of 10 to 15 beats per minute is an expected finding.

The nurse is feeding a resident in the dining room of a long-term care facility. Suddenly, the resident starts to choke and becomes cyanotic. Which is the best action for the nurse to take? 1. Stand behind the resident and deliver a quick blow to the middle of the back with the palm of the hand. 2. Embrace the resident from behind and, with a fist, quickly thrust upward into the abdomen. 3. Check the resident 's mouth and throat for food, and perform a finger sweep. 4. Lay the resident on the floor and prepare to initiate cardiopulmonary resuscitation.

2. Embrace the resident from behind and, with a fist, quickly thrust upward into the abdomen. - This describes the Heimlich maneuver, which expels the remaining air in victim 's lungs, along with the foreign body. Think like a nurse: A client who is visibly choking with cyanosis needs immediate intervention from the nurse. After determining that the client is unable to speak and is unable to take a deep breath, the nurse performs the Heimlich maneuver. This is done by standing behind the client, placing a fist slightly above the client's navel. Then the other hand is placed over the fist and thrusts are delivered inward and upward to dislodge the item from the trachea. This is performed until the object is dispelled or the client become unconscious.

The nurse provides care for a client diagnosed with paranoid schizophrenia. The client's spouse states that the client has not slept in 3 nights. Which action by the nurse is most appropriate? 1. Assign the client to straighten up the day room. 2. Establish a trusting nurse-client relationship. 3. Encourage the client to sleep and offer a sleep aid. 4. Introduce the client to other clients on the unit.

2. Establish a trusting nurse-client relationship. — The client diagnosed with paranoid schizophrenia views the world as hostile and threatening, so the nurse's priority is promoting trust. Trust is promoted by establishing the nurse-client relationship. Think like a nurse: Establishing rapport is essential in therapeutic communication. The nurse should speak calmly and clearly and maintain eye contact with the client. It is very important not to challenge the client's beliefs or delusions. They are very "real" to clients who experience them, and there's little point in arguing with them about their delusions or false beliefs. Instead, move the conversation along to areas or topics upon which both the nurse and the client agree.

While performing hourly rounds for a client diagnosed with sepsis, the nurse finds that the client is very lethargic, but has a pulse. Which nursing action is the priority for the client? 1. Start a normal saline IV through a large bore needle. 2. Establish airway patency and call for a Rapid Response Team (RRT). 3. Call for a "code" and start chest compressions. 4. Obtain a lactic acid level and apply 100% oxygen.

2. Establish airway patency and call for a Rapid Response Team (RRT). - The situation warrants a call for the RRT, while making sure the client's airway is patent. Think like a nurse: Finding a client lethargic with a pulse could mean that the client is not receiving adequate oxygen. The nurse needs to stop and think about the priorities of emergency care by addressing airway, breathing, and circulation (ABCs) first. The best action is to ensure that the client has an adequate airway. Once ABCs are evaluated, the nurse should consider the client's diagnosis of sepsis. The nurse needs to remember that sepsis can cause septic shock, and it is possible that the client's condition is deteriorating. The nurse realizes that the care and needs of this client is beyond the nurse's scope of practice. Additional help is needed and calling for the Rapid Response Team is an appropriate action to take.

The nurse teaches a new mother who is breastfeeding about the stool that the newborn will eliminate. Which information will the nurse include? 1. Several soft formed, brown stools daily are normal. 2. Expect 3 to 6 small, soft, orange-yellow stools each day. 3. One well-formed yellow stool daily. 4. Frequent, loose, green stools will occur each day.

2. Expect 3 to 6 small, soft, orange-yellow stools each day. - The stool of a breastfed infant is orange-yellow, soft, and small with an even consistency. The mother should expect up to 6 stools a day. The number of stools decreases with age. The color changes with the introduction of solid foods. Think like a nurse: Before teaching the client about the type of stool the newborn will eliminate, the nurse should mentally recall the physiological processes associated with breastfeeding and the infant. The infant is not ingesting solid food and is being sustained on breast milk. Because breastmilk is more easily digested by the infant, the appearance and consistency of the bowel movements are affected. The nurse should include this information when teaching, and remind the client that the number of stools will decrease with time, and that the consistency and color will change as solid foods are introduced.

The nurse provides care for a client diagnosed with impaired vision. Which interventions will the nurse implement to meet the client's needs? (Select all that apply.) 1. Keep the voice even throughout conversations. 2. Explain the sounds in the environment. 3. Decrease background noise before speaking. 4. Stay in the client's field of vision. 5. Identify self by name and staff position.

2. Explain the sounds in the environment. 4. Stay in the client's field of vision. 5. Identify self by name and staff position.

The nurse assesses a client at 10 weeks' gestation. Which finding does the nurse expect to observe? 1. Fundus at the umbilicus. 2. Fetal heart rate heard with Doppler. 3. Fetal movement felt with palpation. 4. Ballotment.

2. Fetal heart rate heard with Doppler. — The nurse should be able to hear the fetal heart rate at 110 to 160 beats/min with Doppler at 10 to 12 weeks of gestation. Think like a nurse: The nurse is aware a fetus undergoes many developmental stages. At first, the product of fertilization is identified as an embryo. During this stage, the body organs and structures are in rudimentary development. At the end of the first trimester of pregnancy, all major development has occurred and the embryo is then referred to as a fetus. During the second and third trimesters, body systems mature and the fetus grows physically. One of the body systems that is developed and begins functioning early is the heart. At the end of the first trimester of pregnancy, a heartbeat may be heard with the help of electronic enhancement.

The nurse counsels a client who is trying to conceive on how to best prevent neural tube defects. Which water-soluble vitamin is important for preventing neural tube defects? 1. Riboflavin (vitamin B2). 2. Folic acid (vitamin B9). 3. Ascorbic acid (vitamin C). 4. Thiamine (vitamin B1).

2. Folic acid (vitamin B9) - Maternal folic acid deficiency is a risk factor for the development of neural tube defects (spina bifida). A daily consumption of 0.4 mg of folic acid is recommended for women of childbearing age. Think like a nurse: The nurse is aware that adequate fetal development in utero is contingent upon the health of the mother. The developing fetus needs specific nutrients to ensure for optimal organ development and function. Any maternal nutritional deficiency may be reflected and observed upon birth of the baby. One such nutritional deficiency is folic acid. A deficiency in this vitamin has been linked to the development of neural tube defects in the developing fetus. Because this birth defect can be avoided, clients are counseled to take folic acid supplements prior to and throughout a pregnancy.

The nurse assess a client who is at 24 weeks' gestation. Which finding causes the nurse to be most concerned? 1. Fetal heart rate of 130 to 140 beats per minute. 2. Fundal height at three fingers below the umbilicus. 3. Fetal movements felt faintly on lower part of abdomen. 4. The woman reports backache and leg cramps when sleeping.

2. Fundal height at three fingers below the umbilicus. - The fundus is expected to reach the umbilicus around 20 weeks and should be increasing in height above the umbilicus after 20 weeks. A fundal height of three fingers below the umbilicus indicates a fetal problem and would be a priority concern. Think like a nurse: There are various measurements for the nurse to use when assessing a pregnant client. Before beginning an assessment, the nurse should recall the physiological changes that occur in pregnancy, the findings that should be expected, and those that should be further investigated. One physiological change occurs to the uterus. As the fetus grows, the height of the uterus will increase. A general rule of thumb is that the height of the uterus should be at the level of the client's umbilicus at the 20th week of gestation. Since this client's fundal height is below this expectation, fetal growth is not progressing as expected, and requires further investigation.

The psychiatric nurse is preparing a plan of care for clients who are survivors of intimate partner violence. Which type of therapy is most appropriate for this group of clients? 1. Psychodrama. 2. Group therapy. 3. Psychotropic medication. 4. Behavior modification.

2. Group therapy. CORRECT— Group therapy is commonly offered for survivors of intimate partner violence. Think like a nurse: The nurse considers the expected outcomes of each type of therapy. Survivors of intimate partner violence often feel isolated. A group therapy approach is appropriate if there are a significant number of individuals who have all experienced the same event or situation that effects psychosocial integrity. Attending a group therapy session may be beneficial in that the participants realize that others have experienced the same event, and there are people available to offer support and encouragement.

The nurse notes the health care provider prescribed a diet consisting of increased amounts of fresh fruits and vegetables, chicken, and whole grain breads for an adult male client. Which finding does the nurse expect to see on the client's medical record? 1. Blood pressure of 118/70 mm Hg while supine and 124/84 mm Hg while standing. 2. Hematocrit of 40% (0.40) and hemoglobin of 11.2 g/dL (112 g/L). 3. Aspartate aminotransferase 30 U/L (0.5 µkat/L) and alanine aminotransferase 35 U/L (0.58 µkat/L). 4. Creatinine 12.2 mg/dL (1078.5 µmol/L) and blood urea nitrogen 25 mg/dL (8.9 mmol/L).

2. Hematocrit of 40% (0.40) and hemoglobin of 11.2 g/dL (112 g/L). - The normal hematocrit for a male is 42 to 52% (0.42 to 0.52). The normal hemoglobin for a male is 13 to 18 g/dL (130 to 180 g/L). These lab values indicate anemia, for which a diet high in protein, iron, and vitamins is advised. The prescribed diet will provide high amounts of protein, iron, and folic acid.

The nurse plans care for a client with cystic fibrosis. Which dietary requirement will the nurse consider for this client? 1. High-protein, low-sodium diet. 2. High-protein, high-calorie diet. 3. Low-protein, low-carbohydrate diet. 4. Low-protein, high-sodium diet.

2. High-protein, high-calorie diet. - Impaired intestinal absorption due to the cystic fibrosis necessitates a diet higher in protein and calories. Think like a nurse: A client with cystic fibrosis will have alterations in the metabolism of certain nutrients because of a deficiency in select enzymes required for digestion. Due to this, the client is prone to developing nutritional deficiencies and should ingest a diet high in calories and protein. There is no reason to restrict sodium, carbohydrate, or protein intake.

A client with atrial fibrillation who is receiving maintenance therapy of Warfarin sodium has a prothrombin time (PT) of 35 seconds and an INR of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium. 2. Holding the next dose of Warfarin. 3. Increasing the next dose of Warfarin. 4. Administering the next dose of Warfarin.

2. Holding the next dose of Warfarin. - A PT greater than 32 seconds and an INR greater than 3 for standard Warfarin therapy places the patient at risk for bleeding.

A community experiences a prolonged heat wave. The emergency department has several clients admitted from a construction project. Which indications will alert the nurse to the diagnosis for heat stroke? 1. Elevated temperature, diaphoresis, nystagmus. 2. Hypotension, tachypnea, tachycardia. 3. Hemiplegia, diplopia, dysarthria. 4. Headache, hot dry skin, hypertension.

2. Hypotension, tachypnea, tachycardia. — A client will have a temperature of 105°F (40.6°C) or above with skin that is hot and dry. A client's behavior may be bizarre, with confusion or delirium, or the client may be comatose. Think like a nurse: Heat stroke occurs when the body is not able to dispel accumulated body heat from exposure to high temperatures or warm environments. Manifestations of heat stroke include a drop in blood pressure, rapid heart rate, and rapid respirations.

The nurse teaches the client, who is newly diagnosed with DI, about the prescribed intranasal desmopresin. Which statements by the client indicate understanding? Select all that apply 1. This medication may turn my urine orange 2. I should decrease my oral fluids when I start this medication 3. The amount of urine I make should increase if this medication is working. 4. I need to follow a low-fat diet to avoid pancreatitis when taking this medication. 5. I should report headache and drowsiness to my HCP since these symptoms could be related to my desmopressin.

2. I should decrease my oral fluids when I start this medication. 5. I should report headache and drowsiness to my HCP since these symptoms could be related to my desmopressin.

A client returns to the unit after placement of a split-thickness autograft to a burn on the right arm. Which intervention does the nurse give the highest immediate priority? 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 and the limb is a priority. A thin fibrin network develops quickly after graft placement, but it takes 7 to 10 days for the graft to really adhere and longer than that to mature. Think like a nurse: The priority of care for this client is immobilizing the limb with the graft. Adherence of the graft takes between 7 to 10 days and unnecessary movement can adversely effect this process. Rejection does not occur immediately, but will become a priority after the dressing is removed in 3 to 5 days.

The nurse conducts an educational session on expected age-related changes for older adult clients. Which statement does the nurse include in the session? 1. Increase in the production of digestive enzymes can occur. 2. Increase in the anteroposterior chest diameter is expected. 3. Increase in body mass in the upper extremities can occur. 4. Increase in taste bud sensations is expected.

2. Increase in the anteroposterior chest diameter is expected.

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching is effective? Select all that apply. 1. Bites from ticks or deer flies. 2. Inhalation of bacterial spores. 3. Through a cut or abrasion in the skin. 4. Direct contact with an infected individual. 5. Sexual contact with an infected individual. 6. Ingestion of contaminated undercooked meat.

2. Inhalation of bacterial spores. 3. Through a cut or abrasion in the skin. 6. Ingestion of contaminated undercooked meat.

The nurse monitors the progress of a client recovering at home from a laryngectomy. Which client behavior requires the nurse to intervene? 1. Uses a finger to apply water-soluble ointment around the stoma. 2. Inserts a few drops of water into the stoma every evening. 3. Leaves the stoma uncovered when taking a bubble bath. 4. Covers the stoma with a cotton scarf when outside.

2. Inserts a few drops of water into the stoma every evening. - Humidification should be provided with a humidifier or nebulizer and not by inserting water into the stoma. Think like a nurse: In client teaching, it is important that the client can articulate, via the teach-back method, the rationale of every activity. Instilling water, even only a few drops, into the tracheostomy stoma is an indication of a serious learning gap. The client should be taught about risk and consequences of aspiration. The nurse may reinforce instructions using short videos (e.g., from the website of professional organizations), return-demonstration, and printed materials. Hand hygiene remains a key activity in preventing spread of infection.

During a home health visit, an older adult Asian American client reports nausea and anorexia since taking isoniazid for 4 months. Which action will the nurse take first? 1. Obtain a sputum specimen. 2. Inspect the hard palate. 3. Assess skin color on the abdomen. 4. Instruct the client to stop the medication.

2. Inspect the hard palate. - Due to biocultural skin variations, signs of early jaundice are best observed on the posterior hard palate in people of Asian descent. Even sclera may contain carotene pigments that mimic jaundice in Asian American clients.

The nurse provides care for the client after abdominal surgery, and the client reports gas pains. Which action by the nurse is appropriate? 1. Encourage the client to increase intake of vegetables. 2. Instruct the client to ambulate frequently. 3. Show the client how to splint the abdomen. 4. Position the client on the right side.

2. Instruct the client to ambulate frequently. — Frequent ambulation increases the return of peristalsis and facilitates the expulsion of flatus. This is the best way to relieve the gas pain. Think like a nurse: The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in medical-surgical sub-specialties. For clients recovering from abdominal surgeries, ambulation can promote return of peristalsis and prevent post-operative ileus. The nurse should assess the client's hemodynamic stability for ambulation and offer use of assistive devices such as a walker. Secondary gains from early ambulation include reduced respiratory decompensation and reduced risk of pneumonia, deep venous thrombosis, pulmonary embolism, and urinary tract infections.

The nurse prepares as list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included in the list? Select all that apply. 1. Use the fingertips to lift the cast while it is drying. 2. Keep small toys and sharp objects away from the cast. 3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches. 4. Placing a heating pad on the lower end of the case and over the fingers if the fingers feel cold. 5. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling. 6. Contact the HCP if the child complains of numbness or tingling in the extremity.

2. Keep small toys and sharp objects away from the cast. 5. Elevate the extremity on pillows for the first 24-48 hours after casting to prevent swelling. 6. Contact the HCP if the child complains of numbness or tingling in the extremity.

The nurse discovers the IV infusion tubing disconnected from a peripherally inserted central catheter, and the client has tachycardia, chest pain, and shortness of breath. In which position will the nurse place the client? 1. Supine with the head of bed elevated 30 to 45 degrees. 2. Left side-lying Trendelenburg. 3. Right lateral decubitus. 4. Reverse Trendelenburg.

2. Left side-lying Trendelenburg. - The client exhibits signs and symptoms of an air embolism. Therefore, the nurse should position the client on the left side in the Trendelenburg position to trap the air in the lower portion of the right ventricle. Think like a nurse: Before considering the best action to take, the nurse needs to recall the anatomical location of the peripherally inserted central catheter. The treatment of this access site should be the same as if the catheter was placed in a central location. And, because of the type of device, the client's symptoms indicate an air embolism. Treatment of these symptoms should begin with positioning the client on the left side. This forces the air embolism to move to the right side of the heart. The Trendelenburg position helps contain the embolism to the right ventricle. The goal of this nursing intervention is to prevent the air embolism from entering the lungs or brain, which can cause life-threatening complications.

A nurse is monitoring a client diagnosed with acromegaly who was treated with transphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should altert the nurse to the presence of a possible postoperative complication? Select all that apply 1. Anxiety 2. Leukocytosis 3. Chvostek's Sign 4. Urinary output of 800 mL/hour 5. Clear drainage on the nasal dripper pad

2. Leukocytosis 4. Urinary output of 800 mL/hour 5. Clear drainage on the nasal dripper pad - Acromegaly results from excess secretion of growth hormone, usually by a benign tumor on the anterior pituitary gland. Leukocytosis (elevated WBC count) can indicate infection and excessive urine output (i.e. diabetes insipidus) is a potential complication of the procedure to remove the tumor (transphenoidal hypophysectomy). Lastly, clear drainage on the drip pad is suggestve of a CSF leak.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which of the following diets would be most appropriate? 1. High-carbohydrate, high-protein. 2. Low-protein, low-sodium, low-potassium. 3. Low-protein, high-potassium. 4. High-calcium, high-potassium, high-protein.

2. Low-protein, low-sodium, low-potassium. Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

The nurse provides care for a client who anticipates using a prosthesis after an above-the-knee amputation. Which action should the nurse take when caring for this client? 1. Encourage the client to sit in a chair for extended periods of time. 2. Maintain the compression dressing to the amputation site. 3. Provide range-of-motion exercises twice a day. 4. Elevate the residual limb for 72 hours.

2. Maintain the compression dressing to the amputation site. - When caring for a client after an above-the-knee amputation, the nurse needs to maintain the compression dressing to the amputation site. This minimizes edema and prevents infection. Think like a nurse: Proper residual limb bandaging fosters shaping and molding for eventual prosthesis fitting. A compression dressing is typically ordered to reduce edema, support soft tissues, and promote limb shrinkage and maturation. The delayed prosthetic fitting may be the best choice for clients who had above knee or below the elbow amputations, older adults, debilitated individuals and those with infections. The compression bandage should be worn at all times except during physical therapy and bathing.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis - Patient is losing acidic gastric fluid through suction. Metabolic alkalosis occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood and hyperaldosteronism.

The nurse provides care for a client admitted for an adrenalectomy for treatment of Cushing syndrome. Which intervention is most important for the nurse to implement? 1. Evaluate the client 's mood. 2. Monitor the client 's blood glucose. 3. Take the client 's temperature. 4. Obtain the client 's weight.

2. Monitor the client 's blood glucose. - Hypercortisolism causes hyperglycemia and the blood glucose is monitored closely. Other symptoms include fatigue, weakness, osteoporosis, cramps, edema, hypertension, decreased resistance to infection, truncal obesity, buffalo hump, and moon face. Think like a nurse: Cushing syndrome is caused by an increased amount of cortisol in the body. Cortisol adversely effects blood glucose, causing hyperglycemia. Because of this, the client's blood glucose level should be monitored frequently.

The nurse placed a client on therapeutic hypothermia 1 hour ago. Which action does the nurse take to determine whether the client is having an adverse reaction to therapeutic hypothermia? 1. Install a working suction setup. 2. Monitor the client for seizure activity. 3. Measure the Braden Scale score. 4. Assess bowel sounds every 2 hours.

2. Monitor the client for seizure activity. — The client is monitored for seizure activity, which is an adverse reaction to hypothermia. Think like a nurse: The nurse has a responsibility to understand the purpose, expectations, and unexpected responses to prescribed treatment. Therapeutic hypothermia is prescribed for serious conditions, such as after cardiac arrest. The nurse needs to be aware seizures are common in comatose clients receiving the prescribed therapy. The nurse might anticipate routine use of electroencephalogram (EEG) monitoring to assist in early detection of seizures in this client, providing an opportunity for intervention to potentially improve outcomes. The nurse should also remember that hypothermia, or a temperature less than 95.9°F (35.5°C), causes peripheral vasoconstriction, and a shift of the oxygen-hemoglobin dissociation curve to the left. A shift to the left indicates that less oxygen is released from hemoglobin to the tissues, causing tissue hypoxemia.

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development with plans to discuss Kohlberg's Theory of Moral Development. What information should the nurse include in the session? Select all that apply. 1. Individuals move through all 6 stages in a sequential fashion. 2. Moral development progresses in relationship to cognitive development. 3. A person's ability to make moral judgements develops over a period of time. 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 5. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain reward or have favors returned.

2. Moral development progresses in relationship to cognitive development. 3. A person's ability to make moral judgements develops over a period of time. 4. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. 6. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain reward or have favors returned.

The nurse provides care for a client diagnosed with myasthenia gravis. When completing a physical assessment, which clinical manifestations does the nurse expect to see? (Select all that apply.) 1. Rigidity. 2. Muscle weakness. 3. Facial paralysis. 4. Propulsive gait. 5. Ptosis. 6. Diplopia.

2. Muscle weakness. - Muscle weakness is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. 5. Ptosis. - Ptosis, or drooping eyelids, is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. 6. Diplopia. - Diplopia, or double vision, is a clinical manifestation associated with myasthenia gravis. The nurse expects this clinical manifestation upon assessment. Think like a nurse. Myasthenia gravis causes muscle weakness and fatigue because of a change in response to the neurotransmitter that controls muscle movement and function. Manifestations of this disorder include muscle weakness, eye ptosis, and diplopia. The eyes are affected first because of the size of the muscles.

During a pregnant client's nonstress test (NST), the nurse observes several late fetal heart rate decelerations. Which nursing action is most appropriate? 1. Reposition the client on the right side. 2. Notify the health care provider for further evaluation. 3. Document these results in the client's record. 4. Stop the oxytocin immediately.

2. Notify the health care provider for further evaluation. - The appearance of any decelerations of the fetal heart rate during the NST should be immediately evaluated by the health care provider. Think like a nurse: A nonstress test (NST) is performed to check fetal well-being when it is determined that the fetus might be at risk for an adverse outcome. An NST might be performed when the mother has diabetes mellitus, heart disease, or hypertension. Often, an NST is performed for a post-term fetus to determine whether pregnancy can continue until natural labor occurs or whether labor induction is needed. During this test, the only stress is the baby's own movements. A decreased fetal heart rate in response to fetal movement indicates poor fetal oxygenation. This finding indicates a need to notify the health care provider and likely will result in induction of labor.

The nurse assesses hypotension, tachycardia, and crackles in the lung bases of a client with an acute inferior wall myocardial infarction. Which action does the nurse take first? 1. Encourage fluid intake. 2. Notify the health care provider. 3. Monitor intake and output. 4. Administer sublingual nitroglycerin, as prescribed.

2. Notify the health care provider. — The client exhibits signs of heart failure, a complication of acute myocardial infarction. The nurse should notify the health care provider of the change in the client's condition to prevent a delay in treatment. Think like a nurse: The nurse should recognize hypotension, tachycardia, and crackles in the lung bases of a client with an acute inferior wall myocardial infarction (MI) indicates potential heart failure. It is important for the nurse to recognize the condition requires immediate collaboration with the health care provider. There is no nursing intervention in this scenario that will improve the client's well-being. In massive MI, a significant reduction of cardiac output can be due to heart failure and papillary muscle dysfunction (causing mitral valve regurgitation). The nurse should auscultate the client for S3 heart sound and anticipate giving the client a diuretic as prescribed.

The nurse provides care for a client following a thyroidectomy. Which data is most important for the nurse to monitor for during the assessment? 1. Muscle flaccidity. 2. Numbness in the fingers. 3. Pain in the lower extremities. 4. Confusion.

2. Numbness in the fingers. - Injury to parathyroid glands during surgery causes a decrease in serum calcium. It is most important for the nurse to assess for tingling around the mouth, toes, and fingers, along with muscular twitching.

The nurse provides care to a client receiving furosemide. Which is the most important assessment for the nurse to make? 1. Potassium level for hyperkalemia. 2. Orthostatic blood pressure measurement. 3. Bowel movements for diarrhea. 4. Eyes for visual disturbances.

2. Orthostatic blood pressure measurement. - Monitoring of therapy for the client receiving furosemide includes frequent assessment of blood pressure and pulse rate, including orthostatic blood pressures and pulse rates (supine and standing), hydration status, and capillary refill, as well as daily measurement of weight. Constipation, not diarrhea, is a side effect of furosemide. Think like a nurse: In this scenario, the nurse should recall the mechanism of action of furosemide and the purpose it is prescribed. Since this medication removes excess fluid from the body and does not spare potassium, the assessment should focus on parameters that measure body fluid balance. This would include heart rate and blood pressure. Body weight should be routinely measured in this client as the most accurate measurement of body fluid status. The nurse will also monitor the client's lab results and monitor for hypokalemia.

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply. 1. Pain and erythema 2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin. 5. Formation of a red streak and purulent drainage.

2. Pallor and coolness 3. Numbness and pain 4. Edema and blanched skin.

The nurse notes that a client, experiencing dull pain in the anterior and posterior neck, has full neck range of motion and no throat redness or enlargement of the head or neck lymph nodes. Which assessment will the nurse complete next? 1. Examination of the ears. 2. Palpation of the liver. 3. Auscultation of heart sounds. 4. Auscultation of bowel sounds.

2. Palpation of the liver. - The right neck and the flank are common areas of referred pain from liver damage, so the liver should be examined when dull pain in the anterior and posterior neck occurs. Think like a nurse: The nurse needs to understand the assessment principles that are needed when assessing pain. Most frequently, pain is located in the specific area related to an acute injury or a chronic illness. However, the nurse should understand that sometimes the reason for the pain is not as obvious. In this scenario, the nurse assesses for all of the obvious reasons first. If the data are inconclusive, then the nurse should mentally ask, "What area of the body would cause the client to experience referred pain at this site?" The right side of the neck and flank area are sites for referred pain from the liver. So after assessing the neck region and finding no evidence for injury, the nurse should assess the liver.

The home care nurse visits an older adult client with a recent history of a cerebrovascular accident (CVA) resulting in a neurogenic bladder. The client is incontinent and has developed repeated urinary tract infections (UTI). Which action by the nurse is most appropriate? 1. Teach the client exercises to strengthen the pelvic floor. 2. Perform an intermittent catheterization for residual urine. 3. Assess the client's fluid intake over the last 48 hours. 4. Teach the client about high fiber dietary intake.

2. Perform an intermittent catheterization for residual urine. — Even though a client with a neurogenic bladder is incontinent, the bladder may not be empty completely. Residual urine can cause a UTI. Think like a nurse: A neurogenic bladder occurs when the nerves that control urination are damaged or injured. The result is an inability to void or urinary retention. Incontinence with a neurogenic bladder occurs when the volume of urine in the bladder is so great, excess urine is released. Since the client is experiencing repeated urinary tract infections, the most likely cause is excess urine in the bladder. The client's bladder needs to be drained and bladder distention closely monitored to reduce the risk of future infections.

The nurse provides care for a client with a hemoglobin level of 6.8 g/dL (68 g/L). Which intervention does the nurse implement first when providing care for this client? 1. Draw a type and crossmatch for 2 units of packed red blood cells. 2. Place the client on 2 liters of oxygen per nasal cannula. 3. Insert a 19-gauge intravenous catheter. 4. Place the client on a cardiac monitor.

2. Place the client on 2 liters of oxygen per nasal cannula. — This hemoglobin level is critically low, which indicates less circulating oxygen. It is important to be certain that the available hemoglobin is well-oxygenated. The nurse first will apply oxygen to the client to address the oxygenation needs. The normal hemoglobin for men is 13 to 18 g/dL (130 to 180 g/L), and for women it is 12 to 16 g/dL (120 to 160 g/L). Think like a nurse: Hemoglobin is the oxygen-carrying capacity of the blood. When the hemoglobin level is low, the amount of available oxygen to nourish the body organs and tissues is affected. The priority action is to provide supplemental oxygen to maximize tissue oxygenation.

The nurse notes that a client who delivered a newborn 18 hours ago reports swelling and pain in the right calf. Which action is appropriate for the nurse to implement? 1. Assess the client for a positive Homan sign. 2. Place the client on bed rest with the right leg elevated on a pillow. 3. Elevate both legs on a pillow and apply ice. 4. Palpate both legs to determine actual nature of pain.

2. Place the client on bed rest with the right leg elevated on a pillow. - Initial treatment when a deep vein thrombosis has occurred includes bed rest, with the affected leg elevated to decrease interstitial swelling and to promote venous return from the leg. Think like a nurse: The development of a deep vein thrombosis (DVT) can occur during pregnancy due to the increase in circulating blood volume, influence of hormones, and the change in activity level. Following delivery, the risk for DVT is related to the amount of time spent in the lithotomy position and inactivity. Should DVT occur, the nurse should recall the pathophysiologic process of the health problem and immediately implement measures to prevent complications. The client's extremity will be warm and edematous. The pulses in the foot of the affected extremity may be weak. The first action is to support the affected limb by placing it on a pillow and instructing the client to remain on bed rest until the health care provider can further evaluate the limb and prescribe treatment.

The nurse assesses a 2-hour old newborn. The nurse notes the newborn's hands and feet are bluish in color. To which reason does the nurse attribute this finding? 1. A lack of adjustment to environmental temperature. 2. Poor perfusion of blood to the periphery of the body. 3. A lowered oxygen tension. 4. A low hemoglobin level.

2. Poor perfusion of blood to the periphery of the body. - Acrocyanosis is a bluish color of hands and feet of the newborn. This is an expected finding and is caused by sluggish peripheral circulation. Think like a nurse: After delivery the nurse needs to focus on two clients: the mother and the newborn. Assessment of the newborn is focused on how well the baby is adjusting to extrauterine life. This assessment is completed through the use of the Apgar scoring system. One criteria is the color of the infant's body and extremities. Ideally, the body and extremities should be pink, which indicates adequate perfusion. If the extremities are blue-tinged, perfusion of the newborn is not at the maximum level and the newborn needs more time to adjust to being outside of the uterus.

A rubella titer result of a 1-day postpartum client is less than 1:8 and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs.

The nurse provides care for a client who had an exploratory laparotomy a day ago due to a small-bowel obstruction. Upon assessment, the client reports the pain is 4 out of 10. Which actions will the nurse implement? (Select all that apply.) 1. Administer oxycodone 5 mg /acetaminophen 325 mg tablets by mouth. 2. Prepare a dose of ketorolac 30 mg by IV push. 3. Push the patient-controlled analgesia (PCA) button. 4. Assist the client to ambulate in the hall. 5. Encourage the client to eat a high-fiber diet. 6. Auscultate for bowel sounds in four quadrants.

2. Prepare a dose of ketorolac 30 mg by IV push - IV pain medication such as ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is an appropriate intervention for this client 's pain. In addition, this client will have an NG tube after surgery to repair a small-bowel obstruction. Administering pain medication by mouth is not appropriate at this time. 4. Assist the client to ambulate in the hall - After abdominal surgery, trapped air can cause gas pains. Ambulation is the best way to help this gas to move out of the body via the rectum. 6. Auscultate for bowel sounds in four quadrants - Part of the post-operative abdominal assessment is auscultation of bowel sounds. Hypoactive or absent bowel sounds may indicate formation of an ileus.

The nurse plans care for a client diagnosed with Grave disease. Which intervention will the nurse include in the plan of care? 1. Serve the client two meals per day. 2. Provide frequent rest periods. 3. Provide extra clothes for warmth. 4. Offer coffee and tea with meals.

2. Provide frequent rest periods. — The nurse will provide an environment that is free of stress and activity due to the high metabolic rate. The nurse should restrict visitors and control choice of roommates to provide the client with rest and an environment with few stimuli. Think like a nurse: The nurse knows that Grave disease is another term for hyperthyroidism. Because this client's metabolic rate is high, there is a need for frequent rest periods in a non-stimulating environment. The client will need additional calories and should avoid stimulants, such as caffeine. The nurse understands the importance of monitoring dietary intake and weight, adjusting the room temperature for comfort, and reviewing lab results. If surgery is performed, the nurse should observe for postoperative complications, such as hemorrhage, thyrotoxicosis, hypocalcemia, hypothyroidism, and damage to the laryngeal nerve.

The nurse provides care to a client with a cast on the left leg. Which exercise will the nurse recommend to this client? 1. Passive exercise of the affected limb. 2. Quadriceps setting of the affected limb. 3. Active range of motion exercises of the unaffected limb. 4. Passive exercise of the upper extremities.

2. Quadriceps setting of the affected limb. — Quadriceps setting is an isometric exercise. It is performed by contracting the muscle without moving the joint. This exercise maintains muscle strength while the limb is in a cast. Think like a nurse: Quadriceps setting, also known as "quad sets," is an isometric exercise that helps promote muscle maintenance in a casted extremity. Desired outcomes associated with performance of quad sets include preventing disuse syndrome, which is characterized by muscle wasting, weakness, and disability. To perform quad sets, the client sits on a flat, level surface and extends the casted leg in front of the body. The client then contracts the thigh muscles while pressing the knee toward the surface beneath the leg. The client maintains the muscle contraction for a few seconds before relaxing. The exercise is repeated for approximately 10 sets. Ideally, quad sets should be performed hourly to maintain muscle mass while the limb is immobilized.

The home health nurse visits a client with a history of type 1 diabetes mellitus. The client has recently experienced permanent loss of vision and is having difficulty adjusting. Which action by the nurse is most appropriate? 1. Ask the health care provider for a psychiatric referral. 2. Recommend that the client join a support group. 3. Warn the client that failure to adapt can increase risk for injury. 4. Reassure client that a change in visual abilities does not change personal identity.

2. Recommend that the client join a support group. — Clients often respond more positively to peers with the same health alterations than to health care providers. The most appropriate action at this time is to recommend that the client join a support group. Think like a nurse: The client has recently lost a major sensory organ and is having difficulty adjusting to the loss. The best recommendation would be for the client to attend a support group with others who are experiencing a similar situation. A psychiatric referral would be premature since the client is not demonstrating any signs of a mood or other mental health disorder. The client should not be threatened. While the vision loss may not affect personal identity, the nurse's reassurance does not improve the client's ability to cope with the loss.

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply 1. Maintain the child in a semiprivate room. 2. Reduce exposure to environmental organisms. 3. Use strict aseptic technique for all procedures. 4. Ensure that anyone entering the child's room wears a mask. 5. Apply firm pressure to a needle stick area for at least 10 minutes.

2. Reduce exposure to environmental organisms. 3. Use strict aseptic technique for all procedures. 4. Ensure that anyone entering the child's room wears a mask.

The nurse presents a teaching session to a postpartum client who just delivered her first newborn. When educating the client about breastfeeding, which action does the nurse implement? 1. Instruct the client to use an antiseptic soap to cleanse her breasts. 2. Remain with the client and newborn during the breastfeeding. 3. Inform the client that the newborn will require breastfeeding 4-6 times per day. 4. Advise the client to use only the cradle position when breastfeeding.

2. Remain with the client and newborn during the breastfeeding. — The nurse should remain with the client to assess effectiveness of the newborn's suck, swallow, and gag reflex. Observation of the breastfeeding sessions offers an excellent opportunity to evaluate effectiveness of the feeding and provide additional teaching. Think like a nurse: Observation of a newborn breastfeeding from the mother offers clues to the nurse about what further instruction might be required and opportunities to praise the new mother's efforts. Techniques and tips can be offered during this time, if needed. This is also an opportunity for the nurse to observe maternal-infant bonding behaviors and to offer the significant other, if present, ways in which to participate.

The nurse provides care for clients on the psychiatric unit. A client yells that nobody cares and throws a lunch tray at a group of other clients. Which action does the nurse take first? 1. Instruct the client to stop yelling and throwing things. 2. Remove the client from the lunchroom. 3. Ask the client why the client is upset. 4. Administer 5 mg of haloperidol intramuscularly.

2. Remove the client from the lunchroom. — When the client becomes violent, the nurse should intercede immediately. The nurse should remove the client from the group environment as quickly as possible, and then address the client's behavior with the client. Think like a nurse: A client who acts out with violence threatens the safety of staff and other clients. The nurse should think, "How can I first ensure the safety of all clients?" The nurse can prevent further violence and ensure the safety of others present by removing the client from the lunchroom. Considering that the client is in a mental health facility, the likelihood of the client's behavior negatively impacting other clients is great.

The nurse is preparing care for a client with a potassium deficit. The nurse reviews the clients records and determines that the client is at risk for developing potassium deficit because of which situation. 1. Sustained tissue damage. 2. Requires nasogastric suction. 3. Has a history of Addison's disease. 4. Uric acid level of 9.4 mg/dL (559 umol/L)

2. Requires nasogastric suction. (Normal serum potassium level: 3.5 to 5.0 mEq/L) - Potassium rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. - Patients with sustained tissue damage, a history of Addison's disease, and increased uric acid levels (normal female levels 2.7-7.3 mg/dL & for men 4.0-8.5 mg/dL) are all at risk for hyperkalemia.

The nurse provides care to a client admitted with mild hyponatremia secondary to excessive water consumption. Which intervention does the nurse anticipate including in the client's plan of care? 1. Administering 0.45% sodium chloride IV. 2. Restricting fluid intake. 3. Administering 3% sodium chloride IV. 4. Encouraging frequent ambulation.

2. Restricting fluid intake. - For treatment of hyponatremia secondary to hypervolemia, restriction of fluid intake is an appropriate intervention. Think like a nurse: The nurse is aware there are a variety of reasons for a client to develop hyponatremia. However, in this scenario the client is diagnosed with the disorder being caused by excess free water consumption. The nurse needs to consider application of the principles of physiology. When the water is metabolized, it takes body sodium with it. (Remember: where sodium is, water will follow.) To reverse the process and re-balance the sodium level, a fluid restriction will be prescribed. The nurse is aware that when possible the cause of any imbalance is best addressed when identified. In this scenario, the nurse should anticipate fluid restrictions.

The nurse prepares to measure a client's central venous pressure (CVP). Which parameter is measured by the CVP? 1. Pulmonary artery pressure. 2. Right atrium pressure. 3. Cardiac output. 4. Left ventricle pressure.

2. Right atrium pressure. - Right atrium pressure is determined by blood volume, vascular tone, and the action of the right side of the heart. It is obtained from the CVP line.

The nurse provides care to a client who is experiencing dyspnea. Which symptom does the nurse expect to observe in the client? 1. Tachycardia. 2. Shortness of breath. 3. Hemoptysis. 4. High blood pressure.

2. Shortness of breath. - Dyspnea refers to a persistent feeling of inadequate ventilation, or "air hunger," and is often accompanied by difficult and labored breathing. Shortness of breath is commonly associated with dyspnea. Think like a nurse: The nurse needs to have a solid understanding of medical terminology. Any unknown term should be validated using a reliable resource. Sometimes, the nurse can break down the term to aid in interpretation ("dys" means difficult; "pnea" means breathing). The nurse must then mentally clarify what is expected when assessing a client with dyspnea. Individuals who experience dyspnea will state that they feel "short of breath" or are unable to "catch their breath." The nurse should expect the client with dyspnea to have rapid respirations. Depending upon the degree of dyspnea, the client may display anxiety. The nurse will also need to assess for signs of hypoxia.

The nurse teaches a community education program about cancer prevention for both men and women. Which strategy is most important for the nurse to include in the teaching? 1. Regular examination of reproductive organs. 2. Smoking cessation. 3. Routine colonoscopies. 4. Protection from ultraviolet light.

2. Smoking cessation. — Lung cancer is the leading cause of cancer deaths in the United States for men and women. Stopping the use of tobacco is one of the most important cancer prevention behaviors. Think like a nurse: One of the most effective strategies available to nurses to support health promotion and disease prevention is to provide health teaching. Oftentimes this teaching is provided when the client is experiencing a health problem and prevention is no longer an option. However, ideally, teaching is received when the client is experiencing optimum health and offers strategies to maintain the current health level. One of the most effective recommendations to make to a client to maximize health is to avoid smoking and the use of other tobacco products. The use or exposure to tobacco products has been directly linked to many health conditions, which can be avoided if the client does not use the substance.

A school-age child with cystic fibrosis asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be appropriate for the nurse to suggest? 1. Javelin throwing. 2. Swimming. 3. Baseball. 4. Track.

2. Swimming Swimming would be the most appropriate suggestion because it coordinates breathing and movement of all muscle groups and can be done on an individual basis or as a team sport. Because track events, baseball, and javelin throwing usually are performed outdoors, the child would be breathing in large amounts of dust and dirt, which would be irritating to her mucous membranes and pulmonary system. The strenuous activity and increased energy expenditure associated with track events, in conjunction with the dust and possible heat, would play a role in placing the child at risk for an upper respiratory tract infection and compromising her respiratory function

The nurse supervises the unlicensed assistive personnel (UAP) who provides care for a client diagnosed with a cervical spinal cord injury (C7-C8). Which action by the UAP requires intervention by the nurse? 1. The UAP elevates the head of the bed 30 degrees when assisting with meals. 2. The UAP firmly massages the client's lower back and buttocks with lotion. 3. The UAP instructs the client to shift weight every 15 minutes when sitting. 4. The UAP positions the client in a 30-degree lateral turn position in bed.

2. The UAP firmly massages the client's lower back and buttocks with lotion. - Providing a firm massage can damage tissue, increasing the risk for skin breakdown. This client is already at risk for skin breakdown due to immobility. This action requires immediate intervention by the nurse. Think like a nurse: The nurse supervises the unlicensed assistive personnel (UAP). When a breach in proper procedure is observed, the nurse should take this opportunity to teach the UAP the correct actions. The nurse can use the "sandwich" method in giving feedback. First, the nurse should point out the positive (focusing on the stren

The nurse asks the unlicensed assistive personnel (UAP) to perform soapsuds enemas for a client scheduled for a diagnostic test. Which action does the nurse expect from the UAP? 1. The UAP describes the returns from the enema. 2. The UAP observes the returns from the enemas in the bedside commode. 3. The UAP asks the client to describe the returns from the enema. 4. The UAP palpates the client's abdomen, noting firmness and tenderness.

2. The UAP observes the returns from the enemas in the bedside commode. — Performing an enema is a standard, unchanging procedure that can be delegated to the UAP with the responsibility and authority for performing the task. It is the nurse's responsibility to describe clear outcomes. Observing returns is a part of the task delegated and should be performed by the UAP. Think like a nurse: Before delegating a skill, the nurse needs to consider the scope of practice of the care provider. Unlicensed assistive personnel (UAP) are permitted to provide soapsuds enemas if competency on the skill is validated and the client is stable. When delegating the task, the nurse should clearly explain the expectations. For the soapsuds enemas, UAP should observe the returns and report these findings to the nurse. Remember that assessment is beyond the scope of practice for UAP.

The nurse provides care for clients on the psychiatric unit. Which behavior indicates the client is beginning to develop a trusting relationship with the nurse? 1. The client describes delusions to the nurse. 2. The client discusses personal feelings with the nurse. 3. The nurse feels more comfortable with the client. 4. The nurse observes that the client appears less anxious.

2. The client discusses personal feelings with the nurse. - To encourage a trusting relationship, the nurse demonstrates genuineness and empathy, and shows positive regard and consistency. A client 's being able to discuss feelings demonstrates that the client trusts the nurse. Think like a nurse: To determine whether the client is developing a trusting relationship, the nurse will evaluate client behaviors. The nurse will not rely on the nurse's personal feelings or beliefs about the client, but will focus on the client's behaviors towards the nurse. Evidence of a trusting relationship includes the client being more open with the nurse and discussing personal thoughts, concerns, and feelings. The principles of therapeutic communication are key to development of a therapeutic nurse-client relationship.

The nurse supervises hospice care for a client who practices orthodox Judaism. Which observation best indicates to the nurse that the care of this client is appropriate? 1. The client is given a wafer which is placed on the tongue. 2. The client has a continuous intravenous morphine infusion. 3. The client is turned to face east as signs of death appear. 4. The client is provided the sacrament of

2. The client has a continuous intravenous morphine infusion. - Pain management is appropriate for many clients at the end of life. Some members of the orthodox Jewish faith may wish for all of the following from caregivers at the end of life: facilitating lucidity, maximizing function, pain management, providing peace, and respecting dignity. Therefore, pain management with a continuous morphine infusion is considered appropriate care. Think like a nurse. When providing culturally sensitive care at the end of life, the nurse must be aware of his or her own personal beliefs, values, and behaviors regarding pain and pain management. The nurse must also be open to the cultural effects regarding how clients perceive and react to pain. To develop an effective and caring relationship with the client from a different culture, the nurse respects the client, respects the client's response to pain, and avoids stereotyping.

The nurse provides care for a client diagnosed with Alzheimer disease. The client lives with an adult child who serves as the caregiver. Which observation most concerns the nurse? 1. The caregiver assists the client into a wheelchair daily. 2. The home environment is extremely cluttered at each visit. 3. The caregiver is always in pajamas at the time of the nurse 's visits. 4. The caregiver's spouse is seen assisting with the client's care.

2. The home environment is extremely cluttered at each visit. —A cluttered environment may represent depression and burnout. In addition, the cluttered environment poses a risk for infection and falls. Think like a nurse: The nurse evaluates each statement for client safety risks. For the client with Alzheimer disease, a cluttered environment could increase the risk for injury and falls. Since the client lives with an adult family caregiver, the disarray could indicate burnout or depression and should be assessed. The nurse should carefully evaluate all environmental findings that represent safety risks for the client with Alzheimer disease.

The nurse administers medication on the pediatric unit. Which is the first action action by the nurse? 1. Validate the prescription with the medical record after the medication has been administered. 2. Verify the client by looking at the armband before administering the medication. 3. Contact the pharmacist to find out about possible adverse reactions. 4. Administer the medication mixed in the client's formula.

2. Verify the client by looking at the armband before administering the medication. - Medication errors often occur because of improper identification. The nurse should remember the rights of medication administration. Think like a nurse: The nurse always implements the rights of medication administration when administering prescribed drugs to the client. One of these rights is identifying the right client. The client's identity is confirmed using two approved identifiers, such as name and date of birth. The nurse asks the client to state this information. The nurse verifies this information using the armband on the client's wrist.

The nurse screens clients for the risk of developing gastric cancer. Which question does the nurse ask the client during the assessment process? 1. "Do you have a history of colon polyps?" 2. "How often do your drink caffeinated beverages?" 3. "Do you have a history of peptic ulcer disease?" 4. "How many carbonated soft drinks do you drink each day?"

3. "Do you have a history of peptic ulcer disease?" - The presence of H. pylori in the stomach increases the risk for gastric cancer. H. pylori causes peptic ulcer disease. Think like a nurse: General factors that increase an individual's cancer risk include obesity, tobacco use, chronic stress, and consumption of a high-nitrate diet. Alcohol consumption is also a factor that generally increases the risk for developing cancer, though research suggests the degree of risk depends of the amount and frequency of alcohol intake. Certain types of cancer are associated with risk factors that are disease specific. For gastric cancer, additional risk factors include a history of H. pylori infection, pernicious anemia, or Epstein-Barr virus. Genetic alterations that are usually associated with other cancer types, but also occur with gastric cancer, include BRCA1, BRCA2, and hereditary nonpolyposis colorectal cancer (HNPCC).

A client is scheduled to have a transabdominal pelvic ultrasound for evaluation of a uterine mass. The nurse includes which statement when preparing the client for the procedure? 1. "Do not eat anything for at least 8 hours before the test." 2. "You may feel a stinging sensation as the machine moves over your skin." 3. "Drink four glasses of water 1 hour before the test and do not urinate." 4. "Be prepared for the test to take 1 to 2 hours."

3. "Drink four glasses of water 1 hour before the test and do not urinate." - A full bladder is necessary for this test for several reasons, including the fact that it serves as a window for the ultrasound beam transmission. It also provides a less obstructed view by pushing the uterus away from the pubic symphysis, as well as by pushing the intestine out of the pelvis. Think like a nurse: The nurse will have access to diagnostic study requirements specific to the facility of employment and will not need to recall every pre-procedure and post-procedure detail. However, whenever a client procedure is scheduled, consider the purpose and nature of the procedure. The uterus sits low and deep in the pelvis. Given the structure of the pelvis, lifting the uterus out of the pelvic cavity offers a better view of a potential pelvic mass. Filling the bladder with water prior to the test expands the uterus, causing it to move up and out of the pelvic cavity, which improves visualization.

The unlicensed assistive personnel (UAP) calls the nurse and states, "The client in room 218 is reporting shortness of breath." Which response by the nurse is appropriate? 1. "Call the respiratory therapist and request an arterial blood gas be performed." 2. "Ask the client when the shortness of breath started." 3. "Ensure the nasal cannula is in the client's nares." 4. "Listen to the client's lung sounds and notify me if you hear wheezing or crackles."

3. "Ensure the nasal cannula is in the client's nares." — Ensuring the nasal cannula is in the client's nares can immediately improve oxygenation. The skill of applying (not setting or adjusting oxygen flow) and adjusting a nasal cannula can be delegated to the UAP. Think like a nurse: The nurse is aware the unlicensed assistive personnel (UAP) are able to complete routine tasks for stable clients within the identified scope of practice. Assisting with the application of nasal cannula is within the scope of practice for this level of care provider. The nurse always need to understand In delegation, the nurse retains the accountability and responsibility for assessing and evaluating the effectiveness of treatment (the nursing process). In this scenario, the UAP is performing correctly by informing the nurse of a client issue or a change in the client's status. Shortness of breath is noted without the process of assessment.

The nurse instructs the client who is diagnosed with mastitis of the left breast about breastfeeding the client's infant. Which statement by the client best indicates understanding of the instructions? 1. "I will feed the baby only from the right breast until this infection clears." 2. "It will be necessary for me to wean my baby from breastfeeding very quickly." 3. "Everyone in my family should use good handwashing techniques at all times." 4. "I should wear a tight compression bra to decrease the tenderness."

3. "Everyone in my family should use good handwashing techniques at all times." — Anyone who is in contact with the infant should use good handwashing techniques to prevent the spread of infection. It is not necessary to discontinue breastfeeding on the affected breast and is not desired, as discontinuing breastfeeding will increase breast engorgement and exacerbate pain. Think like a nurse: The nurse should assess the client for risk factors for mastitis, such as poor hygiene, ductal abnormalities, nipple cracks and fissures, lowered maternal defenses due to fatigue, tight clothing, poor support of pendulous breast, failure to empty the breast properly while breastfeeding, or missing a breastfeeding. The nurse should use the teach-back method in all client education activities.

The nursing student asks the nurse, "What are Good Samaritan laws?" Which response by the nurse is accurate? 1. "Good Samaritan laws require health care facilities to provide material to clients about rights." 2. "Good Samaritan laws provide clients with the right to be free from chemical restraints." 3. "Good Samaritan laws limit the liability of professionals in emergency situations." 4. "Good Samaritan laws require the reporting of threatened suicide or harm to others."

3. "Good Samaritan laws limit the liability of professionals in emergency situations." - This response accurately describes Good Samaritan laws. If the client subsequently develops complications as a result of a professional's actions, the professional is immune from liability as long as the professional acted without gross negligence. Think like a nurse. Any care provider might find themselves in a situation in which someone is in need of care that is outside of the employing organization. As a nurse, it is difficult to turn away from someone in need of physical, psychological, or emotional care. Even though nurses are licensed, there still needs to be some provision that protects the nurse's actions in the event that the care offered and provided is outside of what the person eventually needs. For this reason and many others, the federal government created a law that protects care providers who may be offering care in a situation in which the provider is not protected through the auspices of an employing organization.

The nurse provides care for a client at 28 weeks' gestation. The nurse counsels the client about how to prepare her 2-year-old child for the new baby. Which statement made by the client indicates that further teaching is necessary? 1. "I am going to wait another month to tell my child about the new baby." 2. "I have given my child a baby doll, bottles, and diapers." 3. "I am talking to my child about being a big sibling." 4. "We are already getting my child used to sleeping in a bed rather than the crib."

3. "I am talking to my child about being a big sibling." — This is not age-appropriate. A toddler is too young to understand and focus on the big sister/big brother concept. Explaining this concept would be more appropriate for preschoolers. Think like a nurse: It is important to prepare children for the arrival of a new family member during a pregnancy. This information should be presented to the child using age-appropriate explanation. The toddler is not developmentally prepared to understand the concept of sibling order or time. Therefore, it is best to prepare the toddler for the arrival of the new baby in other ways, such as waiting until closer to the time of delivery to explain the arrival of the new member to the family.

The nurse prepares to discharge a client after an abdominal cholecystectomy with a T-tube in place. Which statement by a client indicates to the nurse a need for further teaching? 1. "It will be great to finally get home, take a shower, and wash my hair." 2. "If the amount of drainage increases over the next several days, I should call my health care provider." 3. "I can resume swimming laps three times a week in my pool." 4. "I will check the skin around the tube once a day to see how it is doing."

3. "I can resume swimming laps three times a week in my pool." - A client should avoid strenuous exercise for up to 6 weeks. Due to the chance of bacteria entering the incision and tube, the T-tube should not be immersed in water. Swimming and tub baths are not permitted. Think like a nurse: Clients are often sent home with drains or tubes that they must care for. Therefore, the nurse provides instruction on how to keep these devices clean and dry, how to monitor drainage and the site for infection, how to empty and drain the device, and how to document the amount and color of drainage. Reasons for leaving a drain in place after surgery include allowing the wound to heal, reducing pain by preventing fluid collection, preventing fluid collection that might lead to infection, and minimizing tissue damage.

The home care nurse evaluates a client diagnosed with tuberculosis receiving isoniazid, rifampin, and pyrazinamide. Which client statement requires further assessment by the nurse? 1. "I have gained 5 pounds since I started taking the medication." 2. "I cover my nose and mouth when I cough or sneeze." 3. "I drink a glass of wine with dinner each night." 4. "I have stopped eating tuna salad sandwiches."

3. "I drink a glass of wine with dinner each night." — An adverse reaction of isoniazid is hepatitis. Instruct a client to avoid ingesting alcohol when taking the drug.

As part of a health center educational program on tuberculosis (TB), skin tests are offered as a screening measure. Which statement by a participant to the nurse requires further exploration by the nurse? 1. "My grandfather had tuberculosis and died from it." 2. "When I have these skin tests, nothing ever shows up." 3. "I had a shot for tuberculosis 5 years ago." 4. "I won't take medicine even if they do find something."

3. "I had a shot for tuberculosis 5 years ago." — This statement is indicative of possible contraindication for skin testing. The nurse explores the meaning of the word "shot" and what was actually done. This may have been the bacillus Calmette-Guerin (BCG) vaccine used to promote active immunity to TB, and false-positive reactions to tuberculosis skin testing can occur in individuals who received this vaccine. Think like a nurse: The statement "I had a shot for tuberculosis 5 years ago" requires clarification because bacillus Calmette-Guerin (BCG) is not generally recommended for immunization in the United States because of the low risk of infection with Mycobacterium tuberculosis. The nurse should be familiarized with required immunizations for adults and children. Prescribing treatments may be complicated because the BCG vaccination may result in a false-positive reaction to a tuberculin skin test (TST). Protection against tuberculosis (TB) cannot be predicted by the presence or size of a TST reaction in clients who have received the BCG vaccination.

The nurse instructs a client who is newly diagnosed with type 1 diabetes mellitus (DM) about proper foot care. Which client statement indicates to the nurse that additional teaching is needed? 1. "I should cut my toenails straight across." 2. "I should not go barefoot." 3. "I should inspect my feet once a week." 4. "I should bathe my feet daily in warm water."

3. "I should inspect my feet once a week." — The client should inspect feet daily for blisters, sores, ingrown nails, and cuts. This statement indicates that additional teaching is needed. Think like a nurse: When caring for a client with type 1 diabetes mellitus (DM), the nurse needs to apply knowledge about factors that can negatively impact the client's health and wellbeing. Because of the risk for foot wounds caused by changes in peripheral nerve sensation, the client with diabetes mellitus should be instructed to examine the feet every day. This can be accomplished by having the client hold a mirror up to the bottom of the foot to conduct a complete inspection.

The nurse instructs a client on self-instillation of gentamicin sulfate eye drops. Which client statement indicates to the nurse that further teaching is required? 1. "I should apply light pressure with my finger at the inner corner of my eye for one minute after instilling the drops. " 2. "I should gently clean away any crusts around my eye before I put in more drops. " 3. "I should place the tip of the eye dropper against my lower eyelid to steady my hand, and then squeeze the bottle. " 4. "I should call my health care provider if my eyelids start to itch or swell. "

3. "I should place the tip of the eye dropper against my lower eyelid to steady my hand, and then squeeze the bottle." — The client should be instructed to never touch the eye with the medication dropper. This will contaminate the medication. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. Proper eye drop and eye ointment administration requires the medication (in this case gentamicin) to have good contact with the absorptive surface of the inner eyelid. To avoid contamination, the medication container should not contact any surface of the eye. Self-administering eye medication can be difficult, because it goes against natural instincts to avoid touching the eye and to rub the eye when something foreign enters it. The client requires teaching and then should be encouraged to provide a return demonstration of the procedure to evaluate the effectiveness of that teaching.

The nurse follows up a community education session by asking clients to describe ways to reduce their cancer risk. Which client statement requires clarification by the nurse? (Select all that apply.) 1. "I will limit my exposure to second-hand smoke." 2. "I will walk for 30 minutes, at least 5 days a week." 3. "I should stop eating meat." 4. "I will lose 20 pounds." 5. "I should not go outside on very sunny days." 6. "I will avoid being around persons consuming alcohol."

3. "I should stop eating meat." - The nurse should clarify that it is not necessary to give up all meat. If the client desires to omit meat, the nurse may inform the client of ways to meet dietary requirements without meat. 4. "I will lose 20 pounds." - The nurse should clarify that persons should strive for a normal weight. Each client will have different weight loss or maintenance goals, depending on age, gender, height, and weight. 5. "I should not go outside on very sunny days." - the nurse should clarify that clients may spend a moderate amount of time in the sun, as long as they use sunscreen and wear a protective hat and clothing. 6. "I will avoid being around persons consuming alcohol." - The nurse should clarify that clients should limit alcohol intake, but being around persons who drink is not a risk factor for cancer. Think like a nurse: Risk factors for the development of cancer include smoking, obesity, inactivity, sun exposure, high intake of red meat, and chronic intake of alcohol. The client should limit, but does not need to abstain from, eating all red meat. The client should be encouraged to attain and maintain a normal body weight. The client should wear sunscreen or protective clothing in the sun, but not completely avoid the sun. Personal alcohol intake should be limited. Avoiding second-hand smoke is an established method to reduce cancer risk.

The nurse is teaching a client diagnosed with type 1 diabetes mellitus (DM) about disease management during an illness. Which client statement indicates to the nurse that further teaching is needed? 1. "I will monitor my blood glucose levels every 2 to 3 hours." 2. "I should contact the health care provider if I am unable to eat for more than 24 hours." 3. "I should stop taking insulin during the time I am sick." 4. "I should notify the health care provider if I have vomiting and diarrhea for more than 24 hours."

3. "I should stop taking insulin during the time I am sick." — The nurse will provide further teaching. The client with type 1 DM does not have any endogenous insulin, which means that glucose cannot be transported into the cell without the prescribed insulin. The client should take the usual dose of insulin and substitute easily digested foods and fluids to provide adequate nutrition and prevent dehydration. Think like a nurse: Clients with diabetes should be instructed on "sick day rules," which include taking medication as prescribed. An illness stresses the body. The stress causes the release of cortisol, which leads to increased blood glucose levels. It is essential for the client to ingest adequate food and fluids to ensure nutritional status and prevent dehydration.

The nurse counsels an older client about peripheral vascular disease. Which client statement 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 extreme weather. "

3. "I should use warm packs if my hands and feet get cold. " — Decreased sensitivity may result in burns. The client should be instructed to use gloves and socks to warm the hands and feet. Warm moist packs hold heat longer than warm packs and increase the risk for injury. Think like a nurse: In clients with peripheral vascular disease (PVD) , an important nursing outcome is prevention of injury to the affected leg. The client should be informed that due to reduced circulation and sensation, the leg is at a higher risk for injury. The nurse should use the teach-back method to verify the client's knowledge related to foot care. The client is taught to inspect feet and legs daily, wear clean cotton or wool socks and well-fitting shoes, avoid sitting with legs crossed, and avoid prolonged standing.

The home care nurse makes an initial visit to a client with heart failure. The client takes digoxin 0.25 mg and furosemide 40 mg daily. It is most important for the nurse to intervene if the client makes which statement? 1. "I take my digoxin either in the morning or midday." 2. "I eat a dish of ice cream for dessert every night." 3. "I take herbal licorice to control my stomach ulcer." 4. "I take the furosemide after supper each day."

3. "I take herbal licorice to control my stomach ulcer." - Licorice can increase potassium loss and may cause digoxin toxicity and arrhythmias. Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. Using the Maslow hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports ingesting foods and drugs that may interact. Licorice increases the potassium loss that results from furosemide, a loop diuretic. Hypokalemia interacts with digoxin to result in toxicity. Digoxin toxicity causes adverse effects, including arrhythmias.

The nurse instructs a client with gout about the disease process. Which client statement indicates additional teaching is required? 1. "I will limit my alcohol intake to one drink per day." 2. "I will take a water bottle with me to work." 3. "I will be able to eat mussels and clams for dinner." 4. "I will skip the anchovies from my pizza toppings."

3. "I will be able to eat mussels and clams for dinner." - Shellfish, such as mussels and clams, are high in purine, which can lead to an increase in uric acid. Think like a nurse: The nurse needs to recognize that purines are substances in animal and plant foods that convert to uric acid. High levels of serum uric acid can lead to the formation of crystals that often accumulate in the joints, causing inflammation and a gout attack. The client is informed to avoid organ and glandular meats (liver, kidney, and sweetbreads), which have high purine levels. The client is advised to avoid beer, as well as distilled liquors and high fructose corn syrup. Research shows drinking more water means fewer gout flares. Low-fat dairy products may improve excretion of uric acid in the urine.

The nurse teaches a group of pregnant clients about prenatal care. Which client statement requires follow up by the nurse? 1. "I will avoid changing my cat's litter box." 2. "I will drink 8 glasses of water a day." 3. "I will put my legs up on a pillow when I lie on my back to watch television." 4. "I can continue with my exercise class until I become too short of breath."

3. "I will put my legs up on a pillow when I lie on my back to watch television." - Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the woman lies on her back. The heavy uterus compresses her inferior vena cava, reducing the amount of blood returned to her heart. Circulation to the placenta may also be reduced by increased pressure on the woman's aorta, resulting in fetal hypoxia. The nurse should instruct the client to lie on her side. Think like a nurse: The nurse should consider the health of the client and the fetus when preparing teaching material for this population. Teaching should focus on wellness activities and actions to ensure viability of both client and fetus. In this scenario, the pregnant client should be instructed to avoid the supine position. The information is based on the fact that the weight of the growing fetus compresses the client's inferior vena cava, reducing the return of blood to the heart and general circulation. Supine position also hinders the blood flow to the fetus. Lying prone is another position that adversely affects both the client and fetus and should be avoided.

The nurse provides care for a client receiving aluminum hydroxide gel. The nurse determines that teaching is effective when the client makes which statement? 1. "I will only take this medication before bedtime." 2. "I will take this medication before meals." 3. "I will take this medication 1 hour after meals." 4. "I will take this medication when I feel epigastric pain."

3. "I will take this medication 1 hour after meals." - Antacids neutralize gastric acids, increase gastric pH, and inactivate pepsin. The medications should be taken 1 hour after meals. Think like a nurse: Aluminum hydroxide is an antacid that is taken after meals to neutralize gastric acid. The medication needs to be taken more frequently than at bedtime. The medication is not as effective if taken before meals. The nurse should teach the client that regular use of an antacid prevents the development of epigastric pain, and is more effective than taking the medication after pain occurs.

A client is prescribed phenazopyridine 200 mg three times a day by mouth. Which information will the nurse include when teaching the client about this medication? 1. "Take your medication at least 6 hours before bed so it doesn 't cause insomnia. " 2. "Wear sunglasses when you are outdoors and try to avoid bright lights. " 3. "If your skin or sclera develops a yellowish tinge, call the health care provider. " 4. "Avoid driving or activities that require alertness while taking this medication. "

3. "If your skin or sclera develops a yellowish tinge, call the health care provider. " — Yellowish discoloration of the skin or sclera indicates that the drug is accumulating in the body because of renal impairment. This finding should be reported to the health care provider. Phenazopyridine is a urinary tract analgesic.

The unlicensed assistive personnel (UAP) reports to the nurse that a client diagnosed with type 1 diabetes mellitus states, "The room is spinning around me." Which is the priority responseby the nurse? 1. "Did the client eat breakfast?" 2. "Has the client experienced episodes of vomiting?" 3. "Is the client in bed?" 4. "Has the client had this problem before?"

3. "Is the client in bed?" - The priority is client safety. The client should sit down or lie down to prevent falling. Think like a nurse: When caring for a client, the nurse's priority action is to always ensure the safety of a client. A client who is experiencing dizziness is at high risk for a fall and injury. The most important response is to ask if the client is sitting down or lying in bed. The nurse must first assure that any contributing factor to the client's safety is addressed. Additional assessment can occur once the client's safety is ensured.

The prenatal client asks the nurse why she is going to receive Rho(D) immune globulin during her pregnancy. Which information does the nurse include in the response? 1. "It resolves the incompatibility between your blood type and your infant's blood type." 2. "It prevents your infant from developing jaundice due to blood incompatibility." 3. "It prevents your body from having an immune reaction against your infant's blood." 4. "It prevents your blood from mixing with the blood of your infant."

3. "It prevents your body from having an immune reaction against your infant's blood." — Rho(D) immune globulin prevents the mother from forming antibodies to a developing fetus's Rh-positive blood. Sensitization may occur during pregnancy, birth, abortion, or amniocentesis. Think like a nurse: Maternal-fetal differences in Rh incompatibility are treated prophylactically with Rh immune globulin (RhoGAM) during pregnancy and treated again after pregnancy depending on the newborn's blood. A mother with Rh negative blood will develop an immune response to a fetus with Rh positive blood. This only impacts mothers with Rh negative blood; a mother with Rh positive blood will not develop an immune response regardless of the fetal Rh factor. The mother's body identifies the child as foreign, just as it would an influenza infection, and mounts a defense to protect the maternal body. If the mother is allowed to create an immune response to this child, subsequent children are at risk of miscarriage, illness, or death.

The nurse develops a teaching plan for a pregnant client. A goal of the plan is to promote cardiac output during pregnancy. Which instruction is most important for the nurse to tell the client? 1. "Take frequent rest periods." 2. "Modify your regular aerobic exercise as pregnancy progresses." 3. "Lie on your left side when sleeping or resting." 4. "Elevate feet whenever sitting."

3. "Lie on your left side when sleeping or resting." - In the supine position, particularly during the second half of pregnancy, the weight of the gravid (pregnant) uterus partially occludes the vena cava and the aorta. This reduces cardiac output and can lead to the development of supine hypotensive syndrome. Lying on left side takes the weight of the uterus off the vena cava and increases blood return to the heart, which will promote cardiac output. Think like a nurse: Before selecting the most appropriate teaching to support the pregnant client's cardiovascular status, the nurse needs to stop and recall the physiological process of pregnancy. As the uterus enlarges, the client's internal organs become compressed or displaced. This includes the descending aorta within the abdominal cavity. To maximize cardiovascular functioning, the nurse should instruct the client to lie on the left side, which prevents compression of the descending aorta. Elevating the lower extremities may further press the gravid uterus onto the aorta if the client does not shift the abdomen to the side.

The nurse performs a routine health screening at the middle school. Which statement made by the student most concerns the nurse? 1. "I do not want to go home today. My dad is going to be really mad when I tell him I failed my math test." 2. "I never get to go out with my friends. I have to watch my baby brother after school every day." 3. "My friends and I play this cool game called 'the choking game.' Nobody really gets hurt so it is okay to play." 4. "My best friend will not talk to me. She is upset because I would not let her copy my homework."

3. "My friends and I play this cool game called 'the choking game.' Nobody really gets hurt so it is okay to play." — The student is in imminent danger of physical harm. The "choking game," also called the "fainting game," is an activity in which the child puts their self or another child in a choke hold and squeezes until the child being choked loses consciousness. The nurse must immediately intervene. Think like a nurse: The choking game is a red flag. This "game" is played by having the airway and trachea occluded to the point where the person loses consciousness. This is a dangerous action, should not be considered a "game," and requires immediate intervention by the nurse. The person being choked is at risk for hypoxia and brain damage. The school nurse should explain this to the student and strongly suggest to avoid participating in this "game" in the future. Nurses, especially in school settings, need to be aware of "fads" and "trends" that place clients at risk.

The nurse evaluates the health status of an older adult client during a home visit. Which client statement causes the nurse the most concern? 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 legs 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 legs throb when I take my dog for a walk." — Throbbing legs could indicate peripheral vascular disease. This finding should be followed up and reported to the health care provider. Think like a nurse: Lower extremity pain worsened with activity may indicate peripheral arterial disease (PAD). The most common risk factors for lower-extremity PAD are advance age (≥70 years) history of smoking or diabetes, hypertension, dyslipidemia, hyperhomocysteinemia, and known coronary, carotid, or renal atherosclerotic disease. During the visit, the nurse can assess the neurovascular status of the legs, noting pain, pallor, paresthesia, and pulses. The nurse should refer the client for immediate evaluation of the legs. This would also be an opportunity to teach the client how to prevent injury of the lower extremities and smoking cessation, if applicable.

The home health nurse visits a client diagnosed with systemic lupus erythematosus (SLE). Which client statement is most important for the nurse to follow up? 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." — The nurse would follow up because sun exposure, infection, and joint stress are major problems. The skin of a client with SLE often has discoid lesions in various body areas and they can become especially erythematous on exposure to sun. Clients 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. Clients who are immunosuppressed should wear gloves working with houseplants or in a garden because of the risk both for injury, even simple cuts, and for exposure to bacteria in soil. The joints of a client with SLE are usually inflamed by the disease itself in a polyarthritis manner. The joint problems may make it difficult, if not impossible, for a client to garden. Think like a nurse: Clients with systemic lupus erythematosus (SLE) should be instructed to avoid exposure to direct sunlight to prevent skin changes. The client should also use gardening gloves to reduce the risk of contracting an infection from microorganisms present in the soil. SLE affects energy levels, which can vary from day to day. To conserve energy, the client should be encouraged to pace activities and plan rest periods.

The nurse learns that a new admission was responsible for the death of a neighbor during a robbery. The nurse says to the head nurse, "I don't think that I can care for that client." Which is the best response by the head nurse? 1. "I will talk with the supervisor about your situation." 2. "I can see about transferring you to another unit." 3. "Please share with me your concerns." 4. "You are a professional and will care for the client."

3. "Please share with me your concerns." — This is therapeutic, as it allows the nurse to express concerns and resolve the situation. Think like a nurse: The nurse is a professional who should be able to care for any individual, regardless of the circumstances; however, the nurse is also a human with thoughts, feelings, and experiences. The head nurse asks the nurse for his or her concerns, carefully listening for true conflicts in providing care. If the nurse was friendly with this neighbor, that likely is a true conflict, and the nurse should not be assigned to the client.

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1. "The father transmits the gene to the 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 the daughters."

3. "The mother transmits the gene to her son." — Hemophilia is a sex-linked disorder

An adolescent experiences severe left lower quadrant abdominal pain 2 days after the start of a menstrual period. Which response is the best for the nurse to make when the parent asks for pain medication so the client can participate in cheerleading tryouts? 1. "You will need to discuss that with the health care provider. " 2. "Your child probably should not be trying out for the cheerleading squad today. " 3. "The signs and symptoms sound as if they involve more than the menstrual period. " 4. "You appear very concerned about your child 's condition. "

3. "The signs and symptoms sound as if they involve more than the menstrual period. " - A sudden onset of severe pain could indicate tissue injury or rupture of an organ. Think like a nurse: The nurse is facing a situation where the amount of discomfort is greater than is expected for the situation. An adolescent client can experience abdominal cramping with menstruation. However, this client's level of pain is severe and should be further assessed. Unfortunately, the client's parent is distracted with another event and is not taking the client's pain issue into consideration. The nurse needs to support the client by stating that the symptoms need further evaluation and intervention prior to assuming the cause is menstruation.

The parents sit at the bedside and discuss a bicycle accident involving their older son who was riding his bicycle and accidentally hit their school-age daughter, who experienced a concussion. Which statement made by a parent validates the nursing diagnosis of dysfunctional family process? 1. "Our daughter never watches where she's going. She doesn't pay attention." 2. "It was an accident. I don't want to hear that our son has always been jealous of her." 3. "This would not have happened if you had not stopped at the bar on the way home." 4. "We are going to have to talk to our son about bicycle safety."

3. "This would not have happened if you had not stopped at the bar on the way home." - Blaming a spouse for the accident combined with potential substance abuse indicates a dysfunctional family process. Substance abuse is a primary cause of dysfunctional family systems. Think like a nurse: Evidence of a dysfunctional family includes blaming and using substances or alcohol to cope with stressful life situations. Planning to talk with a child about bicycle safety is evidence of a well-functioning family unit.

A client diagnosed with borderline personality disorder becomes angry when the nurse refuses to permit the client's partner to spend the night with the client in the hospital. Which response by the nurse is best? 1. "If I made the rule, I could help you, but I can't." 2. "It's not fair to put me in this difficult position." 3. "Visiting hours are over at 8 pm, and all visitors must leave." 4. "Your partner can stay until I leave at midnight, but lock your door."

3. "Visiting hours are over at 8 pm, and all visitors must leave." — Stating visiting hours and expectations that visitors must leave provides information and sets limits and expectations for the client to behave according to unit policy. Think like a nurse: In dealing with clients who have borderline personality disorder, the nurse should understand why the clients act and react the way they do, then respond in ways that validate their feelings and help them regain and maintain emotional control. For example, the nurse may say, "I understand how you feel." The nurse should not focus on the situation, but the emotion behind it. The nurse can set limits and should invoke institutional policy consistently.

The nurse teaches the client about preventing recurrent urinary tract infections. Which statement by the client indicates to the nurse that teaching is effective? (Select all that apply.) 1. "I should bathe in the tub rather than shower." 2. "Coffee and alcohol are good for my bladder." 3. "Vitamin C will help by acidifying my urine." 4. "I should void every couple of hours during the day." 5. "I should wipe back to front after urinating."

3. "Vitamin C will help by acidifying my urine." — Vitamin C (ascorbic acid) 1000 mg daily, or cranberry juice, may help prevent recurrent urinary tract infections by acidifying the urine. 4. "I should void every couple of hours during the day." — Voiding frequently prevents over-distention of the bladder and compromised blood supply to the bladder wall. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including any literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. The nurse should explain to the client various self-management activities to prevent urinary tract infection (UTI).

A client in a domestic violence shelter asks the nurse to explain why the client continues to be beaten. Which response is the best for the nurse to make? 1. "Can you remember what you said or did just before being hit? " 2. "Let 's focus on getting your face and ribs healed first. " 3. "We can help you when you 're ready. You do not deserve to be abused. " 4. "Only the person who is beating you can tell us what causes the violence. "

3. "We can help you when you 're ready. You do not deserve to be abused. " - Saying that help is available when the client is ready is a reflective statement that is therapeutic. This statement also provides information because it offers support and a path to help, coupled with reinforcement that the client does not deserve to be abused. Think like a nurse: The nurse can help the client understand that the client is not responsible for the perpetrator 's violent behavior (e.g. saying to the client: "You are not responsible for your partner 's violence. ") As a general rule, when communicating with victims of violence, it is best for the nurse not to say anything the nurse is unsure can be followed through. The nurse should inquire if the violence involves children and follow protocol on how to protect them. In some institutions, a standardized screening form is used and an intervention algorithm is implemented.

The parent of an infant client with tetralogy of Fallot (TOF) is pumping her breasts at the client's bedside. The unlicensed assistive personnel (UAP) says to the nurse, "She should breast feed that baby instead of pumping all the time. What's wrong with her?" Which is the best response for the nurse to make? 1. "You sound upset about what you observed." 2. "Why don't you ask her why she is pumping?" 3. "What do you understand about her baby's illness?" 4. "It's not our business to judge the decisions of others."

3. "What do you understand about her baby's illness?" - This is a non-judgmental response and provides opportunity and a starting point for needed staff teaching. Infants with congenital heart diseases, including TOF, are weak, fatigue easily, and need to be fed carefully and with the least amount of required effort on their part. Think like a nurse: "What do you understand about her baby's illness?" is a question that explores the UAP's knowledge about the client. The nurse may use this opportunity to educate or correct misconceptions. The nurse should also consider including key information during hand-off communication with the UAP and providing rationale for why the baby must be fed carefully.

An adolescent student asks the school nurse what to do when a parent has a panic attack every time the parent attempts to leave the house. Which statement is the best response for the nurse to make? 1. "Have your parent practice deep breathing and relaxation techniques before leaving the house." 2. "Tell your parent that this behavior is disruptive to the whole family." 3. "You are concerned for your parent, but more help is needed than you are able to provide." 4. "Desensitize your parent by having them get into the car and quickly leave the area."

3. "You are concerned for your parent, but more help is needed than you are able to provide." — The student is describing a phobic disorder that is treated with behavior therapy and medication that can reduce or block the panic attacks. Phobias are an extreme expression of anxiety, apprehension, or helplessness when confronted with the phobic situation or feared object. The person avoids the situation in which the symptoms have occurred and restricts life in ways that become as problematic as the original phobic object. Think like a nurse: Dealing with a parent who suffers from panic attacks is stressful, particularly for adolescent children. The nurse can assist by clarifying the situation the child is facing and acknowledging the limits of what the child can provide to help the parent. The nurse should escalate the scenario by making appropriate referrals to community-based organizations that can help the child. The nurse can offer reassurance and hope to the child. In small ways, this may help the child build resiliency.

The nurse provides care to a client who is scheduled to undergo lumbar puncture during a workup for suspected multiple sclerosis (MS). Which information does the nurse include when preparing the client for lumbar puncture? 1. "You will receive general anesthesia for this procedure." 2. "You cannot eat or drink for 8 hours immediately before having the procedure." 3. "You will need to remain very still during the procedure." 4. "You will wear a compression dressing at the puncture site for 24 hours after the procedure."

3. "You will need to remain very still during the procedure." - Movement during lumbar puncture can result in misplacement of the spinal needle and subsequent damage to nerves or blood vessels. The client should be advised to remain still and to breathe normally during the procedure. Think like a nurse: In preparation for the lumbar puncture, the nurse should follow institution protocol. Key activities include: obtaining the informed consent and placing it in the medical record, having the client empty the bladder, obtaining the appropriate lumbar puncture kit, performing a time out prior to the procedure, placing the client in an appropriate position and identifying landmarks, cleaning the site using sterile technique, and placing sterile drapes while observing aseptic technique. The nurse can assist the health care provider during the procedure and support the client in positioning, as well as provide emotional reassurance. The nurse will inform the client about staying on bed rest for 6 to 8 hours after lumbar puncture. The client is monitored for headache and signs of meningeal irritation.

The nurse conducts a quality assurance review of a laboring client's health record. Which entry does the nurse reviewer bring to the attention of the nurse manager? 1. 1035: Five minutes after epidural initiated, client's blood pressure is 80/48 mm Hg. Client positioned left side down. 2. 1050: Fetal heart rate is 90 to 100 beats/min after epidural block. O2 by face mask administered to client at 10 L/min. 3. 0820: 500 mL IV fluid bolus of Lactated Ringer's solution completed. 1030: Anesthesiologist present to begin administration of epidural block. 4. 1102: Fetal heart rate sustained at 100 beats/min for more than 10 minutes. Lactated Ringer's solution infusion rate increased to wide open per protocol.

3. 0820: 500 mL IV fluid bolus of Lactated Ringer's solution completed. 1030: Anesthesiologist present to begin administration of epidural block. — Epidural blockade produces vasodilation and typically causes a decrease in blood pressure. Administration of an IV fluid bolus prior to an epidural block is intended to offset potential hypotension by increasing the fluid volume in the intravascular space. To optimize the effects of the fluid bolus, the IV fluid should be administered over 20-30 minutes and the epidural procedure begun shortly thereafter. Think like a nurse: When administering medication, the nurse considers the intended purpose of the medication. The purpose of the fluid bolus is not hydration, but to rapidly increase circulatory volume and cardiac output. When administering a bolus to a client who is about to have an epidural placed, a bolus is a prophylactic measure that avoids the adverse effect of hypotension. Prevention is essential to the mother and baby's well-being. Fluid administered 2 hours before the epidural placement has already distributed through circulation to be excreted through the kidneys. When there is a delay in epidural placement, the nurse considers administering an additional bolus.

The nurse receives report on a group of clients at the beginning of the shift. Which client does the nurse assess first? 1. A client drinking contrast for an abdominal CT scan who reports nausea and abdominal pain. 2. A client with a respiratory rate of 24 breaths per minute and an oxygen saturation of 93% on room air. 3. A client reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea. 4. A client whose family member threatened to sue the hospital if the nurse does not talk with the family immediately.

3. A client reporting frequent small amounts of watery diarrhea with abdominal cramping and nausea. — Frequent and small amounts of diarrhea may indicate a possible bowel obstruction that can be life-threatening if the bowel perforates. The nurse needs to assess this client so interventions can be implemented quickly. Think like a nurse: Untreated intestinal obstruction can lead to life-threatening complications, including bowel infarction and infection secondary to peritonitis. The resulting inflammation in bowel obstruction can lead to fluid sequestration, increased capillary permeability, and severe reduction in circulating blood volume. The nurse should think of preventing hypovolemic shock in clients with suspected bowel obstruction. The nurse needs to assess this client first in order to escalate interventions, such as an emergency exploratory laparotomy or aggressive fluid resuscitation.

Which client on the pediatric unit requires the immediate attention of the nurse? 1. A client with epilepsy who has a loose tooth. 2. A client experiencing diarrhea with a sickle cell crisis. 3. A client saying the arm cast feels too tight. 4. A client who is blind and has a nosebleed.

3. A client saying the arm cast feels too tight. - A cast that is too tight may indicate compartment syndrome. This child has a current neurovascular status threat and is the priority patient. Think like a nurse: Prompt and accurate diagnosis of compartment syndrome is critical. Prevention and early recognition are the priorities of care. Of the four clients, the one reporting tightness of the cast requires immediate attention as it could lead to tissue hypoxia and necrosis. The client with epilepsy is not actively seizing, although the risk for aspiration from a loose tooth should be evaluated. The client experiencing symptoms of compartment syndrome requires immediate assessment and intervention to decrease the risk for a loss of limb due to circulatory compromise. While the client experiencing a sickle cell crisis with diarrhea requires assessment and treatment, there is no immediate danger. Epistaxis is rarely fatal.

The nurse provides care to clients in an outpatient surgical center. Four clients scheduled for surgery present to the surgical center at the same time. To prioritize safety, which client does the nurse assess first? 1. A client scheduled for a shoulder arthroscopy. 2. A client scheduled for an inguinal hernia repair. 3. A client scheduled for a mastoidectomy. 4. A client scheduled for removal of nasal polyps.

3. A client scheduled for a mastoidectomy. — The client scheduled to undergo mastoidectomy likely experiences chronic ear infections, which are often accompanied by dizziness or vertigo. Due to the potential for injury related to falls, the client scheduled for mastoidectomy should be assessed first.

The nurse teaches a group of nursing students about elder abuse. Which older adult client does the nurse list as most likely to be a victim of abuse? 1. A male diagnosed with moderate hypertension. 2. A male with newly diagnosed cataracts. 3. A female with advanced Parkinson disease. 4. A female diagnosed with early stage Lyme disease.

3. A female with advanced Parkinson disease. - The typical abuse victim is a woman of advanced age with reduced social interaction and at least one physical or mental impairment. Abuse of the older adult client can be physical, sexual, domestic, psychological, or financial in nature. In some cases, elder abuse takes the form of neglect. The nurse assesses at-risk and vulnerable people carefully for signs of an abusive situation. Nurses have a duty to report suspected abuse situations to specified state agencies. The nurse must have a reasonable suspicion, not proof, that abuse is occurring. If this condition is met, the reporting nurse has immunity from legal repercussions. Reports are confidential to protect the reporting nurse. On the other hand, failure to report such instances can result in legal consequences.

The nurse in a maternity unit is reviewing the client's records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1. A primigravida with mild preeclampsia. 2. A primigravida who delivered a 10-lb infant 3 hours ago. 3. A gravida II who has just been diagnosed with dead fetus syndrome. 4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood. 5. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia.

3. A gravida II who has just been diagnosed with dead fetus syndrome. 5. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia. - DIC is a condition in which the clothing cascade is activated, resulting in the formation of clots in the microcirculation. - Dead fetus syndrome, severe preeclampsia, and hemorrhage are risk factors for DIC

The nurse provides care for a client diagnosed with pneumonia who is pale and reports shortness of breath. Which laboratory test does the nurse expect the health care provider to prescribe to determine oxygenation status? 1. RBC count. 2. Sputum culture. 3. ABG analysis. 4. Urine culture and sensitivity.

3. ABG analysis. — ABGs evaluate gas exchange in the lungs, providing information about client's oxygenation status. Think like a nurse: The nurse is aware the client experiencing shortness of breath because of an acute lung infection may need an adjustment to supplemental oxygen or a change in prescribed medications. However, the nurse will expect the health care provider to gather diagnostic data before any changes are made. One test that will provide the most current and accurate information about respiratory functioning is the arterial blood gas. The nurse knows this test requires a sample of arterial blood. The blood is analyzed for the amount of oxygen and carbon dioxide in the blood. Based upon the results of this test, further treatment can be planned that will be the most effective for the client's symptoms.

A client diagnosed with type 2 diabetes mellitus (DM) is treated for hypertension with propanolol. The history reveals that the client is diagnosed with glaucoma and is allergic to sulfa. Which prescribed medication requires an immediate intervention by the nurse? 1. Glycerin. 2. Pilocarpine. 3. Acetazolamide. 4. Timolol maleate.

3. Acetazolamide. — This medication is contraindicated. Clients with a sulfa allergy should not take acetazolamide, as an allergic reaction may occur. Think like a nurse: The nurse should review the medication list and assess for those that may interfere with a current health problem or create a new one. Acetazolamide is contraindicated in clients with an allergy to sulfa. This is the medication that the nurse should question before administering to the client.

The nurse admits an older adult client who has a full thickness burn over 15% of the total body surface area (TBSA). Which action does the nurse take first? 1. Administer prophylactic intravenous antibiotics. 2. Administer a tetanus toxoid injection intramuscularly. 3. Administer Lactated Ringer's solution intravenously. 4. Administer intravenous morphine every 5 to 10 minutes.

3. Administer Lactated Ringer's solution intravenously. -Burns result in large insensible fluid loss through damaged skin. The greatest risk to the client following a full thickness burn of 15% of the TBSA is hypovolemia shock. The nurse should first administer crystalloid IV solution to maintain vascular volume. Think like a nurse: Before implementing any interventions or prescriptions, the nurse should stop and recall, "What happens to the body when the skin is burned?" The skin has several functions; one being the containment of body fluids and maintenance of electrolyte status. Since the client experienced a major burn, an area of the skin is gone, body fluid and electrolytes are lost, and the client is at risk for low fluid volume and electrolyte imbalance. The priority should be to begin fluid resuscitation, using fluids that will maintain vascular volume and electrolyte levels. Once fluid replacement is started, the nurse can then address the client's needs for pain management, which is considered a psychosocial need according to Maslow.

The nurse provides care for clients at risk for colorectal cancer. Which client does the nurse identify as being at highest risk for the development of colorectal cancer? 1. Caucasian client with a family history of adenomatous polyposis, consumes 2 servings of red meat per week, avoids alcohol, and is physically active. 2. African American client with a history of gastrectomy, consumes diet high in fruits and vegetables, avoids red meats, and is physically active. 3. African American client with a history of inflammatory bowel disease, smokes cigarettes, consumes 12 alcoholic beverages per week, and avoids red meats. 4. Caucasian client with a body mass index of 32, avoids alcohol, smokes cigarettes, and has a first-degree relative with a diagnosis of colorectal cancer.

3. African American client with a history of inflammatory bowel disease, smokes cigarettes, consumes 12 alcoholic beverages per week, and avoids red meats. - This client has four risk factors, which include being African American, having a history of inflammatory bowel disease, smoking, and having an alcohol intake of >4 drinks per week. This client is at highest risk for developing colorectal cancer. Think like a nurse: Colorectal cancer has been identified as a pathologic condition that can be avoided if caught early through screening and symptom identification. The nurse should recall the etiology of this health problem, specifically modifiable and non-modifiable risk factors. Non-modifiable risk factors cannot be changed and include age, gender race, and family history. Modifiable risk factors are those that can be changed and include lifestyle, alcohol intake, smoking history, dietary intake, and body weight. Of the clients being assessed, the nurse should identify the client with the most risk factors as having the highest risk for developing the disorder.

A client is brought to the emergency department by friends who state, "Our friend has been hanging with the wrong crowd. We are worried about drug use." 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. Which manifestation(s) is/are most important for the nurse to anticipate? 1. Torticollis. 2. Hypotension, hypothermia, bradycardia. 3. Aggression. 4. Nausea, vomiting, abdominal cramping.

3. Aggression. — The symptoms of blank stare, rigid muscles, ataxia, and nystagmus that are both vertical and horizontal indicate probable PCP intoxication. Aggression in all forms is another symptom that manifests with PCP use. This can take the form of assault, belligerence, impulsiveness, or suicidality, and it is very often bizarre in nature. It often occurs in unpredictable outbursts. This manifestation impacts safety. Therefore, this is the most important clinical manifestation for the nurse to monitor for when providing care for this client. Think like a nurse: Aggressive behavior is a safety concern for the client and those providing care to the client. To enhance safety, the nurse specifically monitors this client for signs of aggression. Interventions should be implemented to prevent aggressive behaviors, and to manage them should they occur. Decreasing stimuli, securing potential injurious objects in the environment, and having chemical and physical restraints (along with sufficient staff) available are all measures that can be planned in advance and utilized.

The parish nurse knows that it is most important to encourage which parishioner to obtain screening for prostate cancer? 1. A Caucasian young adult computer programmer diagnosed with cryptorchidism. 2. An Asian-American adult restaurant owner diagnosed with ulcerative colitis. 3. An African-American middle-aged adult factory worker in automobile tire manufacturing. 4. A Caucasian older adult retired house painter who has been smoking for 40 years.

3. An African-American middle-aged adult factory worker in automobile tire manufacturing. — This client has three major risk factors for prostate cancer: age, race, and 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 (which have a higher incidence of prostate cancer) and in occupations such as fertilizer, rubber, and textile industries. Think like a nurse: Risk factors for the development of prostate cancer include age, African-American race, and environmental exposure to carcinogens. Based on this information, the African-American client who is middle-aged and works in the automobile industry has the highest risk for the disease.

The hospital has just received word that a major disaster has occurred and a large influx of clients is expected in less than 1 hour. The nurse considers which current client is most appropriate for immediate discharge? 1. An older adult client admitted 4 days ago with a diagnosis of a stage 3 pressure injury. 2. An older adult client admitted 12 hours ago with a diagnosis of pyelonephritis. 3. An older adult client 4 days postoperative after a total hip replacement. 4. An adult client 24 hours postoperative after a vaginal hysterectomy.

3. An older adult client 4 days postoperative after a total hip replacement. — This is the most stable client. Clients post-total hip replacement are typically discharged on postoperative day 2 to 3 to a rehab facility or home. Think like a nurse: In response to a disaster, the hospital activates its emergency operations plan (EOP). Planning for coordinated care of clients into and out of the hospital is an essential component of the EOP. This involves identifying which clients can be discharged or transferred to another facility to make beds readily available for an influx of clients. Hip replacement surgery commonly requires 2 to 3 days of hospitalization; this client has been hospitalized for 4 days. A stage 3 pressure injury requires aggressive treatment. Treatment for pyelonephritis requires a course of IV antibiotics to prevent progression to sepsis. After a vaginal hysterectomy, the client typically remains hospitalized for 48 hours due to the risk for bleeding.

The nurse determines which client is at highest risk of developing colorectal cancer? 1. An adult client who teaches high school and has a history of endometrial cancer. 2. An adult client who owns a restaurant and has a history of alcoholism. 3. An older adult client who is a cattle farmer diagnosed with Crohn disease. 4. An older adult client who is a bus driver and has a hiatal hernia and obesity.

3. An older adult client who is a cattle farmer diagnosed with Crohn disease. — Age is a general risk factor for cancer. A history of inflammatory bowel disease is a significant risk factor that is specific to colorectal cancer. This is enough information to place this client at higher risk. However, the nurse might also assess that the cattle farmer enjoys a high quantity of red meat, further increasing the risk of developing colorectal cancer. Think like a nurse: Awareness of factors that increase the risk for developing health alterations allows the nurse to develop client-specific strategies aimed at health promotion and disease prevention. Because each client demonstrates risk factors for cancer, education about disease prevention is helpful for all the clients. Age is a non-modifiable risk factor. The clients who experience chronic stress may benefit from learning stress reduction techniques. The client with obesity may be taught general activity and diet alterations and referred to a dietitian.

The health care provider removes the peripherally inserted central catheter (PICC) from a client. A portion of the catheter breaks off. Which action does the nurse take first? 1. Check the client's radial pulse. 2. Turn the client to the right side. 3. Apply a tourniquet to the upper arm. 4. Instruct the unit secretary to call for an emergent x-ray.

3. Apply a tourniquet to the upper arm. - The nurse will place a tourniquet close to the axilla. This prevents the catheter piece from advancing into the right atrium and acting as an embolism. After the tourniquet is applied, check for the presence of the radial pulse to ensure that arterial flow is not eliminated. The tourniquet will be kept in place until an x-ray is obtained and surgical retrieval attempted. Think like a nurse: With proper placement, the distal end of peripherally inserted central catheter (PICC) lies near the heart in the superior vena cava. A catheter tip embolus may be the actual tip or a portion of the catheter. The original length of the PICC should be noted in the procedure documentation. If the entire catheter is not retrieved upon removal, the nurse may apply a tourniquet to the upper arm with the hope that the catheter embolus is lodged in the arm and not in a major vessel. The health care provider, rapid response team, and PICC insertion team should be notified of the adverse event. Documentation should be completed per the organizational policy.

The nurse provides care for a client who is having an anaphylactic reaction. The client is hypotensive and in respiratory distress. The nurse notes the client has swollen lips and tongue. Which intervention should the nurse perform first? 1. Be prepared to administer intravenous (IV) epinephrine. 2. Start an IV immediately and run normal saline. 3. Apply oxygen using a high-flow, non-rebreather mask. 4. Ensure that intubation and tracheotomy equipment is ready.

3. Apply oxygen using a high-flow, non- rebreather mask. — When a client is having an anaphylactic reaction, oxygen should immediately be applied to ensure there is adequate oxygenation helping to prevent hypoxia, dysrhythmia, shock, and cardiopulmonary arrest. Think like a nurse: A client demonstrating the symptoms of an anaphylactic reaction needs immediate respiratory support. The nurse should follow the airway, breathing, and circulation (ABCs) system and begin with establishing an airway. The client's tongue and lips are swollen; however, the client is still breathing. A source of oxygen should be provided immediately. The nurse should stay with the client, monitor respiratory rate and blood pressure, and call for help in the event the client's condition deteriorates. Epinephrine will be administered to assist in reducing airway edema after the oxygen is applied.

The health care provider documents in a client's medical record the statement "bizarre gesturing, decline in hygiene, and command hallucinations." Which action is most important for the nurse to take when caring for this client? 1. Note the quality and duration of the gestures. 2. Offer the client a fresh change of clothing. 3. Ask the client what the voices are saying. 4. Administer antipsychotic medication.

3. Ask the client what the voices are saying. - The nurse must assess the nature of command hallucinations and then take appropriate safety action, as the voices may be telling the client to harm self or others. Think like a nurse: The priority for the nurse is to assess the content of the hallucinations so appropriate safety actions can be implemented. After safety needs are met the nurse can help meet the client's hygiene needs. Medications will be provided as prescribed after safety needs are met.

When arriving for a home visit, the nurse learns that a toddler has just swallowed another family members ' medication. Which action will the nurse take first? 1. Call poison control. 2. Notify the health care provider. 3. Assess the child. 4. Administer syrup of ipecac.

3. Assess the child. — The child should be immediately assessed before implementing any actions. The child might need cardiopulmonary resuscitation or treatment of other symptoms, such as seizure activity. Think like a nurse: Developmentally, a toddler is curious and is interested in learning about the environment. Because of this, small objects, medications, and chemicals should be removed or secured in the environment to prevent the child from accidentally ingesting a potentially harmful substance. In this scenario, the toddler ingested another person's medication. The first action to take is to assess the toddler for adverse effects. Depending upon the findings, the nurse can suggest additional actions, the first of which is to contact the Poison Control Center for direction for treatment.

The nurse provides care for a client diagnosed with Hantavirus pulmonary syndrome (HPS). Which action by the nurse is most appropriate? 1. Assess the client for signs/symptoms of seizures. 2. Assess the client for signs/symptoms of renal failure. 3. Assess the client for signs/symptoms of thrombocytopenia. 4. Assess the client for signs/symptoms of liver failure.

3. Assess the client for signs/symptoms of thrombocytopenia. — Thrombocytopenia is caused by HPS. The nurse should observe for hematuria, hematemesis, bleeding gums, and melena. Think like a nurse: The nurse caring for a client infected with Hantavirus pulmonary syndrome (HPS) knows that the this virus primarily attacks the circulatory and pulmonary systems. HPS can cause hemorrhagic fever, which causes the client to bleed from access sites and mucous membranes. This client should be thoroughly assessed for any signs of bleeding from the gums, intravenous insertion sites, and gastrointestinal and urinary tracts. If the client experiences hemorrhagic fever, the client may develop renal failure secondary to shock. However, the risk of bleeding poses a more acute risk of harm to the client.

The nurse provides care for a client who had a hypophysectomy. The client reports being thirsty and having to urinate frequently. Which action does the nurse take? 1. Assess for glucose in the urine. 2. Increase fluid intake. 3. Assess urine specific gravity. 4. Document the client's concerns.

3. Assess urine specific gravity. — After this procedure, diabetes insipidus can temporarily occur because of an antidiuretic hormone deficiency. Think like a nurse: The nurse should first mentally review the type of surgery the client had, the reason for the procedure, expected manifestations, and any possible indications of complications. A hypophysectomy is the removal of a part or the entire pituitary gland, which controls specific hormones. One hormone is the antidiuretic hormone, which controls fluid balance. After surgery and due to the lack of this hormone, the client will have increased urine output, which is indicative of the complication diabetes insipidus. The nurse should expect to find low urine specific gravity due to high urine output and high serum sodium (hypernatremia) due to low fluid volume.

The charge nurse notes problematic nurse-client interactions when the nurse is assigned a client who is a survivor of sexual abuse. The charge nurse learns that the nurse was sexually abused as a child. The charge nurse takes which action when making assignments? 1. Organize the nurse's assignments to include clients who have been sexually abused to promote a therapeutic environment. 2. Create the nurse's assignments as is normally done and request that the nurse begin outpatient counseling. 3. Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact therapeutically. 4. Inform the nurse that clients with a psychiatric diagnosis will no longer be assigned due to the history of sexual abuse.

3. Assign the nurse to clients who do not have a history of sexual abuse so that the nurse is able to interact therapeutically. — Assign the nurse to clients who the nurse is able to deal with in a therapeutic way. Think like a nurse: While nurses are expected to deliver quality, non-judgmental client care, nurses are also humans who deserve reasonable accommodations when a conflict arises. In this case, situation-specific problematic behaviors have been noted. The charge nurse's responsibilities include making fair, reasonable client assignments. When determining a nurse's suitability to provide client care to a specific client, factors that must be considered are both technical and psychosocial in nature. For example, the nurse whose parent recently passed away due to lung cancer may be emotionally overwhelmed by caring for a client who is diagnosed with end-stage lung cancer. Likewise, ethical considerations have an impact on client assignments. For example, a nurse who objects to administering chemotherapy to aid in a nonviable pregnancy termination is not assigned to provide care to a client undergoing this procedure.

The nurse in the emergency department provides care for a client admitted with a possible cervical spinal cord injury (SCI). Which action does the nurse perform first? 1. Ask how the accident occurred. 2. Assess neurological functioning. 3. Auscultate respirations. 4. Ask about previous medical conditions.

3. Auscultate respirations. — Assessing respiratory and breathing function is the priority assessment, especially for the client with a suspected cervical injury.

A client with type 2 diabetes mellitus is prescribed pioglitazone and metformin. Which client health history information causes the nurse to question the prescription of these medications? (Select all that apply.) 1. History of essential hypertension. 2. Weight loss of 30 lb (13.6 kg) over the past 6 months. 3. Being 6 weeks pregnant. 4. History of heart failure. 5. History of lactic acidosis.

3. Being 6 weeks pregnant. - Pioglitazone is contraindicated in pregnancy. Metformin must be used cautiously during pregnancy. 4. History of heart failure. - Pioglitazone is contraindicated in clients with a history of heart failure. 5. History of lactic acidosis. - Metformin is contraindicated in clients with a history of lactic acidosis.

The nurse is teaching a group of clients about vasectomies and tubal ligations. Which information does the nurse include in the teaching? 1. A tubal ligation is medically less complicated than a vasectomy. 2. Menstruation ceases after a tubal ligation. 3. Birth control measures are required after a vasectomyuntil the client has a negative sperm count. 4. A vasectomy is performed as a laparoscopic surgery.

3. Birth control measures are required after a vasectomyuntil the client has a negative sperm count. - It may take approximately 3 months for the client to achieve a negative sperm count in seminal fluid analysis after a vasectomy. Alternative methods of birth control should be used during this period. Think like a nurse: Sterilization is a personal decision, and both vasectomy and tubal ligation are generally considered irreversible pregnancy prevention options. Vasectomy is accomplished via a 30-minute procedure in the health care provider's office, complications are low, and it is 99% effective after about 3 months. Vasectomy reversal is not guaranteed and is costly and complex. Tubal ligation, which is performed at a surgery center, requires anesthesia (general, spinal, or local) and also takes around 30 minutes to complete. Compared to vasectomy, tubal ligation has a higher risk of complications and is about 99% effective. Reversal of tubal ligation requires surgery.

A client requires a paracentesis. Which item is most important for the nurse to place at the client's bedside prior to the procedure? 1. Tape measure. 2. Emesis basin. 3. Blood pressure cuff. 4. Scale.

3. Blood pressure cuff - A blood pressure cuff should be placed on the client's arm before the procedure begins, and kept in place throughout the immediate post-procedure period. It is essential to continually monitor the client's blood pressure to assess for the development of shock from the removal of fluid.

The nurse notes that after a laboratory technician draws a blood specimen from a client there are drops of blood on the floor and the wall next to the needle container. Which action does the nurse take first? 1. Contact the laboratory supervisor to report the incident. 2. Contact the nurse manager to report the incident. 3. Call housekeeping to clean and disinfect the area. 4. Counsel the laboratory technician about appropriate technique.

3. Call housekeeping to clean and disinfect the area. - The priority for the nurse is cleaning up the contaminated area in the client's room by contacting housekeeping to clean and disinfect the area. Think like a nurse. The nurse identifies two concerns in this situation: a biohazard spill that poses a risk of contamination and an inappropriate action on the part of the lab technician that led to a spill. The nurse first needs to address the immediate physical risk of contamination. A blood spill needs to be immediately cleaned by the person or department with the appropriate cleansing materials. Contacting the housekeeping or environmental department to clean the spill is the best approach for the nurse to take.

The nurse provides care for a client with an exacerbation of ulcerative colitis. The nurse determines teaching is effective when the client makes which dietary choice? (Select all that apply.) 1. Meatless chili with lentils and kidney beans. 2. A multigrain sandwich with lean turkey and alfalfa sprouts. 3. Canned green beans and applesauce. 4. Carrots and celery sticks with vegetable dip. 5. Grilled cheese sandwich on white bread with creamed tomato soup. 6. Roast beef and mashed potatoes.

3. Canned green beans and applesauce. - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Canned, cooked, and seedless vegetables without skins are permitted on a low-residue diet. This dietary choice indicates understanding by the client. 5. Grilled cheese sandwich on white bread with creamed tomato soup. - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Refined grains are permitted, as well as cheese and milk. This dietary choice indicates understanding by the client. 6. Roast beef and mashed potatoes. - A client experiencing an exacerbation of ulcerative colitis should eat a low-residue diet. Meats and cooked skinless vegetables are permitted. This dietary choice indicates understanding by the client.

The nurse notes that an adolescent client without any previous health problems is prescribed intravenous and oral fluids to treat meningitis. For which serious complication does the nurse monitor this client? 1. Heart failure. 2. Hypovolemic shock. 3. Cerebral edema. 4. Pulmonary edema.

3. Cerebral edema. - Since the client has inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. Think like a nurse: The nurse should recall the pathophysiologic and infectious disease processes of meningitis. In this illness, the meninges are irritated with either a bacteria or virus. This irritation causes nuchal rigidity and photophobia as two major symptoms of the disorder. It is essential to keep in mind the location of the infection and the impact interventions will have on the client's status. The nurse should be aware of actions that contribute to increased intracranial pressure (IICP). One major cause of IICP is fluid overload. Since the client is prescribed both oral and intravenous fluids, the risk for IICP is high. The client needs close monitoring.

A client returns to the care area following abdominal exploratory surgery. Once the nurse measures vital signs, which action will the nurse perform next? 1. Position on left side, supported with pillows. 2. Check the medical record and determine the status of the fluid balance from surgery. 3. Check the abdominal dressing for any evidence of bleeding. 4. Monitor the incision and pulmonary status for the presence of infection.

3. Check the abdominal dressing for any evidence of bleeding. -The surgical dressing should be assessed upon arrival to the care area and frequently for the next several hours. Think like a nurse: Upon receiving a client immediately following abdominal exploratory surgery, the nurse's priority is to assess for ABC (airway, breathing, circulation). This is typically done while a full set of vital signs are taken and monitored in frequent intervals. The surgical site should be assesses and re-assessed closely. The nurse should note the integrity of the dressing, swelling, bleeding, and the presence of any drainage collection devices. Another priority assessment is pain. The nurse should document a comprehensive pain assessment during the peri-operative period.

A client in labor is unable to get to the hospital because of inclement weather and calls the nurse who lives next door for help. Once the fetal head is delivered, which action is appropriate for the nurse to take? 1. Instruct the client to bear down and push. 2. Turn the neonate 's head in a clockwise direction. 3. Check the neonate 's neck for the umbilical cord. 4. Ask the client to pant through her mouth.

3. Check the neonate 's neck for the umbilical cord. — The neonate's neck should be assessed for presence of the umbilical cord. The newborn could become anoxic if the cord is around the neck. Think like a nurse: The nurse needs to be concerned with the welfare of both the mother and the fetus, and should immediately apply the concepts of airway, breathing, and circulation (ABCs). Since the baby's head has been delivered, the nurse needs to make sure the neonate will have adequate placental circulation until the first breath is taken. If the umbilical cord is wrapped around the neonate's neck, there is a risk for oxygen deficiency and respiratory distress. To check for the cord, the nurse should slide a finger around the circumference of the baby's neck. If the cord is present, the nurse needs to slip two fingers under the cord to ensure adequate oxygenation. Once the nurse ensures the neonate is able to receive oxygen, the rest of the body can be delivered.

The nurse notes a client recovering from a pancreatectomy has minimal drainage from the nasogastric tube. Which action will the nurse take next? 1. Replace the nasogastric tube. 2. Increase the intravenous fluids. 3. Check the tubing for kinks. 4. Notify the health care provider.

3. Check the tubing for kinks. — Assessing the tube checks for kinks and ensures the tubing is in a dependent position. Think like a nurse: The nurse should stop and recall the physiology of the abdomen and the pancreas. For a surgery where the pancreas is being removed, a nasogastric tube will be inserted in order to keep the stomach decompressed and to prevent stress on the surgical wound. If the tube is not draining, the first action is to try and determine "why." The nurse should perform the easiest assessment first by checking to see if the tube is kinked. If present, removing the kink should resume the flow of drainage through the tube. However, if the tube is not kinked, further assessment is needed. Other concerns may include an obstructed drainage tube or a malfunction of the drainage system. Some drainage systems work on the principle of suction. If this is the case, the nurse should make sure that drainage suction mechanism is activated. An obstructed drainage tube will involve notifying the health care provider for additional directions.

The nurse provides care for a client taking oral contraceptives. While taking the client's history, the nurse learns that the client smokes a pack of cigarettes per day. Which observation most concerns the nurse? 1. Weakness. 2. Irritability. 3. Chest pain. 4. Abdominal cramping.

3. Chest pain. — Smoking while taking oral contraceptives places the client at increased risk for cardiovascular or thromboembolic disease. The nurse should immediately assess this client for a myocardial infarction. This is a life-threatening circulatory concern and requires immediate intervention. This is the priority assessment. Think like a nurse: Oral contraceptives are contraindicated in the client who smokes because of the risk of developing blood clots. Because of this fact, the nurse should mentally ask, "What symptoms would indicate that the client is having adverse reactions related to this medication and lifestyle?" Chest pain could indicate a myocardial infarction or pulmonary embolism, both of which can be life-threatening. This client needs further assessment and may require immediate medical attention.

The nurse receives hand-off communication from the previous shift. Which client does the nurse see first? 1. Client recovering from coronary artery bypass graft surgery who is having the atrioventricular wires removed later in the day. 2. Client with type 1 diabetes mellitus who is scheduled for a cardiac catheterization later today. 3. Client recovering from surgery a day ago with an spinal anesthesia in place. 4. Client with cardiomyopathy who is being evaluated for a heart transplant.

3. Client recovering from surgery a day ago with an spinal anesthesia in place. - Spinal anesthesia is used for pain relief. The client needs monitored for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting. Think like a nurse: The presence of an spinal anesthesia used for pain management increases the risk for respiratory depression, hypotension, and alterations in bowel and bladder function. This client should be assessed first. The client recovering from coronary surgery is stable enough to have pacer wires removed. The client with diabetes mellitus is awaiting a procedure. The client with cardiomyopathy is awaiting a transplant and does not have acute issues at this time.

The nurse reviews new prescriptions written for assigned clients. For which client will the nurse question a prescription for propranolol? 1. Client with type 1 diabetes mellitus. 2. Client with peptic ulcer disease. 3. Client with a history of bronchial asthma. 4. Client with atrial tachycardia.

3. Client with a history of bronchial asthma — Propranolol may cause bronchospasm and should be questioned for a client with a history of bronchial asthma. Other side effects include bradycardia and depression. Nursing care includes measuring the pulse before administering the medication. The dosage should be gradually reduced before the medication is discontinued.

The nurse receives hand-off communication from the previous shift. Which client will the nurse see first? 1. Client with chronic renal failure reporting swollen fingers and ankle edema. 2. Client 1 day postoperative after abdominal surgery with dried blood on the abdominal dressing. 3. Client with type 1 diabetes mellitus who states, "I have this quivering feeling in my abdomen." 4. Client on high doses of antibiotics for a resistant infection reporting diarrhea.

3. Client with type 1 diabetes mellitus who states, "I have this quivering feeling in my abdomen." CORRECT - A quivering feeling indicates hypoglycemia. Additional symptoms include tachycardia, cold and clammy skin, weakness, and pallor. The client's capillary blood glucose level should be assessed, and a carbohydrate source provided.

A parent brings a toddler, age 19 months, to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find? 1. Open anterior and posterior fontanels 2. Closed anterior fontanel and open posterior fontanel 3. Closed anterior and posterior fontanels 4. Open anterior fontanel and closed posterior fontanel

3. Closed anterior and posterior fontanels By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.

The nurse prepares teaching for a client receiving sulfasalazine. Which information will the nurse include in this client's instructions? 1. Restrict fluids to 1500 mL per day. 2. Expect that stools may become clay-colored. 3. Continue the medication even after symptoms subside. 4. Discontinue the medication if diarrhea occurs.

3. Continue the medication even after symptoms subside. — Sulfasalazine decreases bowel inflammation. It should be taken as prescribed. Think like a nurse: For teaching and learning, ensure a comfortable environment with adequate lighting. Prepare for the teaching activity. Determine the client's knowledge level and previous experiences with taking sulfasalazine. Allow time for discussion and questions. Stop for a break when the client indicates that one is needed. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Determine which factors help or hinder the learning process. Evaluate the effectiveness of the teaching and learning session.

The nurse provides care to an older adult client with partial and full thickness burns over 75% of the body. Which assessment 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. — The body responds to early hypovolemic shock by adrenergic stimulation. Vasoconstriction compensates for the loss of fluid and causes cool, clammy skin and a rapid rate of breathing. Think like a nurse: The older adult clients are predisposed to shock due to co-existing co-morbidities, repeated and prolonged hospitalizations, reduced immunity, functional limitations, and above all due to the effects of aging itself. One of the major age-associated changes in the cardiovascular response to physical or emotional stress is a decrease in cardiac output due to decreased heart muscle contractility and heart rate response to increased stress. The nurse should monitor the older adult client with shock more closely when providing fluid boluses due to increased risk for heart failure. The nurse should be attentive in looking for atypical signs of shock such as alteration in mental status.

A hospitalized client is started on phenelzine for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies

3. Crackers 5. Tossed salad - Phenelzine is a monoamine oxide inhibitor (MAOI), so the client should avoid ingesting foods high in tyramine, which can trigger a potentially fatal hypertensive crisis. - Foods to avoid: yogurt, aged cheeses, smoked or processed meats, red wines, fruits (such as avocados, raisins or figs)

The nurse assesses a client for stress-related risk factors. Which factor in the client's recent history places the client at the greatest risk for a stress-related disorder based on the Social Readjustment Rating Scale? 1. Mortgage foreclosure. 2. Change in financial status. 3. Death of a spouse. 4. Death of a close family member.

3. Death of a spouse. - According to the Social Readjustment Rating Scale, death of a spouse ranks as the highest risk factor for stress-related disorder. Think like a nurse: Holistic care takes into consideration the client's body, mind, and spirit. The nurse recognizes a problem within any of these health domains can result in disease. When stressed, the body responds by increasing the release of cortisol, the stress hormone. With prolonged stress, the body may not be able to fend off other diseases because of the constantly elevated level of stress hormone in the bloodstream. The nurse should recall that there are different types and levels of stress and should mentally ask, "What would cause the client to experience the most amount of total body discontent?" In this scenario, the one that would cause the most acute physical, mental, and emotional stress response would be the death of a spouse.

A school-age client with asthma reports feeling progressively worse. Which assessment finding causes the nurse the most concern? 1. Client reports chest tightness. 2. Wheezes auscultated at the end of each expiration. 3. Decreased breath sounds bilateral lung fields. 4. Cough increases when supine.

3. Decreased breath sounds bilateral lung fields. — In asthma with a severe spasm or obstruction, breath sounds and crackles may become inaudible. This finding indicates the need for immediate intervention. Think like a nurse: A change in breath sounds in a client with asthma could indicate increasing obstruction. This client needs immediate medical intervention. Chest tightness, wheezing, and coughing when supine are symptoms associated with asthma; however, these do not indicate a worsening respiratory status.

The home care nurse receives a phone call from the caregiver for a client diagnosed with AIDS. The caregiver reports having the flu and is afraid of giving the client an infection. Which action does the nurse take first? 1. Instruct the caregiver to wear a well fitting surgical mask that covers the mouth and nose. 2. Assess whether the caregiver is washing hands frequently before providing care. 3. Determine if there is someone else available to provide care for the client. 4. Inform the caregiver to clean the client's bathroom daily.

3. Determine if there is someone else available to provide care for the client. - The priority is to prevent the client's exposure to infection. The nurse should first determine whether another healthy caregiver can provide care in place of the caregiver with the flu. This will protect the client from exposure to the flu. Think like a nurse: The situation posed in the question represents a serious safety risk to the client with acquired immune deficiency syndrome (AIDS). The nurse must assess the situation and determine the best course of action. Ideally, the caregiver should not provide care to the client and should be sequestered from the client. If possible, another caregiver should be identified as a temporary substitute. If this is not possible, then the nurse should instruct the caregiver on infection control measures and also contact the health care provider to discuss the possibility of prescribing anti-influenza medication (e.g. oseltamivir phosphate) prophylactically for the client.

The nurse is assessing the functioning of a chest tube drainage system of a client who has just returned from the recovery room following a thoracotomy with wedge rejection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber. 2. Vigorous bubbling in the suction control chamber. 3. Drainage system maintained below the client's chest. 4. 50 mL of drainage in the drainage collection chamber. 5. Occlusive dressing in place over the chest tube insertion site. 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation.

3. Drainage system maintained below the client's chest. 4. 50 mL of drainage in the drainage collection chamber. 5. Occlusive dressing in place over the chest tube insertion site. 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation. - Excessive bubbling in the water seal chamber may indicate an air leak and the bubbling of water in the water seal chamber indicates air drainage, usually seen when intrathoracic pressure is higher than atmospheric pressure and may occur during exhalation, coughing or sneezing. - Absence of fluctuation is an indication of a blockage or that there is no longer any air leakage in the plural space. - Drainage that is more than 70-100 mL is considered excessive and requires notification of the HCP.

The nurse provides care for the client diagnosed with gastroesophageal reflux disease (GERD). Which information does the nurse include when educating the client about strategies to help decrease nighttime GERD symptoms? 1. Lie down within 30 minutes after meals. 2. Increase fluid intake prior to bedtime. 3. Elevate the head of the bed on 6-inch blocks. 4. Eat a snack every night at bedtime.

3. Elevate the head of the bed on 6-inch blocks. - For the client with GERD, when lying in a supine position, elevating the head of the bed helps decrease the risk for regurgitation of stomach acid into the esophagus. Think like a nurse: The nurse must provide information to the client diagnosed with gastroesophageal reflux disease (GERD). Interventions to treat GERD serve one of two purposes: (1) decreasing stomach acid production, or (2) decreasing reflux of stomach acid through the lower esophageal sphincter (LES). Certain foods cause the stomach to produce additional acid and should be avoided, such as fatty meals. Oatmeal and rice are filling foods that do not cause reflux. Strategies to reduce pressure on the LES include maintaining a healthy weight, avoiding tight-fitting clothing, staying upright after a meal, eating smaller meals, not smoking, and elevating the head of the bed at night.

The nurse assesses a school-age child after the surgical removal of a brain tumor. Which sign indicates to the nurse that brainstem involvement occurred during the surgery? 1. Orthostatic hypotension. 2. Hearing loss. 3. Elevated temperature. 4. Swallowing difficulty.

3. Elevated temperature. - The temperature may be elevated because of hypothalamus or brainstem involvement during surgery. Think like a nurse: Before identifying a deviation in assessed data, the nurse should stop and recall the physiology of the brain and the type of surgery from which the client is recovering. Depending upon the location of the brain tumor, the client may demonstrate a change in motor or sensory function or an alteration in vital signs. Considering the brain structures, the nurse knows the data that should be further investigated is the elevated body temperature, which could be indicative of brain stem involvement. The nurse is aware that pressure on the brain stem is a complication of brain surgery. Therefore, it is important for the nurse to report the elevated temperature to the health care provider so that the client can be further evaluated.

The nurse in the outpatient clinic assesses the client who reports "burning with urination. " Which action is the most important for the nurse to take? 1. Ask if the client has experienced this before. 2. Encourage the client to drink cranberry juice. 3. Examine the client's urethral meatus and vaginal introitus. 4. Instruct the client to wear loose-fitting cotton undergarments.

3. Examine the client's urethral meatus and vaginal introitus. — Normal acidic urine can cause burning if labial tissues are inflamed because of a vaginal infection or injury. Physical examination is necessary to determine the cause of the burning sensation.

A client receiving peritoneal dialysis for newly diagnosed renal failure experiences abdominal pain during the dialysate infusion. Which action is appropriate for the nurse to implement? 1. Stop the dialysis treatment immediately. 2. Decrease the amount of dialysate to be infused. 3. Explain that discomfort subsides after the first few exchanges. 4. Slow the infusion of the dialysate to increase comfort.

3. Explain that discomfort subsides after the first few exchanges. — Discomfort is common during the first few dialysis exchanges because of peritoneal irritation. It usually subsides within 1 to 2 weeks of treatment.

The nurse assesses a school-age child with suspected Hodgkin lymphoma. Which finding is most characteristic of this disease? 1. Fever and malaise. 2. Enlarged, painful inguinal lymph nodes. 3. Firm, painless, and movable adenopathy in the cervical area. 4. Anorexia and weight loss.

3. Firm, painless, and movable adenopathy in the cervical area. - Firm, painless, and movable adenopathy of the cervical area is associated with this disease. Think like a nurse: Prior to assessing this client, the nurse should mentally review the pathophysiology of the disease process to serve as a guide for identifying symptoms of the illness. In Hodgkin lymphoma, cancer cells develop in the lymph nodes and glands, primarily those of the neck region. When assessing this client, the nurse should expect to find enlarged lymph nodes along the neck. These nodes will be firm, painless, and freely movable upon palpation. The findings are classic characteristics of a metastatic disease of the lymph system. The nurse will then assess the client for additional, but more generalized, manifestations of Hodgkin lymphoma.

The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take? 1. Tell the client that the hospital is a safe place. 2. Urge the client to reveal more information. 3. Focus on developing a trusting relationship with the client. 4. Introduce the client to other clients on the unit.

3. Focus on developing a trusting relationship with the client. — When caring for a client who is resistant and paranoid, the first priority is to develop a trusting relationship with the client. Think like a nurse: The client experiencing paranoia has an issue with trust. The most important action for the nurse to take is to establish a trusting relationship with the client. Without trust, the nurse-client relationship cannot move forward. One way for the nurse to earn the client's trust is to follow through on things promised to the client. When the client realizes that the nurse will follow through when needed, the client will be inclined to share more information with the nurse. This is essential to developing a beneficial and realistic plan of care.

The nurse discovers a pediatric client in bed clenching the teeth and making tonic-clonic movements of the extremities. Which action will the nurse implement? 1. Restrain the client's movements. 2. Insert an oral airway. 3. Gently turn the client to one side. 4. Insert a tongue blade.

3. Gently turn the client to one side. - The nurse should gently turn the client to one side to maintain a patent airway and prevent aspiration of secretions. Think like a nurse: Finding a client in a posture or performing skeletal muscle movements that are out of the ordinary requires quick thinking by the nurse. The nurse should recognize the manifestations that indicate the client is having a seizure. The nurse should immediately implement the airway, breathing, and circulation (ABCs) of emergency care, with the first action to assess and protect the client's airway. The nurse is aware of the need to gently turn the client to a side-lying position, which will help maintain the airway and decrease the risk for aspiration. The position permits the tongue to fall forward and secretions to run out of the client's mouth, preventing airway occlusion. The nurse should never attempt to insert anything into the mouth of a client with seizure activity.

The nurse prepares an adolescent for a pelvic exam because the client is experiencing sharp bilateral pelvic pain. Which is the priority action by the nurse? 1. Instruct the client to remove all clothing. 2. Collect a urine and fecal specimen. 3. Give a brief explanation of the procedure. 4. Perform teaching about sexually transmitted infections.

3. Give a brief explanation of the procedure. - The nurse should prioritize preparing the client for the procedure by providing an explanation of what to expect. Think like a nurse: Since it is unlikely that the adolescent client has had a previous pelvic examination, the priority for the nurse would be to explain the procedure to the client. This will help reduce the client's anxiety and add support applicable to the client's developmental level. The nurse should also encourage the client to ask questions before and after the procedure. The nurse will advocate for the client's right to privacy, and only allow other persons in the examination room if the client gives permission.

The nurse in a community clinic evaluates a client diagnosed with type 1 diabetes mellitus. Which observation indicates to the nurse that the client is not rotating insulin injection sites? 1. Wheal present at an injection site. 2. Discomfort at an injection site. 3. Glucose levels rise temporarily. 4. Increased muscle mass at an injection site.

3. Glucose levels rise temporarily. - Failure to rotate sites results in poor absorption of the insulin, which increases the blood glucose level. Think like a nurse. Clients diagnosed with diabetes mellitus are often required to perform self-injection of prescribed insulin. The nurse teaches the client to use sites on the front of the body. The abdomen absorbs insulin the fastest, followed by the arms, thighs, and buttocks. The client is reminded to keep a record of which injection sites are used and to rotate appropriately so that absorption is not negatively affected. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. It is best to use the teach-back method to verify the client understands what was taught.

The nurse provides care to a client with a pulse oximeter probe. Which situation requires intervention by the nurse? 1. Probe is on the ring finger and there is clear polish on the nail. 2. Emitting and receiving sensors of the probe are directly opposite each other. 3. Hand with the probe attached is directly beneath a procedure light to prevent chilling. 4. Oxygen saturation alarm is set at 95%.

3. Hand with the probe attached is directly beneath a procedure light to prevent chilling. — Exposure of the probe to direct sunlight or strong light causes an inaccurate measurement. The probe should be covered with a dry washcloth and rotated every 4 hours to prevent skin irritation. Think like a nurse: The performance of the pulse oximeter is dependent on the client's pulse. If the client has a weak or absent peripheral pulse, readings will not be accurate. Clients who are cold may have vasoconstriction in their fingers and toes that also may compromise arterial flow and result in falsely low readings. Bright natural or artificial lights (e.g., procedure light) that shine directly on the pulse oximetry sensor may lead to inaccurate results because the pulse oximeter measures the amount of light transmitted through arterial blood. Dirty sensors, dark-colored nail polishes, and dried blood may affect the accuracy of the readings by hindering or altering the light absorption of the contact probes.

The nurse provides care for a client who experienced a spinal cord injury at the level of T-2. The nurse enters the room and notes that the client's face is flushed, is sweating profusely, and the blood pressure is 260/160 mm Hg. Which medication does the nurse prepare to administer? 1. Docusate sodium 100 mg PO. 2. Prochlorperazine 10 mg IM. 3. Hydralazine hydrochloride 10 mg IV. 4. Diazepam 20 mg IV.

3. Hydralazine hydrochloride 10 mg IV. — Symptoms indicate autonomic dysreflexia with the elevated blood pressure as the most critical symptom. Hydralazine hydrochloride is a fast acting antihypertensive and relaxes smooth muscle. Side effects can include headache, angina, tachycardia, palpitations, sodium retention, anorexia, or a lupus erythematosus-like syndrome of sore throat, fever, muscle-joint aches, rash.

The nurse provides care to a client diagnosed with asthma. The client's plan of care includes respiratory treatments administered via nebulizer. The nurse recognizes which condition as a potential complication of prolonged respiratory treatments, such as nebulizer use? 1. Hypovolemia. 2. Metabolic acidosis. 3. Hypervolemia. 4. Metabolic alkalosis.

3. Hypervolemia. - When the use of respiratory treatments is prolonged, hypervolemia can result from the inhalation and absorption of excessive amounts of water vapor through the lung tissue. Think like a nurse: The nurse is aware the use of a nebulizer to administer medications in the treatment of asthma is a common delivery approach. The nebulizer is a device that delivers the medication through a mist, which is inhaled to directly affect constricted lung tissue. The inhaled mist deposits extra fluid in the client's respiratory system that is absorbed into the general circulation. In this scenario, the device is used on an extended basis, which puts the client at risk for an increased amount of total body fluid. The nurse should assess the client for symptoms of fluid volume overload to include pitting edema, bounding pulses, rapid heart rate, dyspnea, and elevated blood pressure.

The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate understanding of the proper way to take this medication? Select all that apply 1. I should take this medication with food. 2. I should take this medication at bedtime. 3. I should sit up for at least 30 minutes after taking this medication. 4. I should take this medication first thing in the morning on an empty stomach. 5. I can pick a time to take this medication that best fits my lifestyle, as long as I take it at the same time each day,

3. I should sit up for at least 30 minutes after taking this medication (and not eat or drink anything) 4. I should take this medication first thing in the morning on an empty stomach.

A client follows a lacto-vegetarian eating plan. Which recommendation is appropriate for the nurse to suggest to this client? 1. Limit the intake of eggs to three per week. 2. Increase consumption of breads and pastas. 3. Increase intake of beans, legumes, and nuts. 4. Supplement diet with calcium and magnesium tablets.

3. Increase intake of beans, legumes, and nuts. — The client should increase the intake of protein from other sources, such as seeds, tofu, and dark green vegetables, along with beans, legumes, and nuts. Think like a nurse: Lacto-vegetarians consume milk and dairy products along with plant-based food. They do not eat eggs, meat, fish, and poultry. The nurse should screen and assess if the client's diet is lacking in protein. If so, the client should increase the intake of protein from other sources, such as seeds, tofu, and dark green vegetables, along with beans, legumes, and nuts. Assessment of the client's nutritional status may include evaluation of serum albumin, pre-albumin, and total protein; cholesterol and serum lipids; complete blood count; and comprehensive metabolic panel. Specific nutritional deficiency can be assessed by obtaining iron tests such as serum iron, total iron binding capacity, and ferritin.

The nurse overhears two unlicensed assistive personnel (UAP) discuss a client's protected health information (PHI) in a public elevator. Which action does the nurse take next? 1. Assess the elevator for visitors and nonstaff passengers. 2. Contact the supervisor on the floor where the UAPs work. 3. Instruct the UAPs to stop the conversation immediately. 4. Notify the hospital risk manager and ethics committee.

3. Instruct the UAPs to stop the conversation immediately. - The nurse's priority action is to stop the conversation before additional, confidential information about the client is shared. PHI should not be discussed in public spaces where information can be heard by those who do not have a "need to know." Think like a nurse. All health care providers have the responsibility to ensure that all clients are treated with respect and receive the privacy that they deserve. The inappropriate discussion of a client's personal health information is a violation of the trust that the client has in the health care system and those who provide the care. The nurse knows that discussing a client's private information hinders this trusting relationship and it must be stopped. The only appropriate action in this scenario is to direct the care providers to immediately stop discussing the client's information.

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client 2. Instruct the client to consume a high-fat diet 3. Instruct the client about thyroid replacement therapy 4. Encourage the client to consume fluids and high-fiber foods in their diet. 5. Encourage the client that iodine preparations will be prescribed to treat the disorder 6. Instruct the client to contact the HCP if episodes of chest pain occur

3. Instruct the client about thyroid replacement therapy 4. Encourage the client to consume fluids and high-fiber foods in their diet. 6. Instruct the client to contact the HCP if episodes of chest pain occur - The nurse encourages the client consume a well-balanced diet that is low in fat for weight reduction and high in fluids and fiber to prevent constipation.

A client who is breastfeeding reports a dry cough, fever, headache, and muscle aches. Which instruction is the best for the nurse to provide to this client? 1. Suggest discontinuing breastfeeding during the illness. 2. Encourage increased fluid intake. 3. Instruct the client to wear a surgical mask. 4. Remind the client to uncover the breasts before washing hands.

3. Instruct the client to wear a surgical mask. — The client needs to prevent the spread of infection to the infant. This is best accomplished by wearing a mask and continuing to do so until the feeding is completed. Think like a nurse: During any "ordinary" illness such as a cold, sore throat, flu, or mastitis, the client should continue to breastfeed. Wearing a surgical mask will prevent transmission of respiratory infectious agents to the newborn. The client, along with all caregivers, should be reminded to practice proper hand hygiene at all times. The client should be reminded to inform the health care provider of the breastfeeding so that if a prescription is required, the health care provider can choose lactation-compatible medications.

A parent asks the nurse when an infant can begin to eat solid foods. The nurse assesses the infant's readiness to begin eating solid foods. Which assessment finding indicates to the nurse that the parent should wait to introduce solid foods? 1. Intact suck-swallow reflex. 2. Drooling present. 3. Intact tongue extrusion reflex. 4. Easily distracted from breastfeeding.

3. Intact tongue extrusion reflex. —Absence of the tongue extrusion reflex indicates readiness to begin solid foods. If the tongue extrusion reflex remains, solid foods should be delayed until it is extinguished Think like a nurse: The techniques used to assess an infant's developmental level are different from those used to assess an older child or adult. The nurse will need to use knowledge or assessment and evaluation that is specific to the infant's development and maturity. The nurse will rely on the presence or absence of reflexes, which serve as a guide to the infant's growth and development. The presence or absence of the tongue extrusion reflex is used to determine if the infant is developmentally prepared to ingest solid food. If the reflex is present, the infant will push food placed in the mouth out, indicating that solid food should not be offered. Once the reflex disappears, solid food can be introduced at the rate and type recommended for the client's age and by the health care provider.

A client experiences a pulmonary embolism after abdominal surgery. Which information in the client's history will contraindicate the use of thrombolytic therapy? 1. Has type 2 diabetes mellitus. 2. Takes medications as needed for angina pectoris. 3. Is recovering from a concussion that occurred 3 weeks ago. 4. Uses an inhaler for treatment of asthma.

3. Is recovering from a concussion that occurred 3 weeks ago. — Thrombolytic therapy is contraindicated in a client who experienced a trauma within the past 2 months. Other contraindications include active internal bleeding, history of hemorrhagic stroke, intracranial or intraspinal surgery, intracranial neoplasm, arteriovenous malformation, aneurysm, and severe uncontrolled hypertension. Think like a nurse: Typically, a health care facility has a standardized checklist (on paper or electronic) to evaluate the client for contraindications for thrombolytic (fibrinolytic) therapy. Major trauma, surgery (including laser eye surgery), and GI/GU bleed within the past 2 to 4 weeks are contraindications for thrombolytics. Other contraindications include: systolic BP > 180 to 200 mm Hg or diastolic BP > 100 to 110 mm Hg; right vs. left arm systolic BP difference > 15 mm Hg (this is why it important to check BP in both arms); history of structural central nervous system disease; significant closed head/facial trauma within the previous 3 months; stroke > 3 hours or < 3 months ago; pregnancy; any history of intracranial hemorrhage; bleeding, clotting problem, or blood thinners; and serious systemic disease (e.g., advanced cancer, severe liver or kidney disease).

The nurse plans care for a client diagnosed with left-sided paralysis and slurred speech. Which direction is most important for the nurse to provide to an unlicensed assistive personnel (UAP)? 1. Report any incontinence. 2. Turn the client every 2 hours. 3. Keep the head of the bed elevated to 30 degrees. 4. Change the linens immediately following a bath.

3. Keep the head of the bed elevated to 30 degrees - Elevating the head of the bed facilitates venous drainage from the brain and reduces intracranial pressure. It is best to also maintain the head in a midline neutral position. Think like a nurse: The nurse considers the outcome of each action and utilizes the ABCs to prioritize. The client has left-sided paralysis and slurred speech, which are symptoms of a stroke. It is important to keep the head of the bed elevated for a client with a stroke to reduce intracranial pressure and prevent aspiration, and to ensure unrestricted venous outflow from the cranium and meet circulatory and airway needs. The nurse needs to recognize which direction to the unlicensed assistive personnel (UAP) is related to client safety and reduces risk for harm. Directing the UAP to keep the head of the bed elevated for this client is within the scope of practice of the UAP.

The nurse provides care to a client receiving radioactive iodine I-130 to treat hyperthyroidism. Which symptoms will the nurse monitor for in this client based on the current treatment? 1. Irritability, weight loss, nausea, vomiting, postural hypotension. 2. Numbness and tingling of toes and fingers, painful muscle spasms. 3. Lethargy, sensitivity to cold, dry skin, weight gain, depression. 4. Frequent urination, excessive thirst, excessive hunger.

3. Lethargy, sensitivity to cold, dry skin, weight gain, depression. - Lethargy, sensitivity to cold, dry skin, weight gain, and depression indicate hypothyroidism, which is a complication of I-130 therapy. Think like a nurse: When being treated for hyperthyroidism, there is a risk that thyroid function might be excessively slowed or altered. If that occurs, the client will demonstrate signs of hypothyroidism, which includes lethargy, sensitivity to cold, dry skin, weight gain, and depression. The other lists of symptoms described health problems that are not related to the function or treatment of a thyroid disorder.

The nurse performs an initial assessment of a client in the outpatient clinic with a diagnosis of myxedema. For which symptoms does the nurse carefully assess the client? 1. Tachycardia, fatigue, and intolerance to heat. 2. Polyphagia, nervousness, and dry hair. 3. Lethargy, weight gain, and intolerance to cold. 4. Tachycardia, hypertension, and tachypnea.

3. Lethargy, weight gain, and intolerance to cold. - These are signs and symptoms of hypothyroidism (myxedema). Other assessment findings may include dry hair, a mask-like facial expression, thickened skin, an enlarged tongue, and drooling. Think like a nurse: Myxedema is a manifestation of severe hypothyroidism. Manifestations of hypothyroidism are associated with a slowing of the metabolism and include lethargy, weight gain, and intolerance to cold temperatures.

A client is admitted to the medical unit for evaluation of headaches, epigastric pain that is relieved by food, anorexia, nausea and vomiting, and periods of both constipation and diarrhea. The health care provider prescribes several diagnostic tests. Which test does the nurse schedule first? 1. Upper gastrointestinal series. 2. Small bowel series. 3. Lower gastrointestinal series. 4. Lumbar puncture.

3. Lower gastrointestinal series. — This is often referred to as a barium enema examination. It is a radiographic visualization of the large intestine and encompasses the rectum, sigmoid, descending, transverse, and ascending colon going to the ileocecal valve. The barium is administered through a rectal catheter, which has an inflatable balloon. When both upper and lower GI series are ordered, the lower GI series should be done first in order to avoid the barium from the upper GI exam traveling down the GI tract and interfering with the results of the lower GI series. Think like a nurse: The nurse needs a solid understanding of diagnostic test procedures along with knowledge about anatomy and physiology. When considering the scheduling of multiple diagnostic tests, the nurse should understand the importance of avoiding future test site "contamination" with the elements of previous tests. Tests used to diagnose a gastrointestinal disorder often include barium. Because barium that is ingested will interfere with a lower gastrointestinal examination, the lower gastrointestinal test should be scheduled first.

The nurse provides care for an adolescent admitted for burns to 50% of the body. What action is the highest priority for the nurse? 1. Counsel the client regarding body image changes. 2. Maintain airborne precautions. 3. Maintain sterile technique during procedures. 4. Encourage the client's friends to visit regularly.

3. Maintain sterile technique during procedures. — The client is at high risk for infection. The nurse should use careful sterile technique when performing wound care. This ensures the client physical safety and is the highest priority. Think like a nurse: The nurse needs to draw on integrated knowledge related to anatomy and physiology in making clinical judgments about this client's needs. Knowing the skin is the body's first line of defense against microorganisms will assist the nurse in making the best and safest care decisions. Since the client has lost 50% of the total body skin surface, the risk for infection is high. The nurse should ensure that all procedures and skin care are provided using sterile technique to reduce the client's risk for infection, which is the nurse's highest priority.

An ice storm paralyzes a community during the night. The two nurses on a 24-bed medical/surgical unit learn that it will be 12-15 hours before they can expect the next shift to arrive. Which action do the nurses take first? 1. Each nurse takes a shower while the other nurse cares for all of the clients. 2. Instruct the unlicensed assistive personnel (UAP) to begin morning care at 0400. 3. Make a list of all of the clients' breathing treatments and intravenous medications for the next 12-15 hours. 4. Plan to administer all of the clients' as needed pain medication before they ask for it.

3. Make a list of all of the clients' breathing treatments and intravenous medications for the next 12-15 hours. - The priority is to determine treatments and medications that are vital to the well-being of the clients. Think like a nurse: After an ice storm paralyzes a community, two night shift nurses working on a 24-bed medical/surgical unit must continue caring for clients on the unit because the day shift nurses cannot access the hospital. To combat the staffing dilemma, the nurses should think, "What essential care must we give to protect the clients from harm?" The nurses should determine which essential medications and treatment interventions, with consideration of the ABCs (airway, breathing, circulation), that they must provide to ensure the clients' well-being. Nonessential interventions should be eliminated.

The home care nurse makes an initial visit to a client diagnosed with nephrotic syndrome caused by acute post-streptococcal glomerulonephritis (ASGN). Which instruction is most crucial for the nurse to stress to the client when providing instruction? 1. Take the blood pressure daily. 2. Foods to avoid on a low fat diet. 3. Manifestations of venous thrombosis. 4. The importance of a low sodium diet.

3. Manifestations of venous thrombosis. — A very common complication of nephrotic syndrome is venous thrombosis. It is critical for the nurse to provide information about this complication when providing instruction. Think like a nurse: The nurse needs a solid knowledge base about the medical diagnosis and the client risks that are possible; assessment should focus on identifying manifestations. The nurse considers each action and determines the risk of harm that it is intended to prevent. Both hypertension and venous thrombosis are concerns related to nephrotic syndrome. However, venous thrombosis poses a greater risk of immediate harm to the client. The signs and symptoms of this complication should be reviewed with the client.

The nurse provides care for a client at 7 months gestation diagnosed with preeclampsia. An IV of magnesium sulfate is initiated at 2 grams/hour. Which is the most important action for the nurse perform? 1. Darken the client's room. 2. Perform a vaginal exam. 3. Measure the deep tendon reflexes. 4. Assist the client to a comfortable position.

3. Measure the deep tendon reflexes. — Magnesium sulfate is given to prevent eclampsia. Hypermagnesemia causes CNS depression, relaxes smooth muscle, and prevents seizures. Assess respirations and tendon reflexes for early signs of toxicity. Vital signs are monitored at least every 15 minutes. Think like a nurse: The client diagnosed with preeclampsia may be prescribed an infusion of magnesium sulfate. The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects. Therapeutic effects of the magnesium infusion are the result of blocked neuromuscular transmission and vasodilation production, and are evidenced by a normal or controlled blood pressure and absence of seizures. Side effects might include flushing, sweating, diplopia, blurred vision, and mild weakness. Adverse effects include respiratory paralysis, circulatory collapse, hypothermia, and hypocalcemia. Adverse reactions are often prevented by careful monitoring of deep tendon reflexes.

The nurse provides care for a client with a nasogastric tube. The tube is attached to low suction. For which complication does the nurse monitor the client? 1. Metabolic acidosis. 2. Respiratory acidosis. 3. Metabolic alkalosis. 4. Respiratory alkalosis.

3. Metabolic alkalosis. — Loss of gastric fluid related to nasogastric suctioning or vomiting causes metabolic alkalosis. Think like a nurse: The nurse applies knowledge about anatomy and physiology, and the concepts of body chemistry. Acid-base changes reflect respiratory and metabolic disorders. In this scenario, the nurse needs to mentally review the function of a nasogastric tube and the anticipated drainage, reaching a conclusion that gastric contents are high in acid are being removed. The acid-base imbalance associated with nasogastric suctioning is metabolic alkalosis. The nurse and health care provider will closely monitored the client's laboratory levels and client manifestations so that treatment can be implemented.

After creating a genogram, the nurse identifies that a client is at risk for hypertension. Which secondary preventive health interventions will the nurse include in the client's plan of care? (Select all that apply.) 1. Consume a diet low in sodium. 2. Join an aerobic exercise class. 3. Monitor blood pressure frequently. 4. Avoid the consumption of alcohol. 5. Monitor cholesterol level.

3. Monitor blood pressure frequently. - Secondary prevention may be directed at individuals who are at risk for the development of a health problem. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Having blood pressure monitored frequently is an example of secondary prevention. 5. Monitor cholesterol level. - Secondary prevention may be directed at individuals who are at risk for health problems. The goal for health intervention during this phase is early detection and diagnosis of health problems before clients exhibit symptoms of disease. Having cholesterol level monitored is an example of secondary prevention. Think like a nurse: Secondary prevention is aimed at slowing or stopping the progression of an existing health alteration. The client may or may not be symptomatic. Screening is an example of secondary prevention. For the client with hypertension, secondary prevention includes aggressive lifestyle changes to incorporate a healthy diet, increased physical activity, and blood pressure monitoring. Desired outcomes include stopping or slowing the progress of hypertension, implementing interventions to return to optimal health, and preventing ongoing illness and complications.

A postpartum client receives an intramuscular injection of butorphanol tartrate 2 mg. Which action does the nurse make a priority after administering this medication? 1. Assess bowel sounds. 2. Monitor fluid and electrolyte balance. 3. Monitor rate and depth of respirations. 4. Assess urinary output.

3. Monitor rate and depth of respirations. — Butorphanol tartrate can cause respiratory depression by decreasing the rate and depth of respirations. This is an analgesic used for moderate to severe pain. Side effects include a change in blood pressure, bradycardia, and respiratory depression. Think like a nurse: Butorphanol tartrate is a synthetically derived opioid agonist-antagonist analgesic. Butorphanol tartrate, in addition to analgesia, can produce the following central nervous system effects: cough suppression, miosis, nausea/vomiting, respiratory depression, and sedation. When providing care to a client who is prescribed any opioid analgesic, the nurse must monitor for respiratory depression as this can quickly escalate to a medical emergency (i.e., respiratory arrest) if not promptly treated. In the event of a butorphanol tartrate overdose manifested by respiratory depression, naloxone should be considered. Repeat dosing with naloxone may be required because butorphanol tartrate's duration of action usually exceeds naloxone's duration of action.

The nurse is caring for a client who has been taking a sulfonamide and should monitor for S/S of which adverse effects of this medication? Select all that apply. 1. Ototoxicity 2. Palpitations 3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects 6. Increased WBC count

3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects - Adverse effects include: nephrotoxicity, bone marrow suppression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms, including headache, dizziness, vertigo, ataxia, depression, and seizures.

A newly admitted client receives a lithium prescription for treatment of bipolar disorder. The client's serum lithium level is 1.7 mEq/L (1.7 mmol/L). Which action does the nurse take first? 1. Administer the next dose on time. 2. Increase the client's oral fluid intake. 3. Notify the health care provider. 4. Encourage the client to rest.

3. Notify the health care provider. - The therapeutic range of lithium for initial management is 1 to 1.5 mEq/L (1 to 1.5 mmol/L). Toxic manifestations may occur at levels greater than 1.5 mEq/L (1.5 mmol/L), and the HCP should be notified. Observe for vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, and muscle twitching. The therapeutic range of lithium for maintenance is 0.8 to 1.2 mEq/L (0.8-1.2 mmol/L). Think like a nurse: The client's lithium level is elevated, which should be reported to the health care provider. Increasing oral fluids will not affect the serum blood level of the medication. Administering the next dose of the medication would be malpractice and should not be done. Resting will not decrease the serum level of the medication or prevent the development of symptoms of lithium toxicity.

The nurse evaluates tasks delegated to the staff. Which observation indicates that the care provided to a client who is positive for human immunocompromised virus (HIV) is appropriate? 1. LPN/LVN applies a gown when entering the room. 2. Nursing assistive personnel uses sterile linen to make the bed. 3. Nursing staff wear gloves when exposed to secretions. 4. Family members wear gown, gloves, and mask when entering the room.

3. Nursing staff wear gloves when exposed to secretions. — Standard precautions are used when caring for this client. This observation indicates appropriate care. Think like a nurse: Standard precautions are used when caring for a client who is positive for human immunocompromised virus (HIV). A gown does not need to be worn when entering the room. Sterile linens are not required when changing the bed. There is no reason for family to wear personal protective equipment upon entering the client's room.

The nurse in the outpatient clinic receives a phone call from a client with type 1 diabetes mellitus. The client reports a blood glucose level of 200 mg/dL (11.1 mmol/L) at 0700. Which instruction to the client is most appropriate? 1. Obtain a blood sugar at 0900 and report the results to the clinic. 2. Increase the morning dose of regular insulin according to health care provider instructions. 3. Obtain a blood sugar at 0300 and report the results to the clinic. 4. Decrease the evening dose of NPH insulin according to health care provider instructions.

3. Obtain a blood sugar at 0300 and report the results to the clinic. — Assess the blood glucose level to determine if the hyperglycemia is caused by the Somogyi effect, which is characterized by a normal or elevated blood glucose at bedtime, hypoglycemia between 0200 and 0300, and a rebound hyperglycemia in the morning.

The nurse assesses a dark-skinned client for the presence of cyanosis. Which body area does the nurse use for the assessment? 1. Back of the hands. 2. Earlobes. 3. Palms of the hands. 4. Sacrum.

3. Palms of the hands. — In a dark-skinned client with cyanosis, the palms of the hands will have a bluish tinge or be ashen gray (acrocyanosis). If experiencing central cyanosis, a bluish or gray tint to the mucous membranes and conjunctiva is expected.

The nurse plans to assess cranial nerve (CN) III in a client. Which item does the nurse use to test cranial nerve III? 1. Coffee. 2. Cotton ball. 3. Penlight. 4. Sugar and salt.

3. Penlight. — A penlight is used to assess CN III (the oculomotor nerve). To test this nerve, assess the pupils for size, equality, and reactivity to light. Think like a nurse: There are many cranial nerve mnemonics to help nurses remember the cranial nerves. Cranial nerves I, II, and III are the "O" nerves: olfactory (I), optic (II), and oculomotor (III). The olfactory nerve is tested using strong smells such as coffee, peppermint, or peanut butter. The optic nerve may be tested via a Snellen chart for visual acuity and by plotting visual fields, which assess how far the peripheral vision extends. The oculomotor nerve is tested by observing for equal pupil reaction to light and observing the client's ability to smoothly move the eyes to track a moving object.

The nurse supervises a team of LPN/LVNs. The nurse intervenes if one of the LPN/LVNs allows clients to take licorice pills when which medications are administered? (Select all that apply.) 1. Promethazine. 2. Ibuprofen. 3. Potassium chloride. 4. Furosemide. 5. Prednisone.

3. Potassium chloride - The nurse needs to intervene in this situation. Licorice can lead to hypokalemia, whereas the client is taking potassium chloride to treat or prevent hypokalemia. 4. Furosemide - The nurse needs to intervene in this situation. Licorice increases the medication effect of diuretics, which includes furosemide. 5. Prednisone - The nurse needs to intervene in this situation. Licorice increases the medication effect of corticosteroids.

The nurse admits a client to the psychiatric unit. During the interview, the client frequently changes the subject. Which response by the nurse is appropriate? 1. Remind the client about the care goals. 2. Focus the interview on the client's symptoms. 3. Recognize the client's behavior relieves discomfort. 4. Ask the client to choose a topic for discussion.

3. Recognize the client's behavior relieves discomfort. — The client appears anxious and is having difficulty focusing. The nurse keeps environmental stresses to a minimum. Think like a nurse: In communicating with the client who frequently changes the subject, the nurse can use the sharing observation technique. The nurse can comment on how the other person is acting, looking, or sounding. Stating observations often helps a client communicate without the need for extensive questioning, focusing, and clarification.

During the admission process, a client reports pain in the right arm and states that it has been hurting since blood was drawn earlier. The nurse discovers a tourniquet in place. Which action does the nurse take next? 1. Notify the health care provider. 2. Assess the arm. 3. Remove the tourniquet. 4. Complete an incident report.

3. Remove the tourniquet. — The first action is to remove the tourniquet to restore blood flow to the client 's arm. The prolonged tourniquet pressure can cause vessel, nerve, muscle, and skin damage. Carefully assess the client after removing the tourniquet. Think like a nurse: The nurse identifies that the reason for the client's discomfort is the presence of a tourniquet. In order to prevent further injury to the client, the first action is to release and remove the tourniquet. The nurse should then complete a neurovascular assessment of the client's limb to ensure that no damage or injury has occurred because of the extended application of the tourniquet. Once the assessment is completed, the nurse will notify the health care provider if needed and finally complete the incident report.

The nurse provides care for a client diagnosed with severe acute pancreatitis. Which finding requires immediate action? 1. Heart rate of 104 beats per minute. 2. Blood pressure of 100/62 mm Hg. 3. Respiratory rate of 34 breaths per minute. 4. Serum glucose of 236 mg/dL (13.1 mmol/L).

3. Respiratory rate of 34 breaths per minute - A respiratory rate of 34 breaths per minute is above the normal range of 12 to 20 breaths per minute. Pleural effusion, atelectasis, pneumonia, and acute respiratory distress syndrome are potential complications of pancreatitis.

The nurse instructs the unlicensed assistive personnel about the care of an older adult client diagnosed with presbycusis. Which client characteristic will the nurse include in the teaching? 1. Often distracted. 2. Has middle ear changes. 3. Responds to low-pitched tones. 4. Develops excessive earwax.

3. Responds to low-pitched tones. - The older adult client diagnosed with presbycusis (age-related hearing loss) has difficulty hearing high-frequency sounds. Think like a nurse: The nurse needs to recall the normal age-related changes that can occur in the older client, and acknowledge these changes can affect the client sensory status, particularly hearing. When reviewing the changes that occur with hearing, the nurse needs to remember that higher-pitched tones are the first to be altered, making them difficult to hear. To ensure that an older client is able to hear effectively, nursing staff should use lower-pitched tones when communicating.

The nurse conducts a neurologic assessment on a new client in the neurology clinic. Assessment of the biceps and patellar deep tendon reflexes does not readily elicit a response. Which action is most important for the nurse to take? 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 client clenches the teeth, and retest the patellar while the client interlaces the fingers and pulls them against each other. 4. Tap the client 's face just below and in front of the ear and leave a blood pressure cuff inflated on client 's arm for 3 minutes.

3. Retest the biceps while the client clenches the teeth, and retest the patellar while the client interlaces the fingers and pulls them against each other. — These actions are known as reinforcement techniques. Isometric contraction of other body 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. Think like a nurse: When abnormal findings occur during the physical assessment, the nurse needs to mentally explore the meaning of, and possible causes for, the abnormal response. At times, a reflex is not able to be elicited and part of the problem is the client's focus on the assessment method. In some instances, the client will react with an over-reactive response. Should this occur, a strategy called a reinforcement technique can be used. This means that another part of the body is used to distract the client from focusing on the area being tested for a reflex.

The nurse provides care for a client with a peptic ulcer. Which initial assessment finding indicates to the nurse that the client has a perforated ulcer? 1. Nausea and vomiting. 2. Bradycardia. 3. Rigid, boardlike abdomen. 4. Swelling in the legs.

3. Rigid, boardlike abdomen. - A rigid, boardlike abdomen is the typical sign of the surgical emergency that occurs when a gastric ulcer perforates. Sharp, sudden, intolerable pain begins and spreads over the abdomen. Think like a nurse. When assessing the client in this scenario, the nurse will apply knowledge of the physiology of the gastrointestinal tract. The stomach is the organ where food begins the digestive process. At times, an excess amount of hydrochloric acid in the stomach injures the tissue wall. If left untreated, the injury enlarges, erodes through the tissue, and can progress to a perforation. The body's immediate response to tissue injury is bleeding, swelling, and pain. Bleeding will be present within the stomach, but also throughout the abdominal cavity. Bleeding into this area will cause the abdominal tissues, organs, and muscles to cramp. The abdomen becomes hard and extremely painful.

A client with cancer asks the nurse about late effects of chemotherapy and radiation treatments. Which late effect will the nurse include when responding to this client? 1. Nausea and vomiting. 2. Third space syndrome. 3. Secondary malignancies. 4. Continuing myelosuppression.

3. Secondary malignancies. - Alkylating chemotherapy and high-dose radiation are likely to cause secondary malignancies as late effects of treatment. Think like a nurse: The nurse understands that secondary malignancy is a potential risk, depending on the type of chemotherapy and radiation the client received. Ideally, the client should have regular follow-ups with an oncologist to monitor for signs and symptoms of secondary malignancies. The client is taught health maintenance and promotion activities such as smoking cessation, weight loss, control of diabetes, stress reduction, and healthy diet to lower the risk for cancer in general. Individual risk should be assessed using validated tools and screening tests. The nurse should use the teach-back method in all educational encounters, giving the client and caregivers an opportunity to ask questions.

The nurse plans care for a client diagnosed with antisocial personality disorder. The client participates in group therapy. Which action is most important for the nurse to take during the group therapy session? 1. Provide time to explore the client's past. 2. Demonstrate acceptance of the client and the client's behavior. 3. Set limits on the client in a nonpunitive manner. 4. Encourage sublimation of the client's leadership potential.

3. Set limits on the client in a nonpunitive manner. — Clients diagnosed with antisocial personality disorders are manipulative and act out. In order to establish trust and avoid power struggles, limits must be set in a nonpunitive manner. Think like a nurse: The nurse needs to mentally ask, "What are the expected behaviors from a client with antisocial personality disorder?", "How can the client's behavior be managed?", and "How can the therapeutic atmosphere of the group therapy be maintained?" A client with an antisocial personality disorder is prone to drama and acting out without concern for others. Anger can be a reaction to setting behavioral limits. The best approach is for the nurse to set non-punitive behavioral limits with the client, such as limiting the client's verbal participation or specifically asking other members to talk. Other members of the group are encouraged to participate, regardless of the client's behavior.

The nurse provides care for a 7-year-old client during a wellness examination. Which factor in the child's history alerts the nurse that hyperlipidemia screening is necessary? 1. Maternal history of obesity. 2. Paternal history of diabetes mellitus. 3. Sibling history of stroke. 4. Grandparent history of hypertension.

3. Sibling history of stroke. - If the child has a sibling with a history of stroke, screening for hyperlipidemia is recommended in children ages 2 to 8 years. Think like a nurse. The nurse is aware that the development of a chronic disease can either be controlled or uncontrolled. A non-modifiable risk factor cannot be controlled and is dependent upon age, race, gender, and family history. The younger a person is when diagnosed with a chronic health problem, the stronger the predisposition for other family members to develop the disease process. If a client at the age of 7 years has a sibling with a chronic health problem, it would be wise to assess the client's risk for the same health problem at an early age.

The nurse monitors a client receiving the first of two units of packed RBCs. The client reports a headache and lower back pain approximately 2 hours into transfusion of the first unit. Which intervention does the nurse perform first? 1. Assess the client's vital signs and respiratory status. 2. Administer acetaminophen as prescribed and monitor response. 3. Stop the infusion of blood. 4. Notify the health care provider.

3. Stop the infusion of blood. — The symptoms indicate a possible hemolytic reaction. Immediately stop the transfusion, as continuing it may worsen the client's reaction and even result in death. Think like a nurse: A headache and back pain are indications of a hemolytic transfusion reaction. The nurse knows that the only way to resolve this problem is to stop the transfusion immediately. After the transfusion is stopped, the client's vital signs should be assessed. The health care provider should be notified and the blood product and tubing preserved in anticipation of returning it to the blood bank for analysis.

The nurse interacts with a client who has just accepted a job in an office located on the 36th floor of a building. The client reports experiencing severe anxiety in elevators and enclosed spaces. Which intervention is most important for the nurse to recommend? 1. Psychopharmacological intervention. 2. Group therapy. 3. Systematic desensitization. 4. Biofeedback.

3. Systematic desensitization. — Systematic desensitization is a form of behavior modification. It is used in conjunction with deep muscle relaxation designed to decrease the extreme response to anxiety-producing situations. This technique is most effective for clients with phobic disorders. Think like a nurse: Most clients benefit from a combination of therapies. Systematic desensitization and pharmacological methods could be used together to help the client get through the work days while biofeedback and group therapy are used after work or on weekends, working toward the same goal. Phobia and anxiety treatment can be complex, but relaxation techniques in combination with the exposure to the anxiety-producing stimulus can be effective.

The nurse observes the LPN/LVN care for a client diagnosed with a stroke. The nurse should intervene if which action is observed? 1. The LPN/LVN places the client in an upright position to eat. 2. The LPN/LVN auscultates breath sounds bilaterally. 3. The LPN/LVN palpates the carotid pulses simultaneously. 4. The LPN/LVN faces the client and speaks clearly.

3. The LPN/LVN palpates the carotid pulses simultaneously. - Palpating the carotid pulses together can cause a vagal response and slow the client's heart rate. This action would require the nurse to intervene. Think like a nurse: When the nurse delegates client care to another member of the health care team, the nurse retains responsibility for the safety and well-being of the client. The nurse should use knowledge of anatomy and physiology to support that palpation of the carotid arteries should be performed one at a time. Palpating both carotid arteries at the same time could cause occlusion and reduce blood flow to the cerebrum. This action also stimulates chemoreceptors in the carotid arteries, which causes a reduction in the heart rate.

The nurse provides care for an older adult client after a left total hip replacement. Which finding will the nurse be most concerned about? 1. The client is positioned with a pillow between the legs. 2. The client moves slowly when getting out of bed. 3. The client 's heels are on the bed with toes pointed upward. 4. The client uses an incentive spirometer every 2 hours.

3. The client 's heels are on the bed with toes pointed upward. — This client is at an increased risk for skin breakdown. It is important to keep the client 's heels off the bed to prevent skin breakdown. Think like a nurse:The National Pressure Ulcer Advisory Panel recommends that the nurse ensure that the client 's heels are free from the bed. Additionally, the staff should use heel offloading devices or polyurethane foam dressings on individuals at high-risk for heel ulcers. The nurse should inspect all of the skin upon admission as soon as possible (but within 8 hours). Heel pressure injury can develop over a short period. When a client suffers from neuropathy (e.g., reduce leg sensation), the client may not feel pain on the injured heels.

The nurse provides postoperative care for a client after an ileal conduit procedure. Which observation most concerns the nurse? 1. There is bleeding from the stoma when the appliance is changed. 2. The skin under the ostomy pouch is irritated. 3. The client has abdominal pain and a temperature of 100.4°F (38°C). 4. Bowel sounds are absent in all four quadrants.

3. The client has abdominal pain and a temperature of 100.4°F (38°C). - Fever, abdominal rigidity and pain are indications of peritonitis. Urine may have entered the peritoneal cavity from anastomosis site leakage or from separation of the ureter from the ileal segment (the conduit). The health care provider should be notified at once, as this requires immediate medical intervention. This poses the greatest risk of harm to the client and is the highest priority. Think like a nurse: The nurse needs to consider the procedure performed and then ask what could be causing the client to have the presented manifestations. Abdominal pain and an elevated temperature after surgery to place an ileal conduit can indicate contamination of the peritoneal cavity by urine that could have occurred during or after the procedure. The health care provider needs to be immediately contacted to report the findings and prescribe appropriate treatment.

The nurse instructs a client with right-sided weakness how to use a cane. Which client behavior indicates to the nurse that teaching is successful? 1. The client holds the cane in the right hand, moves it forward followed by the right leg, and then the left leg. 2. The client holds the cane in the right hand, moves the cane forward followed by the left leg, and then the right leg. 3. The client holds the cane in the left hand, moves the cane forward followed by the right leg, and then the left leg. 4. The client holds the cane in the left hand, moves the cane forward followed by the left leg, and then the right leg.

3. The client holds the cane in the left hand, moves the cane forward followed by the right leg, and then the left leg. — The cane acts as support and aids in weight-bearing for the weaker right leg. The elbow should be flexed 30 degrees and the tip of cane should be 15 cm lateral to the base of the fifth toe. Think like a nurse: A cane is used to provide stability when ambulating. The client who uses a cane needs to have adequate strength to remain upright and be able to advance the cane to support the weaker limb. To begin teaching on the use of a cane, identify the weak limb. The cane is placed on the opposite side as a support to the weaker limb. When walking with the cane, the cane is advanced first, followed by the weak limb, and then the stronger limb is brought forward. This process ensures stability for the weak limb and maintains the client's balance. The handle of the cane should be at the client's wrist so when it is grasped, the elbow is flexed no greater than 30 degrees. The cane is advanced to accommodate the client's step length.

The nurse provides care for a client hospitalized for treatment of uncontrollable aggressive impulses. Which observation does the nurse record before beginning a behavior modification plan for the aggressive impulses? 1. The client tells each nurse that she is his favorite nurse. 2. The client is flirtatious with female members of the staff. 3. The client threatened to hit two other clients within 2 hours. 4. The client appears insincere and superficial in his interactions.

3. The client threatened to hit two other clients within 2 hours. - Concrete evidence of aggressive behavior must be documented. The nurse intercedes early, continues nonthreatening behavior toward the client, but will restrain the client when necessary to protect self and others. Think like a nurse: Thorough and accurate documentation is essential when caring for a client demonstrating aggressive behavior. Threatening to hit others is an objective observation of aggressive behavior and warrants a behavior modification plan.

The nurse provides care for a client who is a victim of sexual abuse by a family member. Which observation by the nurse determines that an initial positive outcome of treatment has occurred? 1. The client acknowledges a willing participation in the abuse. 2. The client reestablishes a trusting relationship with other family members. 3. The client verbalizes not being responsible for the sexual abuse. 4. The client appears anxious when speaking about the abuser.

3. The client verbalizes not being responsible for the sexual abuse. — Abuse survivors need assistance challenging the believe that "I am bad and deserved the abuse. " Verbalization of not being responsible for the sexual abuse is a first step. Think like a nurse: A client who is sexually abused experiences physical and psychological manifestations. First attention is given to the client's physical needs. When addressing the client's psychological issues, the nurse needs to remember a victim of sexual abuse or assault often engages in self-blame for the attacker's behavior. Since the client in this scenario recognizes a lack of responsibility for the attack, it can be determined that the treatment provided thus far has been successful.

The nurse reviews newly written prescriptions for clients who are on a telemetry unit. Which finding does the nurse report to the health care provider? 1. The client who has congestive heart failure (CHF) and has been prescribed intravenous (IV) morphine while receiving a continuous IV infusion of dopamine. 2. The client who has atrial fibrillation (AF) and renal insufficiency (RI) and has been prescribed a low-molecular-weight heparin. 3. The client who had coronary artery bypass graft surgery (CABG) 4 hours ago, has had 800 mL of serosanguineous chest tube drainage since surgery, and has been prescribed enoxaparin. 4. The client who has coronary artery disease (CAD) and has been prescribed warfarin while receiving a continuous IV infusion of heparin.

3. The client who had coronary artery bypass graft surgery (CABG) 4 hours ago, has had 800 mL of serosanguineous chest tube drainage since surgery, and has been prescribed enoxaparin. — Chamber one of the chest tube drainage system collects the fluid draining from the client. This fluid is measured hourly during the first 24 hours. Notify the care provider if more than 100 mL/hr of drainage occurs. Since there is active bleeding, enoxaparin, a synthetic heparin, may be contraindicated. Think like a nurse: Prior to making a decision, the nurse should stop and think, "Which client situation is the most likely to indicate complications?" The client with a chest tube after cardiac surgery is having bloody drainage that is averaging 200 mL/hr. This is twice the acceptable amount, and the nurse should recognize the possibility of active bleeding. Of additional concern is the fact that the client is also prescribed an anticoagulant, which has the potential of making the bleeding become worse. The nurse should assess the client's vital signs and then report the findings to the health care provider for additional evaluation and prescriptions for further treatment.

The nurse provides care for four newborn clients. Which client does the nurse assess first? 1. The newborn who is 6 hours old and has a blue-black discoloration on the right buttock. 2. The newborn who is 10 hours old and has not passed meconium. 3. The newborn who has not voided since having a circumcision 7 hours ago. 4. The newborn who is having the first formula feeding and has not been screened for phenylketonuria (PKU).

3. The newborn who has not voided since having a circumcision 7 hours ago. - Noting the first urination after circumcision is important because edema could cause an obstruction. If the infant goes home before voiding, the mother is instructed to call the health care provider if there is no urinary output within 6 to 8 hours. Think like a nurse: Nurses often need to decide which client needs to be seen first. In making this determination, the nurse should review each client for acuity level, current symptoms, and risk for complication or life-threatening situation. Of the clients in this scenario, the one that causes the most concern is the client who has not voided since being circumcised. This manifestation could be indicative of urethral obstruction caused by

A novice nurse provides care for a 20-month-old child with suspected otitis media. The novice nurse examines the client's ear. Which action, if taken by the novice nurse, requires an intervention by the seasoned nurse? 1. The novice nurse talks to the child as the student looks into the child's ear. 2. The novice nurse allows the child to sit on the parent's lap during the examination. 3. The novice nurse gently pulls the pinna of the ear up and back to straighten the ear canal. 4. The novice nurse places a disposable cover on the tip of the otoscope before the examination.

3. The novice nurse gently pulls the pinna of the ear up and back to straighten the ear canal. - The novice nurse should pull the pinna of the ear down (rather than up) and back to straighten the ear canal when examining a child's ear. The seasoned nurse would intervene with this action. Think like a nurse: The nurse needs to be aware that the techniques and strategies to use when completing a physical assessment can vary depending upon client age and developmental level. When assessing a 20-month-old client, the nurse should consider that not all physical development is complete and major body systems are not fully developed. One such body area in which an alteration in technique is required is the assessment of the ears. An adjustment needs to be made in order to visually assess the tympanic membrane of a client of 20 months of age. The pinna should be pulled down and back for a child under 3 years of age. Over 3 years of age and through adulthood, the pinna is pulled up and back to achieve the same result of straightening the ear canal.

Which nursing action would likely be considered negligence? 1. The nurse does not aspirate before injecting a client's subcutaneous heparin. 2. The nurse removes a client's wrist restraints hourly to conduct a skin assessment. 3. The nurse assesses pedal pulses every 4 hours for a client who just returned from having a cardiac catheterization. 4. The nurse administers a preoperative client's prescribed sedative medication without removing the client's dentures.

3. The nurse assesses pedal pulses every 4 hours for a client who just returned from having a cardiac catheterization. — For the client who undergoes cardiac catheterization, the nurse should follow organizational policy with regard to frequency of assessment. However, general guidelines include assessment of the client's pedal pulses immediately after the procedure, then every 15 minutes for 1 hour. Pedal pulses are then assessed every 30 minutes for 2 hours or until the client's vital signs are stable. Failure to assess the client's pedal pulses until 4 hours following cardiac catheterization likely constitutes negligence, as a nurse in similar circumstances would reasonably assess the client's pedal pulses much sooner and more frequently than 4 hours following the procedure. Think like a nurse: Negligence occurs when a nurse fails to follow the standard of care and client harm could result. Aspiration before subcutaneous injection of heparin is not necessary, and the process may even increase client discomfort. Restraints should be released regularly to assess the client's skin under the restraints and to allow the client to participate in care and perform range-of-motion exercises. It is acceptable to administer preoperative sedation with the client's dentures in place. After cardiac catheterization, the nurse should frequently assess the client's neurovascular status distal to the catheter insertion site to promptly recognize signs of neurovascular compromise that may result from the procedure.

The nurse observes staff providing care to assigned clients. Which observation indicates to the nurse that care is appropriate? 1. The LPN/LVN wears gloves for a client with a stage 1 pressure injury. 2. The unlicensed assistive personnel (UAP) wears gloves while ambulating a client with an indwelling urinary catheter. 3. The nurse wears clean, non-sterile gloves when removing an indwelling urinary catheter. 4. The unlicensed assistive personnel (UAP) removes the mask before removing the gloves when caring for a client on droplet precautions.

3. The nurse wears clean, non-sterile gloves when removing an indwelling urinary catheter. - Sterile gloves are required when inserting the urinary catheter. However, clean, non-sterile gloves can be worn when removing the catheter. Think like a nurse: Clean gloves should be worn when removing an indwelling urinary catheter due to the risk of coming into contact with the client's bodily fluids. The use of sterile gloves when unnecessary is considered a misappropriation of supplies.

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply. 1. The nurse who had roseola. 2. The nurse who never had mumps. 3. The nurse who never had chicken pox. 4. The nurse who never had German measles. 5. The nurse who never received the varicella-zoster vaccine.

3. The nurse who never had chicken pox. 5. The nurse who never received the varicella-zoster vaccine.

The nurse assesses a client 48 hours after a total joint replacement of the right hip. Which finding does the nurse report to the health care provider? 1. The client requests analgesics less frequently. 2. The right leg is abducted beyond the body's midline. 3. The right leg is outwardly rotated. 4. The hip joint is flexed at a 60-degree angle when the client reclines in the chair.

3. The right leg is outwardly rotated. - An outward rotation indicates dislocation of the prosthesis and is immediately reported to the health care provider. The nurse may also see shortening of the extremity, inability to move it, altered alignment, abnormal rotation, and increased pain.

The nurse assesses a 1-month old infant. Which finding will the nurse investigate further? 1. Anterior fontanel taut when the infant cries. 2. Head lag present when the infant is pulled from a lying to a sitting position. 3. Top of the infant's right knee is 1 inch higher than the left knee. 4. Left arm and leg extend when the head is turned to the left.

3. Top of the infant's right knee is 1 inch higher than the left knee. — Unequal knee height suggests developmental dysplasia of the hip. Other symptoms include asymmetry of the gluteal and thigh folds. Think like a nurse: Especially when assessing an infant client, asymmetrical findings are a cause for concern. Vertebrae should be in straight alignment, the arms should demonstrate equal length and range of motion, and the legs should be equal in length. Gluteal and thigh folds should be symmetrical, as well. Asymmetry of gluteal and thigh folds is a sign of hip dysplasia, which may be unilateral or bilateral. For the client diagnosed with unilateral hip dysplasia, assessment findings may include a hip click in addition to unequal limb length and unequal knee height.

The nurse provides care for a client scheduled for surgery the following morning. The preoperative prescriptions include NPO after midnight. No medications are prescribed to be withheld before surgery. Which medication causes the nurse to question its administration prior to surgery? (Select all that apply.) 1. Valsartan 80 mg given daily for hypertension. 2. Clonazepam 2 mg given twice daily to prevent seizures. 3. Triamterene 50 mg given every morning for hypertension. 4. Prednisone 5 mg given once daily for asthma. 5. Dabigatran 75 mg given daily for atrial fibrillation. 6. Quetiapine 50 mg given at bedtime for insomnia.

3. Triamterene 50 mg given every morning for hypertension. - Diuretics are withheld prior to surgery, as they increase the client's risk for hypovolemia and hypokalemia. 5. Dabigatran 75 mg given daily for atrial fibrillation. - Anticoagulants are withheld prior to surgery in order to prevent excessive bleeding intraoperatively.

The nurse provides care to a client diagnosed with chronic heart failure (HF) and an acute bacterial infection. The client's medications include furosemide 40 mg PO daily and aspirin 81 mg PO daily. Which new prescriptions cause the nurse to seek clarification from the health care provider? (Select all that apply.) 1. Potassium chloride (KCl) 40 mEq PO daily. 2. Enalapril 20 mg PO daily. 3. Vancomycin 3 g IV piggyback every 12 hours. 4. Digoxin 0.25 mg PO daily. 5. Clopidogrel 75 mg PO daily.

3. Vancomycin 3 g IV piggyback every 12 hours. - The combination of vancomycin with furosemide, which is a loop diuretic, increases the client's risk for ototoxicity. 4. Digoxin 0.25 mg PO daily. - The combination of digoxin and with furosemide, which is a loop diuretic, increases the client's risk for digoxin toxicity.

The nurse administers intravenous dopamine to a client. Which parameter will the nurse monitor to evaluate the response to this medication? 1. Heart rhythm. 2. Central venous pressure. 3. Vital signs. 4. Daily weights.

3. Vital signs. — Dopamine is indicated for correction of hemodynamic instability as a result of shock. Monitoring vital signs provides the most appropriate information regarding the effects of the medication. Think like a nurse: Dopamine affects the myocardium by increasing heart rate and cardiac contractility. At low doses (less than 2 mcg/kg/min), dopamine increases renal blood flow. At typical doses (3 to 10 mcg/kg/min), dopamine improves heart function and increases blood pressure. At high doses (greater than 10 mcg/kg/min), vasoconstriction increases blood pressure. At doses higher than 20 mcg/kg/min, peripheral circulation becomes compromised by vasoconstriction as the body attempts to maintain cardiac output. The nurse monitors the client carefully for therapeutic and adverse effects. Additionally, the nurse titrates the medication dose according to facility protocol and the health care provider prescriptions to balance an adequate blood pressure with other client needs.

The nurse provides care for a client diagnosed with peripheral artery disease (PAD). The client reports leg pain occurs frequently when walking. Which action does the nurse advise the client to take? 1. Lie down with feet elevated above the heart when experiencing pain. 2. Apply a heating pad to the legs for 15 minutes before walking. 3. Walk until client experiences pain, rest, and then resume walking. 4. Perform stretching exercises 20 minutes before starting to walk.

3. Walk until client experiences pain, rest, and then resume walking. - Exercise increases collateral circulation and should be encouraged. Stopping and resting will usually relieve the pain, and then the client can continue to walk. For a client with PAD, elevating the legs above the heart decreases arterial flow to legs. This will increase, not relieve, the pain. Stretching will not reduce the pain due to intermittent claudication.

The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about proposed gift ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse which idea is best. Which option is the best gift for the nurse to recommend? 1. Perfume and makeup. 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 client with Parkinson. Eating is slow because of overall slowed body movement, tremors, difficulty chewing and swallowing, fatigue, and need for rest periods. This choice directly addresses a physiologic need. A client with Parkinson disease should maintain a neutral alignment of the body and avoid flexion of the neck and shoulders. The client should sleep on a firm mattress without a pillow to prevent flexion of the spine.

The nurse manager observes a staff nurse perform tracheostomy suctioning and tracheostomy care. Which staff nurse action requires an intervention by the nurse manager? 1. Wearing clean gloves when removing the tracheostomy kit from its outer package. 2. Hyperoxygenating the client prior to suctioning the tracheostomy tube. 3. Wearing clean gloves while inserting the new inner cannula. 4. Leaving the old tracheostomy ties in place until the new ties are secured.

3. Wearing clean gloves while inserting the new inner cannula. — Sterile gloves are worn while inserting the new, sterile inner cannula to prevent introduction of organisms into the client's airway. Think like a nurse: Before performing tracheostomy care, the nurse needs to remember that tracheostomy care is a sterile procedure and mentally review the process. The nurse will apply knowledge of anatomy and physiology when accessing the tracheostomy, and the body system that is involved, which is the respiratory system. A tracheostomy is an artificial opening created in the trachea to establish either a temporary or permanent airway. Any procedure that involves the tracheostomy tube must be performed using sterile technique in order to prevent infection from developing in the respiratory system. The nurse will apply sterile gloves when changing the inner cannula of a tracheostomy.

The client is placed on cephalexin prophylactically after surgery. Which foods will the nurse encourage the client to eat? 1. Bran cereals and fruits. 2. Egg whites and lean meats. 3. Yogurt and acidophilus milk. 4. Fish and poultry meats.

3. Yogurt and acidophilus milk. — Yogurt and acidophilus milk will help maintain normal intestinal flora, which may be altered by cephalexin. The nurse should encourage the client to eat these foods. Think like a nurse: When reviewing the client's prescribed medications, the nurse would ask, "Are there medications here with side effects that should be addressed?" An antibiotic such as cephalexin can adversely effect the number and functioning of normal gastrointestinal flora. The client needs to ingest foods that restore the flora, such as yogurt and acidophilus milk. Foods high in fiber or protein will not help return the balance of normal intestinal flora.

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head), the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, causing subsequent burn injuries to the posterior surface of the head and upper half of the posterior torso when the client ran. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

36% - Anterior half of the head: 4.5% - Upper half of the interior torso: 9% - Lower half of both arms: 9% - Posterior half of the head: 4.5% - Upper half of the posterior torso: 9%

A client weighing 50.6 lb (23 kg) is prescribed phenytoin 5 mg/kg/day by mouth every 8 hours. Which amount of medication in milligrams will the nurse provide to the client for each dose? (Round at the end of the equation. Record your answer using one decimal place.)

38.3 mg Ratio/Proportion: 5mg x 23kg = 115 mg 115 mg/3 = 38.3 mg

The nurse prepares a client for a barium enema. Which instruction is most important for the nurse to include? 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 the test to be successful, a client must retain the barium. As barium is introduced, a client may have the urge to defecate. Slow, deep breathing will help ease the discomfort and urge to defecate. Think like a nurse: The nurse has a responsibility to provide information to the client regarding how to tolerate diagnostic testing in order to assure successful test outcomes. A barium enema is a diagnostic test that uses barium as a contrast medium to identify structures and areas of pathology within the large intestines. Because the contrast medium is introduced via an enema, the client may become uncomfortable. A natural reaction to having a feeling of fullness in the rectum and descending colon is to bear down. The nurse should counsel the client to take slow deep breaths when the barium is being introduced to reduce the feeling of rectal fullness.

The nurse provides care to a primipara client who asks the nurse when she is going to deliver. The medical record at 0800 indicates 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 response by the nurse is most appropriate? 1. "If your labor continues to progress as it has, you might deliver between 2:00 and 4:00 p.m." 2. "Because you are a first-time mom, your progress should be at 1 to 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. "Every labor is different. It is impossible to predict when you will deliver."

4. "Every labor is different. It is impossible to predict when you will deliver."

The nurse leads a family therapy session for the family of an adolescent diagnosed with depression. During the first session, one of the parents dominates the discussion. Which response 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 family member is saying?"

4. "How do the rest of you feel about what your family member is saying?" — This allows every member of the family to offer feedback about the effect the parent's monopoly of the session has on each person. This engages the family members and encourages them to practice setting boundaries in the relationship. Think like a nurse: Though this is a family counseling session, the focus must remain on the adolescent with depression. Recognizing one individual's tendency to monopolize the discussion helps the nurse understand the family dynamics. However, allowing the individual to continue to dominate the discussion is not therapeutic. Family members with dominant personalities sometimes do not realize their effect on others and may not be aware that their input could be perceived as overbearing or aggressive. Gathering insight from the other family members can assist the nurse with helping the family develop more productive communication strategies.

The nurse in the pediatric clinic receives a phone call from a parent who says, "My 10-year-old has a nosebleed that will not stop bleeding even though I have applied pressure." Which response 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 the nose." 4. "How long have you applied pressure?"

4. "How long have you applied pressure?" — The nurse should assess before implementing. Initially, the parent should apply direct pressure for 5 to 10 minutes continuously. If this is ineffective, the nurse should tell the parent to take the child to the emergency department or urgent care center as the nosebleed may require treatment with silver nitrate applicator and compressed gelatin foam. Think like a nurse: The client's statement that it "will not stop" requires assessment. All blood looks like too much blood, and any time spent bleeding seems like too much, especially to the lay person worried about their child. Nosebleeds are common and are often caused by dry mucous membranes. The capillaries in the nose are fragile and may bleed easily after chronic exposure to a dry environment. Frequent or prolonged nose bleeds require further assessment, though. Occasionally, nose bleeds are caused by severe problems such as bleeding disorders or cancers and will require medical intervention.

The nurse was assigned to the mental health care area from another area in the facility. A client accuses the nurse of being a terrorist with poisonous pills when the nurse is preparing medications. Which response 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." - The nurse's explanation serves as orientation to reality. It also addresses the client's concern without reinforcing the delusion. Think like a nurse: The client does not recognize the nurse and thinks the nurse plans to do the client harm. The best way to address the client's delusion is to explain who the nurse is.

The nurse prepares to administer the influenza vaccine to a client. Which client statement concerns the nurse? 1. "I am allergic to neomycin." 2. "I am allergic to penicillin." 3. "I am allergic to shellfish." 4. "I am allergic to eggs."

4. "I am allergic to eggs." — An allergy to eggs is a contraindication to the flu vaccine. The nurse should not administer the standard vaccination. Think like a nurse: Before administering any prescribed medication, the nurse needs to identify drug allergies, possible drug and/or food interactions, and recognize when a medication is contraindicated. The influenza vaccine is incubated in a medium that contains egg proteins. Because of this, the nurse knows that a person with an egg allergy should not receive this vaccination. Other circumstances that contraindicate the use of the influenza vaccine include a history of previous allergic reaction and Guillain-Barré Syndrome (GBS). While it is usually okay for a client to receive the influenza vaccine when experiencing a mild illness, it may be appropriate to ask the client to return for the vaccine once he or she is feeling better to decrease the likelihood of a reaction.

The nurse in the community mental health center talks individually with a client with generalized anxiety disorder and who has been attending center programs for 4 months. Which statement made by the client 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 the episodes do 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." - Sleeping well 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, there is a disturbed sleep pattern, sleep deprivation, and fatigue. Intrusive thoughts, worrying, fear, and/or replaying traumatic events contribute to difficulty falling asleep and/or staying asleep.

The unlicensed assistive personnel (UAP) reports to work on the oncology unit with a cough, runny nose, and an elevated temperature. The UAP reports having no sick leave and being the breadwinner of the family. Which response does the nurse provide to the UAP? 1. "Did you receive a flu shot?" 2. "Can you work at the desk and help the unit secretary with the medical records?" 3. "I will call one of the other units where clients are less vulnerable." 4. "I am sorry, but you will have to go home."

4. "I am sorry, but you will have to go home." - During community outbreaks of the flu, it is responsible management to exclude staff with febrile infections from caring for high-risk clients. - If the UAP stayed on the unit in a non-patient caring role, Influenza is spread by droplets, and even though the UAP will not be caring for clients, the UAP will still come in contact with other staff members. Oncology clients are immunocompromised. Think like a nurse: Nurses on a bone marrow transplant or oncology unit are, rightly so, protective of the clients in their care and avoid exposing them to infections that could prove lethal in the immunocompromised population. A cough and runny nose with fever is too symptomatic to work, especially with this client population. Often, if a staff member has only a low grade fever or sore throat, they might continue to work while wearing a mask, but even this is not wise to do when caring for clients with decreased immune systems in which simple infections have serious consequences.

The nurse watches as a parent and infant interact. The infant throws a toy to the floor numerous times. The parent picks up the toy and gives it back to the infant. If the parent does not immediately return the toy, the infant cries loudly. Which statement by the nurse is best? 1. "Be sure to wipe the toy off each time before you give it back. These floors are filthy." 2. "Your baby is either stubborn or wants attention, I cannot figure out which." 3. "I remember when my own baby used to do that." 4. "I bet your baby is about 11 months old. This is normal behavior."

4. "I bet your baby is about 11 months old. This is normal behavior." — At 11 months, an infant drops an object deliberately in order that it can be picked up. Even if the infant is not 11 months, equating a problematic behavior with a developmental norm can help decrease the parent's probable sense of aloneness, inadequacy, embarrassment, and frustration. Think like a nurse: The nurse should recognize that developmental milestones can provide important information when providing care to the pediatric client. One such milestone is object permanence, which develops late in infancy. A client at 11 months of age throws an object in order for it to be retrieved by someone else. When the object is not retrieved, it is not uncommon for the infant to protest. This is considered normal behavior for the client, which should be shared with the parents.

The nurse performs dietary teaching for a client with acute inflammatory bowel disease. The nurse determines that further teaching is required if the client makes which statement? 1. "I make my sandwiches with white bread." 2. "My favorite dessert is tapioca pudding." 3. "My family likes to eat roasted chicken." 4. "I drink a glass of red wine with dinner."

4. "I drink a glass of red wine with dinner." - Wine may exacerbate the inflammatory condition. Think like a nurse: When evaluating client education, the nurse asks the client to teach back. This client describes multiple foods that are acceptable for an individual diagnosed with inflammatory bowel disease (IBD). However, additional teaching is needed to explain that wine may exacerbate the client's symptoms. The client should be advised that intake of even one alcoholic beverage may trigger an exacerbation of IBD. The nurse considers the client's preferred diet and offers similar, acceptable alternatives where indicated.

The nurse provides care for a pregnant client. The client reports heartburn. Which client statement requires the nurse to intervene? 1. "I sit upright for 2 hours after eating." 2. "I sleep with an extra pillow." 3. "I will stop smoking." 4. "I eat every 6 hours."

4. "I eat every 6 hours." —The nurse should intervene. The client should eat small, frequent meals. Think like a nurse: A pregnant client may experience a variety of nuisance health problems that did not exist prior to becoming pregnant. One of these health situations is heartburn. Heartburn can be caused by changes in the client's hormone levels affecting the rate of digestion and tolerance of different foods, or heartburn may be caused by the enlarging uterus putting pressure on the stomach. One action for the mother to take to lessen the effects of heartburn is to eat small meals more frequently and to choose foods that are not spicy or irritating to the gastric lining.

The nurse evaluates comprehension of teaching provided to a client scheduled for surgery. Which client response is the most important for the nurse to report to the health care provider? 1. "Sometimes I feel so claustrophobic I want to run." 2. "I have heard about near-death experiences occurring in the operating room. Have you heard about it?" 3. "I had my will finalized last week just in case anything happens." 4. "I hope they keep the operating room cool. My grandfather died during surgery when he got very hot."

4. "I hope they keep the operating room cool. My grandfather died during surgery when he got very hot." - The statement about keeping the operating room cool may indicate a risk for malignant hyperthermia, which is a genetic predisposition disorder transmitted as an autosomal dominate trait. It is a life-threatening complication of general anesthesia. Symptoms include tachycardia, dysrhythmias, tachypnea, hyperthermia, and hypotension. It is treated with dantrolene sodium.

The nurse in the pediatric clinic provides care for a school-age client diagnosed with infectious mononucleosis. Which statement does the nurse expect the child to make? 1. "My left ear hurts." 2. "I have a cough that won't go away." 3. "My nose is runny all the time." 4. "I just have no energy to do anything."

4. "I just have no energy to do anything." — Mononucleosis is an infectious disease caused by the Epstein-Barr virus. Besides extreme fatigue, other indications include malaise, fever, headache, epistaxis, and severe sore throat. Think like a nurse: The nurse knows that infectious mononucleosis presents with a sore throat, headache, malaise, and fatigue. Malaise and fatigue tend to be the hallmarks of the condition, whereas other symptoms may or may not be present. The fatigue is extreme and persists for up to 6 weeks. Though rare, tonsillar enlargement could potentially obstruct the client's airway, so periodic airway assessment is warranted.

The nurse reviews the importance of receiving an annual influenza vaccination with a client. Which statement indicates to the nurse that the client requires further instruction? 1. "I will get the shot since I am 69 years old." 2. "I had bronchitis twice last year, so I will get the shot." 3. "I volunteer at a preschool, so I will get the shot." 4. "I live with two large dogs, so I will get the shot."

4. "I live with two large dogs, so I will get the shot." - The client is not at risk for getting influenza from a dog. Therefore, this client statement indicates the need for further education. Think like a nurse: The annual influenza vaccination is recommended for most, if not all, people. It is particularly important for older adult clients to receive this vaccination because of a change in immunity that occurs naturally with aging. Older adults are also more likely to have chronic respiratory and cardiovascular illnesses, which would be exacerbated by an episode of the flu. Younger children are prone to contracting and transmitting bacteria and viruses, but the influenza virus is not transmitted from animals.

A client comes to the outpatient clinic for evaluation of a possible basal cell carcinoma of the nose. Which client statement most concerns the nurse? 1. "I am a meat cutter at the local packing plant." 2. "My hobby is raising thoroughbred Great Danes." 3. "My parents immigrated from Sicily when I was born." 4. "I spend nearly every weekend sailing with my family."

4. "I spend nearly every weekend sailing with my family." — Exposure to the sun increases the risk of skin cancer. The nurse should urge the client to use sunscreen with SPF (solar protection factor) to block harmful rays and reapply sunscreen every 2 hours or after swimming. The client should also use lip balm with sunscreen protection and avoid sun exposure during peak sun hours. Think like a nurse: The nurse should understand that exposure to the sun's ultraviolet rays is the number one risk factor for skin cancer. This client spends a considerable amount of time outdoors sailing, which increases the risk for skin cancer. Water also magnifies the intensity of the sun, which could hasten the development of a cancerous lesion. The nurse should plan to teach all clients about the causes, preventions, and treatment for skin cancers. When performing skin assessment/screening, the nurse should be aware of genetic predispositions such as fair skin coloration, light colored eyes, and red or blond hair.

The nurse provides care to a client receiving topiramate. For which client statement will the nurse intervene? 1. "I drink at least 10 glasses of water each day." 2. "I change positions slowly." 3. "I should contact my health care provider if I have blurred vision." 4. "I use oral contraceptives."

4. "I use oral contraceptives." - Non-hormonal contraceptives should be used when taking topiramate. Think like a nurse: Topiramate, an enzyme-inducing anti-epileptic medication, can affect pharmacokinetics of oral contraceptives, leading to contraceptive failure. Generally, the efficacy of combined oral contraceptives is diminished in clients taking enzyme-inducing anti-epileptic drugs, such as, phenytoin, phenobarbital, and carbamazepine. The client and partner should be informed about using other methods of birth control, such as a condom, when taking these medications.

The nurse teaches a client diagnosed with neutropenia about the condition. Which client statement indicates to the nurse an understanding of the instructions? 1. "I will use a soft toothbrush." 2. "I have to wear a mask at all times." 3. "My grandchildren may get an infection from me." 4. "I will call my health care provider if I develop a fever."

4. "I will call my health care provider if I develop a fever." - With neutropenia, the client has an increased risk for acquiring infections. Therefore, the client should notify the health care provider immediately if an increased temperature or chills occur. Think like a nurse: The nurse should apply knowledge regarding the impact of abnormal laboratory values on the well-being of a client. Critical low levels of neutrophils from any cause can lead to lethal complications such as bleeding and infection (e.g. sepsis). The nurse anticipates monitoring the client's absolute neutrophil count (ANC). The normal range for the ANC is 1.5 to 8 × 10 9/L (1500 to 8000/mm 3). The staff should observe strict adherence to standard precautions (e.g. hand hygiene) and transmission-based precautions, if needed. The client with neutropenia is required to wear a mask when leaving the room. The nurse should follow local protocol in neutropenic precautions as they vary by institution.

The staff nurse is reviewing the preparation for insertion of a central venous catheter (CVC) in a client with the nurse supervisor. Which statement by the staff nurse most concerns the nurse supervisor? 1. "I will instruct the client to turn her head to the left until the procedure is complete." 2. "I will shave the skin at the insertion site the night before." 3. "I will inform the client that she will be positioned with her head lower than her feet during the insertion procedure." 4. "I will instruct the client to breathe deeply during the procedure to help her relax."

4. "I will instruct the client to breathe deeply during the procedure to help her relax." - The client should not breathe deeply during the insertion procedure, as this increases the risk for air embolism, which poses an immediate risk of harm and potential death to the client. Clients should be instructed to perform the Valsalva maneuver instead. This is the greatest concern.

The school nurse finds an adolescent client slumped on the floor of the bathroom with a razor blade in hand and bleeding from the wrists. Which response by the nurse is appropriate? 1. "Why are you doing this to yourself?" 2. "What caused you to cut yourself?" 3. "Did you tell anybody about this?" 4. "I will not leave you alone."

4. "I will not leave you alone." — The nurse will stay with client and convey the intent to control the current injury and the teen's self-destructive impulses. Think like a nurse: Staying with the client is the best action of the nurse. After calling for assistance, the nurse should assess the client and the environment for potential hazards. The nurse can follow the protocol of the school. It is likely that a paramedic should be called immediately. As it is a sentinel event, the nurse should participate in debriefing and root-cause analysis. The nurse also should anticipate providing support to the other students in the school who might be affected by the suicidal behavior of the client.

The nurse reviews dietary guidelines with a client diagnosed with gastroesophageal reflux disease (GERD). Which statement by the client helps the nurse determine that teaching was effective? 1. "If my stomach feels bloated, I will drink peppermint tea." 2. "I will switch from orange juice to tomato juice at breakfast." 3. "I will eat three meals per day and not snack between meals." 4. "I will raise the head of my bed 12 inches prior to sleeping each night."

4. "I will raise the head of my bed 12 inches prior to sleeping each night." — The recumbent position significantly impairs esophageal clearance. The client's head should be elevated 6 to 12 inches to prevent nighttime reflux. Think like a nurse: Gastroesophageal reflux disease (GERD) may cause pulmonary microaspiration during sleep. The client is advised to sleep with the head of bed elevated. The client is also taught to eat frequent small meals to prevent gastric distension. Advise the client not to lie down for 2 to 3 hours after eating, not to wear clothing tight around the waist, or to bend over, especially after eating. The nurse should be alert to the risk of asthma exacerbation secondary to GERD. The nurse should anticipate giving the client histamine-2 blockers or proton-pump inhibitors.

The client is to begin treatment with metformin. Which client statement requires immediate intervention by the nurse? 1. "I will be sure to carry a chocolate candy bar with me at all times." 2. "If I get abdominal cramps and a metallic taste in my mouth, I will call the health care provider." 3. "I am glad this medication will not cause me to gain weight." 4. "I will take the medication when I first get up and just before I go to bed."

4. "I will take the medication when I first get up and just before I go to bed." - The client should take metformin with meals to reduce the side effects of the medication. Side effects may include nausea, vomiting, anorexia, and abdominal cramps. Think like a nurse: During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. Key topics of education include the medication's purpose, therapeutic effects, side effects, adverse effects, and administration instructions. Metformin decreases production of glucose by the liver and increases cellular sensitivity to insulin. Metformin also delays glucose absorption, which helps prevent sharp elevations in blood glucose. Metformin is most effective when taken with food.

The nurse assesses a toddler-age client diagnosed with acute diarrhea related to gastroenteritis. There is no evidence of significant dehydration. Which recommendation is most important for the nurse to make to the client's parent? 1. "Encourage your child to drink clear fluids such as fruit juices, gelatin, and carbonated drinks." 2. "Offer your child beef broth or chicken broth as tolerated." 3. "Bananas, rice, and toast are effective for decreasing diarrhea." 4. "It is best to start your child on the usual diet right away, offering food as tolerated."

4. "It is best to start your child on the usual diet right away, offering food as tolerated." — Once rehydration has occurred, or if dehydration is not evident, the child's normal diet should be resumed. Continued feeding or early reintroduction of nutrients as in a normal diet is without adverse effects, decreases the duration and severity of the illness, and improves weight gain compared to gradually reintroducing foods. Think like a nurse: A client recovering from acute gastroenteritis should resume a normal diet once rehydration has occurred to ensure adequate nutritional intake.

The nurse provides education to a breastfeeding mother. Which client statement requires the nurse to follow-up with the mother? 1. "I will need an additional 400 to 500 calories each day while breastfeeding." 2. "I should drink 8 to 10 cups of fluid daily while I am breastfeeding." 3. "I should not diet to lose weight while I am breastfeeding." 4. "It is okay to have a glass of red wine before I breastfeed at night."

4. "It is okay to have a glass of red wine before I breastfeed at night." - Smoking, alcohol intake, and excessive caffeine intake should be avoided during lactation. Alcohol level in the milk peaks at 30 to 60 minutes after drinking if it is taken alone, and 60 to 90 minutes if taken with food. If mothers drink alcohol, they should not breastfeed for at least 2 hours. Think like a nurse: A new mother will need a variety of teaching to support both personal needs and the needs of the newborn. One essential teaching topic is that of breastfeeding. Before beginning this teaching, the nurse should mentally determine, "What information is important for this mother to know so that the baby receives optimal nutrition?" The mother needs to be aware that substances she ingests will be reflected in the breast milk. For this reason, the mother should be reminded that alcohol should be avoided while breastfeeding the baby. If alcohol is ingested, breastfeeding should be avoided for at least 2 hours to allow the mother's body time to process the alcohol from the system.

A client who regains consciousness after passing out while jogging reports seeing and talking with a deceased spouse. Which response is the most appropriate for the nurse to make? 1. "Because your wife died 5 years ago, I don't think you really saw her." 2. "You were probably in a dream state, but everything is fine now." 3. "I'll get the psychiatrist to speak with you about this." 4. "Tell me how you feel about what just happened."

4. "Tell me how you feel about what just happened." - An open-ended response allows the client to explore and express thoughts and feelings. This is the most therapeutic response for the nurse to make. Think like a nurse: The client experienced a visual hallucination or dream that occurred while unconscious. The nurse needs to use therapeutic communication techniques and first assess how the experience affected the client.

A pregnant client tells the nurse about receiving a toy that requires walking as a present for the unborn child. The client asks the nurse when this toy would be appropriate for the child. Which response by the nurse is appropriate? 1. "That toy is good for a 3-month-old child." 2. "That toy is good for a 6-month-old child." 3. "That toy is good for a 12-month-old child." 4. "That toy is good for an 18-month-old child."

4. "That toy is good for an 18-month-old child." — The child would be able to enjoy the toy at 18 months, as the child will be able to walk and begin to coordinate movements Think like a nurse: Part of the nurse's role in working with parents of children is to provide objective information on childhood development and what to expect at each stage. A baby may begin to walk by 12 months of age. The ability to coordinate movements is expected to develop by 18 months of age. The nurse will want to ensure that the mother understands when the toy may be best used, to avoid safety risks or frustration. Teach the parents that age-appropriate toys during the first few months of life include mobiles (maintained at 8- to 10-inch distance from face), rattles, and a cradle gym.

The nurse visits the home of a client receiving carbidopa-levodopa. Which statement by the caretaker indicates to the nurse that the medication is effective? 1. "The client 's weight increased by 2 pounds." 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." — There is no cure for these symptoms that occur with Parkinson disease, but carbidopa-levodopa does reduce the rigidity and tremors. The medication helps facilitate mobility for the client. Think like a nurse: The nurse needs to use knowledge about the manifestations of the client's diagnosis and recall the purpose and mechanism of action related to the prescribed medication. The nurse will be assessing for the manifestations that indicate improvement. Carbidopa-levodopa is used to treat Parkinson disease, which affects dopamine levels in the brain, causing neuromotor deficits. Since the medication facilitates the replacement of dopamine, which is required for motor functioning, evidence that the medication is being effective would be an improvement in physical activity and mobility.

A nursing team discusses the new nurse manager's leadership style. The unlicensed assistive personnel (UAP) states, "The new nurse manager does not give us any direction or supervision." Which is an accurate response by the nurse? 1. "The nurse manager has an autocratic leadership style. It is best to not challenge the nursing chain of command." 2. "The nurse manager has a democratic leadership style. We will vote on all decisions in staff meetings." 3. "The nurse manager has a situational leadership style. Direction will be provided during a crisis." 4. "The nurse manager has a laissez-faire leadership style. Are there specific issues that you have questions about?"

4. "The nurse manager has a laissez-faire leadership style. Are there specific issues that you have questions about?" - This nurse manager is exhibiting a laissez-faire leadership style, which is one in which little direction is provided to the group. Many people feel confused and frustrated under this style of leadership. The nurse is responsible for supervising the UAP and should respond to any concerns that the UAP expresses. The nurse is acknowledging the situation and uses an open-ended question to elicit further concerns. Think like a nurse: The laissez-faire leadership style is characterized by behaviors such as permissiveness, provision of little or no direction, upward and downward communication between members, dispersed decision-making, and lack of criticism. The nurse should keep in mind that the leadership style has a great deal of influence on the climate and outcomes achieved by the nursing unit.

The parents bring their toddler into the emergency department (ED). The nurse observes that the client is having difficulty breathing and appears to be wheezing on inspiration. Which question is most important for the nurse to ask the parents? 1. "Is your child's immunization schedule current?" 2. "Do you or the child's siblings have a history of asthma?" 3. "What toy does your child like playing with the most?" 4. "Was your child eating anything immediately before developing breathing problems?"

4. "Was your child eating anything 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, grapes, or marshmallows. Think like a nurse: The nurse recognizes that the client is exhibiting signs of airway obstruction. Based upon the age and size of the client and the symptoms, the client could have aspirated a small piece of food. If the child was eating immediately prior to symptom onset, ask the parents if the child started coughing or choking. Observe the client's throat and assess for indicators of hypoxia, such as central cyanosis, a low oxygen saturation level, and an altered level of consciousness. If the presence of a foreign body is confirmed or highly suspected, a bronchoscopy for foreign body retrieval will be needed.

A client arrives at the emergency department experiencing tingling and weakness in the lower extremities that started when getting out of bed. The client reports the symptoms seem to be progressing upward. Which statement by the client 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." - This needs immediate further investigation. Immunizations may have been given in preparation for this trip and an immunization could trigger the onset of the neurologic symptoms of Guillain-Barré syndrome. The symptom onset in Guillain-Barré is usually abrupt and can progress rapidly. Symptoms often, but not always, progress in an ascending direction (from feet toward head). It is an emergency condition. The most immediate concern is potential respiratory compromise from respiratory muscle weakness.

The nurse provides information about acute grief reaction to volunteers of a mobile disaster unit. Which statement made by a volunteer indicates to the nurse the need to provide 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 a survivor is able to assist, the activity can help relieve the acute discomfort caused by the grief reaction. Think like a nurse. Survivors of a traumatic event may want to help other victims as a way to alleviate the grief of the disaster. This should be supported as long as the survivor is well enough to participate.

The nurse instructs a client about Kegel exercises to manage urinary stress incontinence. Which statement by the client indicates to the nurse that the teaching is effective? 1. "I will do the exercises for longer periods than required." 2. "When it is time to do the exercises, I will sit down." 3. "I will hold my breath as I am tightening my muscles." 4. "When I do the contractions I will pretend I am trying to stop passing gas."

4. "When I do the contractions I will pretend I am trying to stop passing gas." — Weakened pelvic floor muscles can cause urinary incontinence. Contracting these muscles, which is what occurs with Kegel exercises, strengthens them. Pretending to keep intestinal gas or flatus from escaping automatically use these muscles. Think like a nurse: Clients often are unable to isolate the muscles that are strengthened with Kegel exercises. One suggestion to help isolate the muscles is to teach the client to pretend to prevent flatus from escaping or to stop the urine stream when voiding. The exercises should be performed two to three times a day to prevent muscle fatigue. The exercises should be done while sitting, standing, or lying down.

The parents of a preschooler bring their child to the emergency department during flu season. The parents state that the child has been reporting abdominal pain, is nauseated and vomiting, and refuses to eat. Which question is most important for the nurse to ask the parents? 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, but in acute appendicitis the pain usually comes prior to nausea and vomiting. Nausea and vomiting that come before abdominal pain frequently indicate gastroenteritis. Think like a nurse: The nurse needs to be able to apply knowledge about disease processes and related symptoms. It is important to determine which symptom appeared first in order to differentiate the client's health problem between appendicitis or gastroenteritis. The appearance of abdominal pain as a primary symptom indicates appendicitis. Nausea and vomiting that occurs first indicates gastroenteritis.

The nurse in the ambulatory care clinic prepares to perform a venipuncture on a client diagnosed with Crohn disease. The client suddenly becomes upset and asks, "What are you really going to be injecting into my veins? " Which is the best responses by the nurse? 1. "Nothing. I 'm just going to draw some blood." 2. "What makes you think I'm going to inject anything into your vein?" 3. "It sounds like you had a bad experience with venipunctures before." 4. "You sound frightened. What are your specific concerns?"

4. "You sound frightened. What are your specific concerns? " — This response reflects feelings of the client, and allows the client to verbalize feelings and concerns. Think like a nurse: The nurse should be aware a chronic illness can cause the client to experience anxiety with even the most basic procedures. The nurse should consider the client's health problem before responding and mentally ask, "What can be done to lessen or eliminate the client's concern?" The best way to learn the client's concern is to ask an open-ended question that first reflects the client's behavior and then ask what might be causing the behavior. The client's feelings about the procedure need to be taken into consideration and the nurse needs to respond to the client's statement using a non-threatening approach.

A client with type 1 diabetes mellitus (DM) who delivered a healthy newborn asks how insulin needs will change with breastfeeding. Which response by the nurse is appropriate? 1. "You will need to change to an oral hypoglycemia agent that will control glucose levels more effectively than insulin." 2. "You will need to bottle feed your newborn since insulin received through breastfeeding may cause hypoglycemia in the child." 3. "Your need for insulin will increase while you are breastfeeding." 4. "You will have a decrease in your insulin dosage due to hormonal changes after delivery."

4. "You will have a decrease in your insulin dosage due to hormonal changes after delivery." - Insulin needs should decline rapidly after the delivery of the placenta and abrupt cessation of placental hormones. Blood glucose levels should be monitored at least four times daily so that the insulin dose can be adjusted to meet individual needs. Women with type 1 DM usually return to their pre-pregnancy insulin dosages. Think like a nurse: When caring for a postpartum client with type 1 diabetes mellitus, the nurse needs to recall the pathophysiology of the disease process and the impact it has on gestation. During pregnancy, the nurse is aware that insulin needs will increase to support both the client and developing fetus. Once the newborn is delivered, the need for the additional insulin will decrease. The client's blood glucose levels should be closely monitored immediately after delivery so that the insulin doses can begin to be adjusted.

A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse working on the postpartum/pediatric unit considers which client is most appropriate for discharge within the next hour? 1. A postpartum client who delivered 4 hours ago and has an intact perineum. 2. A postpartum client diagnosed with an infection who has been receiving antibiotics for the past 24 hours. 3. A toddler with newly diagnosed type 1 diabetes mellitus, diarrhea, and vomiting. 4. A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L).

4. A 3-day-old breastfeeding neonate with a total serum bilirubin of 14 mg/dL (239 µmol/L). - This is the most stable client. Phototherapy is considered for the neonate with a total serum bilirubin greater than 15 mg/dL (257 µmol/L) at 72 hours of age. The upper limit for the breastfed neonate is 15 mg/dL (257 µmol/L). Therefore, the current serum bilirubin level does not indicate the need for treatment. Think like a nurse: In response to such a disaster as a tornado, the hospital activates its emergency operations plan (EOP). Planning for coordinated care of clients into and out of the hospital is an essential component of the EOP. This involves identifying the clients which can be discharged to make beds readily available for disaster victims. A client with newly diagnosed diabetes mellitus, nausea, and vomiting requires frequent monitoring. A client with a postpartum infection receiving antibiotics for 24 hours may or may not be responding to treatment, and subsequently requires further monitoring. A postpartum client who delivered 4 hours ago is at risk for postpartum hemorrhage. A total serum bilirubin level of 14 mg/dL (239 µmol/L) in a neonate who is 3 days old and being breastfed falls within normal limits.

The nurse in the long-term care facility provides care for clients during an outbreak of Legionnaire disease. The nurse recognizes that which client is most at risk to develop the disease? 1. A 95-year-old client diagnosed with a fractured right hip. 2. An 85-year-old client diagnosed with a right- sided cerebrovascular accident. 3. A 75-year-old client diagnosed with Alzheimer disease. 4. A 65-year-old client diagnosed with end-stage kidney disease.

4. A 65-year-old client diagnosed with end- stage kidney disease. — Clients diagnosed with Legionnaire disease develop pneumonia caused by Legionella pneumophila. Risk factors include advanced age (50 years or greater), end-stage kidney disease, immunosuppression, diabetes, smoking, and pulmonary disease. The client has two risk factors: advanced age and end-stage kidney disease. This client is at highest risk of developing the disease. Think like a nurse: When evaluating the risk of disease development, the nurse will consider the risk factors for the disease and the number of risk factors that the client possesses. After counting the risk factors for each client, the nurse determines that the client most at risk for developing Legionnaire disease is the one with both advanced age and end-stage kidney disease. An additional risk factor for Legionnaire disease, though not applicable in this case, is recent travel with an overnight stay from the home. The nurse knows to monitor the client for signs of Legionnaire disease, which include fever, body aches, and cough.

The nurse observes an unlicensed assistive personnel (UAP) provide care for clients. Which observation by the nurse requires an intervention? 1. A small pillow is placed under the thighs of a client diagnosed with shortness of breath, and the head of the bed is elevated 60 degrees. 2. A pillow is placed under the head and neck of a client who is lying on the right side after a liver biopsy. 3. A client diagnosed with hemiplegia lies prone with the lower legs placed on a pillow. 4. A client diagnosed with a sacral pressure injury lies on the left side with the right leg extended and resting on the mattress.

4. A client diagnosed with a sacral pressure injury lies on the left side with the right leg extended and resting on the mattress. - This action is to be avoided by having the upper leg mildly flexed and resting on a pillow from groin to feet. A potential trouble area of the side-lying position is hip joints that are internally rotated, adducted, and unsupported. Think like a nurse. The nurse should identify client postures that could damage joint and motor function. When placing a client in the side-lying position, the upper leg should be flexed with the hip supported. A small pillow under the knees when in the high-Fowler's position prevents sliding towards the foot of the bed. A small pillow under the head when in the side-lying position prevents neck flexion. A pillow under the legs when in the prone position keeps pressure off of the toes.

The psychiatric nurse on the inpatient unit identifies which client situation as requiring the nurse's immediate attention? 1. A client taking clozapine for 2 months reports having a sore throat. 2. A client taking diazepam for anxiety asking for the medication on a regular basis. 3. A client taking lithium carbonate for ten days being observed to have frequent urination. 4. A client taking haloperidol for 4 days having a temperature of 102°F (38.9°C).

4. A client taking haloperidol for 4 days having a temperature of 102°F (38.9°C). - The fever may indicate impending neuroleptic malignant syndrome (NMS). NMS is a potentially lethal side effect of antipsychotic medications, especially high-potency drugs such as haloperidol. This is a medical emergency. Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. Using the Maslow hierarchy to evaluate physiological issues first, the nurse is most concerned when a client reports symptoms related to adverse effects, such as a high fever possibly caused by neuroleptic malignant syndrome (NMS). Neutropenia is a physiological concern too, but NMS is an emergency with high potential for quickly causing death. Ruling this out takes priority.

The nurse is assigned to provide care to four clients on the medical-surgical unit. After receiving change-of-shift report, which client does the nurse assess first? 1. A client admitted 3 hours ago with a gunshot wound and 1.5 cm area of dark red drainage noted on the dressing. 2. A client who underwent a mastectomy 2 days ago with 23 mL of serosanguinous fluid noted in the bulb-suction drain. 3. A client with a collapsed lung due to an accident and no drainage noted from the chest tube in last 8 hours. 4. A client who underwent an abdominal perineal resection 3 days ago and who reports chills.

4. A client who underwent an abdominal perineal resection 3 days ago and who reports chills. — This client is the highest priority for assessment. The client's assessment findings indicate a potential complication may be developing. The client who undergoes abdominal perineal resection is at risk for developing peritonitis. Because chills may indicate infection, immediate assessment of the client is indicated.

The triage nurse is prioritizing adult clients to be evaluated in the emergency department. Which client does the nurse assess first? 1. A client with a temperature of 100°F (37.8°C). 2. A client reporting arm pain after falling off a chair. 3. A client reporting vomiting for the past several hours. 4. A client with a persistent nosebleed.

4. A client with a persistent nosebleed. - Compromised circulation takes precedence over the other client needs. Think like a nurse: The client experiencing prolonged epistaxis requires assessment to ensure stability of airway, breathing, and circulation (ABCs). Persistent bleeding into the oropharyngeal cavity may compromise airway patency. Further assessment is needed to allow for estimating the client's blood loss and to determine the presence of circulatory compromise. If the client's vital signs and respiratory status are stable, the health care provider may attempt a tamponade in an effort to promote hemostasis. A severe nosebleed may be reflective of a serious pathophysiological condition and will require careful assessment.

The nurse in the outpatient clinic has four phone messages. Which message does the nurse return first? 1. An older adult client undergoing bowel prep reporting watery diarrhea. 2. A client with a newborn experiencing breast engorgement. 3. A client who had a cataract extraction 3 days ago reporting nausea. 4. A client with a spinal cord injury at the level of C6 reporting a headache.

4. A client with a spinal cord injury at the level of C6 reporting a headache. — A severe headache is indicative of autonomic dysreflexia in the client with a high-level spinal cord injury. Autonomic dysreflexia is associated with a dangerously high blood pressure, and, if untreated, can result in intracranial bleeding and death. The nurse should instruct the client to sit in high-Fowler position and should assess for triggers, such as bowel impaction or urinary retention. When deciding which client to call first, the nurse considers which client is at highest risk for harm by using principles such as stable versus unstable; the airway, breathing, circulation (ABCs) method; and real harm versus potential harm. The client with a spinal cord injury who is reporting a headache is likely unstable due to a circulation issue (dangerously high blood pressure that can lead to stroke and death). This client is priority over the client who is at risk for increased intraocular pressure.

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

4. A pearly papule with a central crater and a waxy border. 5. Location in the bald spot atop the head that is exposed to outdoor sunlight.

The nurse provides discharge teaching to a client recently diagnosed with asthma. Which prescribed medication should the nurse instruct the client to use during an acute asthma episode? 1. Fluticasone. 2. Guaifenesin. 3. Theophylline. 4. Albuterol.

4. Albuterol. - Albuterol is a fast-acting bronchodilator used for treatment of acute asthma episodes. Albuterol may be administered using a metered-dose inhaler or a nebulizer. Think like a nurse. Discharge teaching for a client with asthma includes a thorough explanation on how to use rescue (e.g., albuterol) and maintenance (e.g., ipratropium) medications. The nurse informs the client of potential side effects of albuterol, such as tachycardia, palpitation, or chest pain. The client is also taught how to use and to interpret findings from use of the peak flow meter. When the client is in the "red zone" based on the peak flow meter reading, the client should call 911 or report to the emergency department. The nurse should encourage the client to ask questions and should use the teach-back method in teaching.

The nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment is most critical for the nurse to perform before the procedure? 1. Height and weight. 2. Baseline peripheral pulse rates. 3. Intake and output. 4. Allergy to shellfish or iodine.

4. Allergy to shellfish or iodine. - This is a vital assessment because an allergy to the radiopaque dye used in the procedure may cause anaphylaxis. Think like a nurse: The nurse is aware that cardiac catheterization (e.g., coronary angiogram) requires the use of iodine-based contrast media. Clients who are allergic to shellfish may not get the iodine-based contrast media or require premedication with diphenhydramine IV prior to the procedure. It is also essential for the nurse to inform clients taking metformin to hold the medication 2 days before or after coronary angiogram to prevent kidney damage since metformin is nephrotoxic and the iodine-based contrast media is cleared by the kidneys. The nurse should review the client's baseline blood urea nitrogen (BUN) and creatinine. Typically, clients with acute or chronic kidney injury do not have procedures requiring contrast media due to the risk for kidney failure.

When completing an audit of medical records, the nurse determines that which client is at highest risk for developing hospital-acquired pneumonia? 1. An adolescent client who has diabetes mellitus (DM). 2. An adult client who has smoked for 2 decades. 3. A middle-age adult client diagnosed with hypertension. 4. An older adult client diagnosed with chronic obstructive pulmonary disease (COPD).

4. An older adult client diagnosed with chronic obstructive pulmonary disease (COPD). - The client's age and chronic lung disease place this client at highest risk for developing hospital-acquired pneumonia. Think like a nurse: Hospital-acquired pneumonia occurs due to aspiration of upper airway secretions, dental plaque, ventilator use, decreased immune system functioning, and increased exposure to infectious agents due to health care worker transmission between clients. Basic nursing care is required to prevent this pneumonia, including providing oral hygiene, frequently turning clients who are not alert, observing transmission-based precautions and hand hygiene, and advocating for the client by ensuring all staff, including health care providers, observe infection control standards.

The nurse admits a school-age client diagnosed with an open wound that tests positive for methicillin-resistant Staphylococcus aureus (MRSA). Which room assignment is appropriate for this client? 1. A semiprivate room with a toddler diagnosed with respiratory syncytial virus. 2. A semiprivate room with a preschool client diagnosed with acute respiratory virus. 3. A private room that is close to the nurse's station. 4. Any private room that is available.

4. Any private room that is available. - A private room is best for this client, as a client with MRSA can only room with another client who is also MRSA positive. There is no indication that the client requires close monitoring. Think like a nurse: It is ideal to place a client with a transmissible infection in a private room, even when it is not an infection that requires transmission precautions. The client on transmission precautions is never placed with a client who is immunocompromised or infected with a different transmission precaution illness. For example, a client with methicillin-resistant Staphylococcus aureus (MRSA) and a client with vancomycin-resistant enterococci (VRE) should never be assigned to the same room, and, preferably, are never assigned to the same nurse. Cross-contamination of antibiotic-resistant organisms can have lethal consequences.

The nurse provides care for a preschool-age client diagnosed with epiglottitis. Which action is appropriate for the nurse to implement? 1. Ask the unlicensed assistive personnel (UAP) to take the child to radiology. 2. Use a padded tongue blade to assess the child's gag reflex. 3. Obtain a blood culture and ABGs as prescribed by the health care provider. 4. Apply a pulse oximeter, and start an IV infusion.

4. Apply a pulse oximeter, and start an IV infusion. - Treatment for epiglottitis includes moist air and IV antibiotics to decrease epiglottal swelling. A pulse oximeter measures oxygen saturation to determine the need for supplemental oxygen. Think like a nurse: The nurse needs to review the manifestations and risks associated with the client's diagnosis. The nurse will plan care with the understanding that epiglottis is an acute inflammation and swelling of the upper region of the throat. Because of the location of the swelling, the client is prone to developing an occluded airway. The nurse will apply the principles of airway-breathing-circulation (ABCs) in formulating a plan of care. The client's oxygen saturation level should be monitored to evaluate effectiveness of respirations. Additional treatment includes fluid replacement and medication to address the infection which is causing the health problem.

The school nurse notes that an 8-year-old child experiences stomach aches that are relieved after the nurse contacts the parents at work. Which action is the most important for the nurse to take? 1. Ask the child what is eaten 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. - The nurse needs to validate anxiety, especially separation anxiety. The child may be worrying about the parents and is relieved when the nurse talks to the parents. Think like a nurse: The child is experiencing some form of separation anxiety. Finding out how the child behaves before leaving to go to school will help the nurse validate the source for the child's anxiety. It is premature to assume that the child is in danger and needs social service intervention.

The nurse attaches an external electronic fetal monitor to the abdomen of a pregnant client in labor. Which action does the nurse take next? 1. Determine the frequency of contractions. 2. Identify the types of accelerations. 3. Determine the intensity of contractions. 4. Assess the baseline fetal heart rate.

4. Assess the baseline fetal heart rate. - The baseline fetal cardiac rate is the most important initial assessment so that abnormal variations of the baseline rate can be identified, if they occur. Think like a nurse: When caring for a client in labor, the nurse needs to remember that there are two clients who require care. The mother's needs should be addressed; however, the viability and impact of labor on the fetus needs to be monitored closely. One way to ensure that labor is not causing stress to the fetus is through electronic fetal monitoring. The device monitors the fetal heart rate, which can be assessed for changes related to the length and strength of contractions. The first action for the nurse to take is to acquire a tracing of the fetal heart rate, which is used as a baseline reference for all future tracings.

A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take? 1. Utilize an organized team to place the client in seclusion. 2. Allow time in the client's private assigned room for reflection. 3. Redirect the client to a quiet activity such as journaling 4. Assist the client to express feelings of anger and frustration.

4. Assist the client to express feelings of anger and frustration. — This behavior indicates increased agitation and may indicate impending violence. The nurse de-escalates the client's behavior. The nurse will help the client to verbalize feelings, avoid disagreeing with or threatening the client, and remove threatening components of the environment. Think like a nurse: When clients, visitors, or staff are angry or upset, the nurse first seeks to defuse, or de-escalate, the situation. Strategies for defusing conflict include stating objective observations, such as "you seem frustrated," rather than immediately questioning an individual about details of the situation. At the height of conflict, asking "why" may be perceived as confrontational and can exacerbate a volatile situation. Acknowledging feelings and providing appropriate validation are effective strategies to help the individual feel heard and understood, which in turn may decrease the individual's sense of frustration.

The nurse provides care for a client with frequent premature ventricular contractions. Which assessment is most important for the nurse to complete on this client? 1. Causative factors such as caffeine. 2. Precipitating factors such as infection. 3. Sensation of palpitations. 4. Blood pressure and peripheral perfusion.

4. Blood pressure and peripheral perfusion. - Premature ventricular contractions can cause hemodynamic compromise. Blood pressure and peripheral perfusion would be assessed to anticipate and to monitor the effects of the condition. Think like a nurse: The nurse recognizes a premature ventricular contraction is indicative of a problem with the electrical conduction system within the client's heart. Specifically, the cardiac tissue responds inappropriately to the electrical impulse when it reaches the ventricles, which affects cardiac ventricular functioning. When considering which assessment is a priority for this client, the nurse recalls the pathophysiology of a premature ventricular contraction (PVC). Since the contraction is premature, the ventricle may not be adequately filled with blood before contracting and less blood moves through the vascular system, adversely affecting perfusion. Applying the principles of airway, breathing, and circulation (ABCs), the nurse will assess the blood pressure and adequacy of peripheral pulses.

A client returns to the unit following a pyelolithotomy through a flank incision. Which assessment finding does the nurse expect? 1. Breath sounds that are clear on the nonoperative side, diminished on the operative side. 2. Breath sounds that are diminished on the nonoperative side, clear on the operative side. 3. Breath sounds that are diminished on both sides. 4. Breath sounds that are clear on both sides.

4. Breath sounds that are clear on both sides. - This is an expected outcome. While the client post-pyelolithotomy is at risk for pleural effusion and lung puncture due to the site of the surgery, the expected outcome is clear breath sounds. Think like a nurse: The client had surgery to remove a kidney stone. The nurse needs to be aware of certain findings, postoperatively, that are expected, and others that may indicate the development of complications. Clear breath sounds indicate adequate oxygenation and ventilation. Because of the location of the incision, the client may hesitate to take deep breaths. The nurse must encourage the client to turn, cough, and take deep breaths to decrease the likelihood of developing complications post surgery, such as pneumonia, atelectasis, or pleural effusion.

The nurse discovers the IV infusion tubing disconnected from a central venous access device, and the client is coughing, short of breath, and cyanotic. Which action will the nurse take immediately? 1. Reconnect the tubing to the central venous access device. 2. Measure vital signs. 3. Notify the health care provider. 4. Clamp the central venous access device.

4. Clamp the central venous access device. -The nurse should immediately clamp the central venous access device to prevent further air from entering the client's circulation. Think like a nurse: Air embolism is a rarely encountered but much dreaded complication of surgical procedures, such as chest tube or central venous catheter (CVC) insertion. Signs and symptoms associated with serious air embolism are nonspecific and can be difficult to diagnose. However, the nurse recognizes that clinical symptoms include dyspnea, continuous coughing, and chest pain. Although small volumes of air in the venous system may be asymptomatic, for the arterial system, even small amounts of air can result in end-organ damage. During CVC insertion, the nurse anticipates placing the client in the Trendelenburg position to prevent air embolism. The nurse should periodically assess the integrity of the CVC throughout the shift.

A client needs continuing care after an abdominal hysterectomy. Which roommate is appropriate for the nurse to place this client? 1. Client recovering from a craniotomy for a brain abscess. 2. Client with cellulitis of the left leg. 3. Client with a methicillin-resistant wound infection. 4. Client recovering from gastric bypass surgery.

4. Client recovering from gastric bypass surgery. — The client recovering from gastric bypass surgery is the most comparable with the client recovering from abdominal surgery. Both clients require post-surgical care and are considered "clean. " These clients can safely share a room. Think like a nurse: A client recovering from surgery is at risk for infection because of the effects of anesthesia, the stress of the procedure on the body, and the fact that surgery is an invasive procedure. Before making the room assignment for the post-operative client, the nurse considers the available options. Any client with an infection is immediately ruled out as a potential roommate because of the risk for transmitting the infection to the client recovering from surgery. The only viable option is the client who is also recovering from surgery since the risk for infection for both of the post-operative clients is equal.

The nurse notes that a health care provider prescribed D5W 100 mL with 80 mEq KCl to infuse in 30 minutes. Which action does the nurse take first? 1. Assess the client's urinary output. 2. Ensure the patency of the client's IV. 3. Request a prescription for IV lidocaine. 4. Contact the health care provider.

4. Contact the health care provider. - The rate of IV administration should be no faster than 10 mEq/hr (20 mEq to 30 mEq per hour in highly specialized settings and only through a central venous line). The nurse first contacts the health care provider to clarify this prescribed dose. Think like a nurse: The client is prescribed a large dose of potassium chloride that should be administered at a rate so as not to cause cardiac irritation. This amount of potassium should also be infused through a central line. Because the type of intravenous access is not known and the dose is extremely large, the health care provider should be contacted for clarification of the prescription. The client has a low potassium level and is most likely not experiencing a decline in renal function. Potassium is irritating to the veins. Because of the dose, a central line may be used. If so, lidocaine would not be needed.

A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? 1. Fluid in the chest tube. 2. Fluctuation of fluid in the water-seal chamber. 3. Respiratory rate greater than 16 breaths/minute. 4. Continuous bubbling in the water-seal chamber.

4. Continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.

A client is prescribed pentamidine isethionate by the health care provider. Which observation best indicates to the nurse that the medication is effective? 1. Increased T-cell count. 2. Increased deep tendon reflexes. 3. Decreased bleeding and bruising. 4. Decreased crackles and dyspnea.

4. Decreased crackles and dyspnea. — Pentamidine is an anti-protozoal agent used to prevent or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunocompromised clients. The manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and crackles are heard in the lungs.

The nurse administers meperidine 25 mg IV to a client in labor. Which fetal heart rate (FHR) pattern does the nurse anticipate as a result of administering this medication? 1. Early decelerations. 2. Marked variability. 3. Late decelerations. 4. Decreased variability.

4. Decreased variability. — Opioid medications, such as meperidine, cause decreased variability by depressing the fetal central nervous system (CNS), which causes FHR to decrease. Think like a nurse: Any medication administered during labor has the potential to affect the fetus. Opioids depress the fetal central nervous system and, therefore, alter control of fetal heart rate. This effect is transient and minimal, but requires close monitoring for prolonged effect or fetal bradycardia. If non-reassuring variable decelerations are noted, the nurse repositions the client, administers a fluid bolus, supplies oxygen by facemask, and assesses the mother and fetus for other causes.

A client receives epoetin alfa for chemotherapy-induced anemia. For which medication complication will the nurse closely assess this client? 1. Chronic kidney disease. 2. Hyperkalemia. 3. Hypotension. 4. Deep vein thrombosis.

4. Deep vein thrombosis - It is important for the nurse to assess the client closely for signs of deep vein thrombosis or swelling, pain, and erythema of an affected limb as these are all adverse reactions associated with epoetin alfa therapy.

The nurse in the outpatient clinic receives a phone call from a young adult client who says a friend has overdosed. In caring for the overdosed client, which action does the nurse take first? 1. Instruct the friend to call emergency medical services. 2. Instruct the friend to call the Poison Control Center. 3. Find out what the client ingested and in what amount. 4. Determine if the client is responsive and alert.

4. Determine if the client is responsive and alert. — Ask the friend if the overdosed client is conscious, if there are breathing difficulties, and what the respiratory rate is. Guide the friend through this assessment. After assessing airway, breathing, and circulation, the nurse instructs the friend to notify emergency medical services (EMS). While waiting for EMS, the nurse can guide the friend and the client further, if needed. Think like a nurse: A drug overdose incident is an emergency. The nurse can first instruct the caller to verify if the client is responsive, and then to tell the caller to call 911 immediately. As a general guide in handling drug overdose, the nurse should assess and activate; check for unresponsiveness and call for nearby help; have someone to call 911 and get automated external defibrillator (AED) and naloxone. Observe client for breathing, versus not breathing or only gasping. If client is unresponsive with no breathing or only gasping, begin cardiopulmonary resuscitation (CPR).

The nurse provides care to a client who is prescribed an IV infusion of lactated Ringer (LR) solution for treatment of dehydration. The client appears restless and reports difficulty breathing. Auscultation of the client's lungs reveals bibasilar crackles. Which intervention does the nurse perform first? 1. Notify the health care provider. 2. Lower the head of the client's bed. 3. Administer furosemide as prescribed. 4. Discontinue the client's infusion.

4. Discontinue the client's infusion. - Manifestations of fluid volume overload include restlessness, dyspnea, and development of crackles (rales) in the lung bases. Priority interventions for the client who demonstrates signs and symptoms of fluid overload include discontinuing the infusion of IV fluids. Think like a nurse: The nurse will use knowledge about anatomy and physiology and the assessment step of the nursing process step to protect the client from harm. The nurse mentally asks, "What are the risks associated with administration of IV fluids?" and "What action is need to prevent harm to the client?" The nurse recalls that a sudden increase in fluid volume may overwhelm the circulation, and excess fluid may be routed to other areas of the body such as the lungs and peripheral tissues. If fluid is in the lungs, oxygenation and ventilation is affected, causing concern related to the ABCs. The nurse will implement action to protect the client's airway, breathing, and circulation. However, the priority action is to stop the infusion of fluid, which is the cause for the manifestations noted by the nurse.

When administering preoperative medication to a client, the nurse notices small insects crawling out of the closet where the client placed the suitcase. The client refuses to allow the nurse to inspect the suitcase. Which action by the nurse is best? 1. Notify security. 2. Kill the insects. 3. Inspect the client's suitcase. 4. Double-bag the client's suitcase.

4. Double-bag the client's suitcase. - This is the priority action in order to limit the area of contamination. Think like a nurse: The nurse should think quickly, "What action can I take that respects the client's rights and also protects the area from the small insects?" Sealing the suitcase in two plastic bags, using a double-bagging technique, contains the insects within the plastic bags preventing infestation of the surrounding area. Moreover, it protects the client's rights by complying with the client's wishes to not search the suitcase. Double-bagging the suitcase will eventually kill the insects. The nurse should notify the infection control department of the infestation, so they can gather additional information about the insects, and if needed, report the incident to the local department of health.

A client is recovering from a myelogram that used an oil-based contrast medium. Which action is most important for the nurse to take? 1. Apply ice packs to the puncture site. 2. Ambulate the client. 3. Monitor for seizures. 4. Encourage oral fluids.

4. Encourage oral fluids. — The nurse should encourage oral fluids because the client needs to replace fluids lost with the removal of the oil-based contrast medium. The nurse should also offer oral analgesics if the client experiences headache. Think like a nurse: For a myelogram, different types of contrast dyes, either oil-based or water-soluble, may be used. If an oil-based dye is used, the dye must be withdrawn after the myelogram (before the needle is removed). If a water-soluble dye is used, withdrawing the dye is not necessary because the dye can be absorbed by the body and excreted through the kidneys. If an oil-based contrast agent was used, the client must lie flat in bed for up to 12 hours, positioned with the head raised at least 30 degrees, after the procedure. The client is encouraged to drink clear fluids to avoid dehydration and to help flush out the contrast dye. If a lumbar puncture was done, extra fluids also help to speed the replacement of cerebrospinal fluid.

The nurse is assessing a client who is at 10 weeks' gestation. Which assessment finding does the nurse expect to see? 1. Striae and linea nigra on the abdomen. 2. Chloasma over the facial cheeks. 3. The client reports leg cramping at night. 4. Enlargement of the client's breasts.

4. Enlargement of the client's breasts. - Hypertrophy of mammary glandular tissue and increased vascularization, pigmentation, and size and prominence of nipples and areolae are caused by hormonal stimulation and begin early in the first trimester. Think like a nurse: Each stage of pregnancy is associated with predictable physiological and psychological changes. The nurse offers anticipatory guidance on these matters to reassure the client, to explain the anticipated changes, to differentiate expected changes from issues that need to be brought to the health care provider's attention, and to offer useful and evidence-based strategies for relief. For example, douching is avoided in pregnancy and is not used in response to increased vaginal discharge. Anemia can often be offset by increasing iron-rich foods, but the client should alert the health care provider about unreasonable fatigue and dizziness. Nocturnal leg cramps can be eased with positioning, dietary changes, and applying warm packs to the legs.

The nurse provides care to a client with an above-the-knee amputation (AKA). Which information is appropriate for the nurse to review with the client regarding how to care for the residual limb? 1. Apply cream to the residual limb every day. 2. Cover the amputation site with a nylon sock while awake. 3. Keep the residual limb elevated on a pillow at night. 4. Expose the amputation site to air daily.

4. Expose the amputation site to air daily. - Exposing the amputation site to air facilitates healing of the area. This also allows the client to inspect the incision site daily for pressure areas, dermatitis, and blisters. Think like a nurse: Proper residual limb bandaging fosters shaping and molding for eventual prosthesis fitting. A compression dressing is typically ordered to reduce edema, support soft tissues, and promote limb shrinkage and maturation. The delayed prosthetic fitting may be the best choice for clients who had above the knee or below the elbow amputations, older adults, debilitated individuals, and those with infections. For appropriate wound healing at the amputation site, the nurse should ensure the amputation site stays clean and dry, and teach the client to avoid placing any creams or non-cotton fabric on the site.

The nurse provides care for an older adult client who requires bilateral eye patches. Which action is appropriate for the nurse to take with this client? 1. Sedate the client until the eye patches are removed. 2. Place the client in a private room. 3. Maintain a calm, dark environment. 4. Frequently touch the client while speaking.

4. Frequently touch the client while speaking. — Nurses and other providers always speak to the client who is visually impaired when entering the room. This helps not to startle the client. Touching the client provides reassurance. Think like a nurse: The nurse needs to implement the integrated processes of caring, and therapeutic communication, including touch, with a client who has sensory changes. The nurse is aware the client is at risk for injury and an alteration in sensory stimulation. In this scenario, the client's eyes are being patched, removing the client's ability to see someone in the room. To enhance this client's sensory stimulation, the nurse should speak when entering the room, note the location in relation to the client, and gently touch the client when present.

The nurse counsels the mother of a school-age client who is diagnosed with laryngitis secondary to pharyngitis. Which intervention is appropriate for the nurse to suggest to the mother? 1. Instruct the child to come close and whisper when something is needed. 2. Encourage the child to take frequent sips of warm or cold milk. 3. Encourage the child to sing favorite songs while taking a shower. 4. Give the child a paper and pencil to communicate.

4. Give the child a paper and pencil to communicate. - Resting the voice for at least 24 hours or until the inflammation subsides is the most effective measure for healing laryngitis. The school-age child should be able to use paper and pencil to communicate needs effectively. Think like a nurse. The nurse will apply knowledge about anatomy and physiology when formulating client/parent teaching. The nurse knows that the client's diagnosis involves the larynx and interferes with normal speaking. The nurse instructs the client with laryngitis to rest the voice to promote healing. The client should be offered an alternate method of communication until the vocal cords heal. The nurse's teaching is appropriate because of the age of the client.

The nurse provides care for clients in the psychiatric unit. The nurse is concerned if a client receiving phenelzine sulfate eats which menu item? 1. Roast beef sandwich on white bread. 2. Fried chicken and green beans. 3. Boiled fish and whole milk. 4. Grilled cheddar cheese on wheat bread.

4. Grilled cheddar cheese on wheat bread. - Phenelzine sulfate (Nardil) is an MAOI, and eating aged cheese may cause a hypertensive crisis.

The nurse provides care to a client diagnosed with rheumatoid arthritis (RA). Which intervention will the nurse include in this client's plan of care? 1. Cold packs, immobilization, and hand splints. 2. Maintain flexion of the joints and proper body mechanics. 3. Analgesics, physical therapy, and a soft mattress on the bed. 4. Heat, range-of-motion exercises, and weight reduction.

4. Heat, range-of-motion exercises, and weight reduction. CORRECT- For the client with RA, the goal is to prevent contractures and minimize deformity with a balance of rest and activity. This includes using heat, range-of-motion exercises, and weight reduction if applicable.

A client is admitted to the hospital with an acute myocardial infarction. The client's spouse states, "There has been an issue with heavy drinking for years." Based on this data, the nurse observes the client for which symptoms? 1. Insomnia, hyperactivity, decreased appetite. 2. Lack of energy, avoidance, sense of failure. 3. Watery eyes, cramps, mild tremors. 4. Hyperalertness, easily startled, anorexia.

4. Hyperalertness, easily startled, anorexia. - Hyperalertness, easily startled, and anorexia are symptoms of early withdrawal from alcohol. Other symptoms include increased pulse, anxiety, tremors, insomnia, and hallucinations. Think like a nurse. When signs of acute alcohol withdrawal are first observed, a psychiatric consult should be initiated. Client safety and injury prevention are major nursing priorities when caring for a client with acute alcohol withdrawal. The client's room should be kept quiet with the television off (visitors should be reminded of this). The client is permitted to have visitors unless the client's behavior becomes aggressive. However, relaxing music can be played in the background, as long as the music does not cause agitation. When providing client care, the nurse should provide simple explanations, and questions should be kept to a minimum. The nurse should closely monitor for signs of aggression (e.g., facial expressions, suggestive body language).

The nurse provides care for a malnourished client who is diagnosed with anorexia nervosa. Which abnormality does the nurse expect the client's laboratory tests to reveal? 1. Hypercalcemia. 2. Hyperkalemia. 3. Hypouricemia. 4. Hypophosphatemia.

4. Hypophosphatemia. Hypophosphatemia, which refers to a decreased phosphate concentration in the blood, is often present in clients with anorexia nervosa who are malnourished. Clients with also be hypocalcemic, hypokalemic, and hyperuricemic.

When teaching a client diagnosed with chronic renal disease and heart failure about dietary management, the nurse recommends which action? 1. Increase intake of chicken and fish. 2. Drink 2 to 3 L of water each day. 3. Use salt substitutes rather than salt. 4. Increase intake of whole-grain pasta and breads.

4. Increase intake of whole-grain pasta and breads. - Increasing whole-grain carbohydrate intake helps the client to maintain energy requirements. Think like a nurse: Chronic kidney disease comes with many dietary restrictions and has the potential to significantly decrease clients' quality of life or causes them to decide to eat whatever they desire, ignoring the new, stricter renal needs. The nurse makes general recommendations, such as increasing intake of whole-grain carbohydrates, but then offers specific examples for the client's use and understanding, such as whole-grain bread and pasta.

The nurse in the prenatal clinic assesses a client at 38 weeks' gestation. The client reports an inability to get comfortable. Which statement by the nurse is appropriate? 1. Encourage the client to exercise vigorously to stimulate labor. 2. Tell the client to lie with back on a hard surface and feet elevated. 3. Suggest the client drink 12 ounces of water per hour while awake. 4. Inform the client that low-heeled shoes might help back discomfort.

4. Inform the client that low-heeled shoes might help back discomfort. — Because the client is at 38 weeks' gestation, there are changes in the curvature of the sacrum. Low-heeled shoes (or orthopedic shoes) may relieve back discomfort. Think like a nurse: Musculoskeletal pain is common during pregnancy. This is due to hormonal changes, muscle separation, postural changes, stress, and weight gain. Simple activities the client can do to relieve and prevent back pain include using legs to squat rather than bend over when picking up something from the ground, wearing low-heeled shoes, and wearing support hose. When sitting, the client is advised to use foot support and a pillow behind the back. The nurse should also explore and rule out other causes of back pain, such as uterine contractions, urinary tract infection, and musculoskeletal disorders

The nurse provides care to a client who is newly prescribed lithium carbonate 600 mg by mouth three times a day. Which finding causes the nurse to hold the next scheduled dose? 1. Serum lithium level of 1.2 mEq/L (1.2 mmol/L). 2. Increased urine output. 3. Fine hand tremors. 4. Loose stools.

4. Loose stools. - Diarrhea is a sign of lithium toxicity, along with oversedation, ataxia, tinnitus, slurred speech, and muscle weakness/twitching. The nurse should withhold the next prescribed dose and obtain serum levels when diarrhea occurs. Think like a nurse: Diarrhea or loose stools is an early indication of lithium toxicity. The client needs to have a lithium level drawn and should have the medication withheld until the level is known. Increased urine output and a fine tremor are expected side effects of lithium and do not indicate toxicity. A lithium level of 1.2 mEq/L (1.2 mmol/L) is within the expected range for initial management 1-1.5 mEq/L (1-1.5 mmol/L).

The nurse provides care for clients on the medical-surgical unit. The nurse notes that a client is anxious and in respiratory distress. In which position does the nurse place the client? 1. Flat on back with thighs flexed and legs abducted. 2. Lying with the head of the bed elevated 15 ° to 45°. 3. Lying on the left side with legs bent. 4. Lying with the head of the bed elevated 60 ° to 90°.

4. Lying with the head of the bed elevated 60 ° to 90°. - The high-Fowler position allows optimal pulmonary expansion. It also decreases venous return, which assists in lowering the ventricular output and pulmonary congestion. Think like a nurse: A simple maneuver to assist a client improve lung expansion in the event of respiratory distress is to sit the client up. The nurse should simultaneously obtain a full set of vital signs, perform a focused respiratory assessment, and apply supplemental oxygen as needed. Depending on the individual scenario, the nurse may activate the rapid response team (RRT). The nurse should not leave the client alone.

The nurse reviews the laboratory results of an older adult client diagnosed with a bacterial infection. Which result does the nurse expect to find? 1. Severe thrombocytopenia. 2. Elevated hematocrit. 3. Decreased hemoglobin. 4. Minimal leukocytosis.

4. Minimal leukocytosis. - Leukocytosis refers to an increase in the number of white blood cells (WBCs). Although a bacterial infection typically triggers an increase in the WBC count, up to 40% of older adults with serious infections may not develop leukocytosis. As a result, absence of leukocytosis in an older adult does not necessarily rule out an infectious process. Think like a nurse: When analyzing the laboratory results of an older adult client, the nurse should stop and recall age-related changes that can occur in the immune system. An older adult client will not necessarily have an increase in white blood cell count with an infection. This is due to the normal aging process of the immune system, which reduces the body's ability to develop white blood cells in the bone marrow. This adversely affects the older adult client's ability to fight an infection. The older adult client may also not develop a fever or demonstrate other signs of an infection that would be seen in a client younger in age.

The nurse in the emergency department provides care for a client experiencing a heroin overdose. The nurse administers naloxone to the client. The nurse anticipates which response? 1. Heart rate 74 beats/min and pallor. 2. Blood pressure 82/46 mm Hg. 3. Prolonged lethargic state. 4. Moderate volume emesis.

4. Moderate volume emesis. — Naloxone will cause signs and symptoms of opioid withdrawal: nausea, vomiting, restlessness, abdominal cramping. Think like a nurse: Clients who experience narcotic overdose will demonstrate shallow, slow respirations; flaccidity; and lethargy or unconsciousness. When naloxone is administered to a client for reversal of opioid overdose, the client may experience chest pain, seizures, vomiting, and diaphoresis as opioids are displaced from opiate receptors in the central nervous system. Administration of a reversal agent does not necessarily reverse all symptoms of the overdose. However, naloxone should reverse respiratory depression. The duration of action for naloxone is shorter than the duration of action of most opioids. As such, the client must be monitored for rebound opioid toxicity, especially respiratory depression. If necessary, administration of naloxone should be repeated as prescribed.

A client is prescribed an intravenous dose of naloxone hydrochloride 0.2 mg. Which action is essential for the nurse to perform after administering this medication? 1. Decrease external stimuli. 2. Encourage oral fluids. 3. Place in lateral recumbent position. 4. Monitor respiratory rate.

4. Monitor respiratory rate. — Naloxone hydrochloride is used to reverse narcotic-induced respiratory depression. The client 's blood pressure, respiratory rate, and heart rate should be assessed frequently. Think like a nurse: Naloxone hydrochloride is administered to clients experiencing respiratory compromise as a result of an opioid medication or illicit drug. The nurse assesses a client 's vital signs to determine effectiveness of this medication, particularly the client 's respirations. The duration of action of most opioid drugs will extend beyond the duration of naloxone effectiveness. After naloxone administration, the client experiences acute withdrawal symptoms. Within a few minutes, the client begins to calm as the naloxone wears off and the opioid can attach to the receptors and begin to work again. At this point, the client is in jeopardy of overdose effects recurring. The nurse monitors vital signs and likely administers a follow-up dose of naloxone.

The nurse provides care for a client receiving glipizide and prednisone. Which is the priority nursing assessment? 1. Monitor hemoglobin. 2. Monitor platelets. 3. Monitor photosensitivity. 4. Monitor serum glucose.

4. Monitor serum glucose. — Glipizide is an oral hypoglycemic that decreases blood glucose by stimulating insulin release from the beta cells of the pancreas. Prednisone is a corticosteroid that can cause hyperglycemia. Serum glucose level is the priority nursing assessment. Think like a nurse: The client is receiving an anti-hyperglycemic agent, which reduces blood glucose level. The client also receives a steroid that increases blood glucose level. This raises the risk that the client will have abnormal blood glucose, so the client's blood glucose level needs to be assessed. Glipizide can adversely affect hemoglobin and cause aplastic anemia. A complete blood count would be used to assess if this adverse effect is occurring. However, there is no indication that the client is experiencing a concern related to hemoglobin. Photosensitivity as an adverse effect of glipizide can occur, but this is not the priority.

The nurse obtains a history from a client who is prescribed rosuvastatin. Which client report is most important for the nurse to report to the health care provider? 1. Rash. 2. Headache. 3. Abdominal pain. 4. Muscle tenderness.

4. Muscle tenderness - Even though it is rare, one of the greatest risks to a client who is taking rosuvastatin (Crestor) is myositis, or muscle inflammation, that can progress to rhabdomyolysis. Therefore, a client report of muscle tenderness is the priority for the nurse to report to the health care provider. Think like a nurse: The nurse should recall the purpose, mechanism of action, and side or adverse effects of the prescribed medication. Rosuvastatin is a medication used to lower cholesterol. The nurse is aware medications in this classification (lipid lowering) has rhabdomyolysis as an adverse effect, which begins with muscle aching and soreness. Since the client is experiencing muscle tenderness, the medication will most likely need to be discontinued. The nurse should report the client's symptom to the health care provider for evaluation and adjustments in medication prescriptions.

The nurse on the surgical unit administers preoperative medication to a client scheduled for surgery. After administering the medication, the nurse discovers that the client has not signed the informed consent for the surgery. Which action does the nurse take next? 1. Call the operating room to cancel the surgery. 2. Ask the client to sign the consent form. 3. Transfer the client to the operating room. 4. Notify the health care provider.

4. Notify the health care provider. — The nurse should notify the health care provider. The risks and benefits of the procedure must be explained by the person performing the procedure. Think like a nurse: When preparing a client for surgery, the nurse must complete a checklist to ensure all required steps have been taken prior to the procedure. A review of the consent form is completed by the nurse during this process. The consent form for the surgical procedure must be signed by the client when the client is not influenced by potentially mind-altering medication. Because the consent form was not signed before the preoperative medications were provided, the health care provider needs to be contacted to determine the next steps.

The nurse prepares discharge teaching for a client diagnosed with paraplegia caused by a T4 spinal cord injury. Which instruction is most important for the nurse to provide to this client? 1. Watch for signs and symptoms of urinary tract infection. 2. Make a daily assessment of skin. 3. Perform range-of-motion exercises four times a day. 4. Observe respiratory function.

4. Observe respiratory function. — Spinal cord injuries at the level of T1 through T6 can cause decreased respiratory reserve. Respiratory function is a priority for this client. The client should be instructed to change position at least every 2 hours, and the skin should be inspected with repositioning. Range-of-motion exercises ensure joint mobility and function, and they prevent contractures. However, it is not the most important information to provide.

The nurse provides home care for an older adult client diagnosed with impaired hearing. Which action is most appropriate for the nurse to implement based on this data? 1. Checking expiration dates on food packages. 2. Providing large-print reading material. 3. Teaching the importance of changing position. 4. Obtaining an amplified telephone for the client.

4. Obtaining an amplified telephone for the client. — An amplified phone helps with hearing and provides a means for communicating more easily with others. Think like a nurse: When providing home care, the nurse needs to be concerned with client safety in the home environment. If a client has a sensory disorder, special interventions should be identified and implemented. A client with a hearing disorder may have difficulty hearing a doorbell or not be able to hear when using a telephone. In this situation, a special telephone, or a device attached to the telephone, can amplify the sound. Other actions may be required if the client has a vision disorder, but this is not the case in this scenario.

The nurse provides care for a client who sustained a fractured right femur. The client has a cast applied. Which type of exercise does the nurse assist the client to perform? 1. Passive exercises for the upper extremities. 2. Active range of motion exercise of the left leg. 3. Passive exercise of the right leg. 4. Quadriceps setting of the right leg.

4. Quadriceps setting of the right leg. — Isometric exercise contracts the muscle without movement of the affected joint. This exercise will help maintain strength of the leg. Think like a nurse: The nurse is aware that isometric exercises while wearing a cast are important in preventing complications such as poor circulation and swelling. The exercises should be performed at least three times a day. The simplest exercise is to have the client wiggle the toes. Isometric, non-weight-bearing exercises, where the muscles are made taut and then relaxed in a repetitive manner, help in maintaining the strength of the leg muscles and in preventing weakness and atrophy. The nurse might consider offering the client pain medication prior to performing the exercises, or recommending the client perform the exercises after receiving medication for injury-related pain.

The nurse leads an in-service on the ethical principle of beneficence and discusses the recent case of a client just diagnosed with breast cancer. Which is the best action for the nurse to take? 1. Make a treatment decision for the client. 2. Tell the client that the breast tumor is non-malignant. 3. Explain to the client about the right to privacy at this time. 4. Remain with the client when the client experiences anxiety.

4. Remain with the client when the client experiences anxiety. - Beneficence is taking positive actions to help others. This illustrates the principle of beneficence in action. Think like a nurse: Beneficence refers to the concept of doing good and preventing harm to clients. It requires the nurse to promote the well-being of the client. This principle presupposes compassion, taking positive action to help others, and the desire to do good. In certain health care situations when the team cannot do good, they should aim to do no harm.

A client who uses a triphasic birth control pill calls the clinic with reports of dull pain in the left lower extremity. The pain started after a routine 4-mile run and has continued. Which action does the nurse take first? 1. Instruct the client to elevate the leg for six hours. 2. Ask the client to apply a heat pack to the left leg. 3. Recommend the client take an anti- inflammatory medication. 4. Request that the client come to the clinic immediately.

4. Request that the client come to the clinic immediately. — Deep vein thrombosis (DVT) is an adverse effect of birth control pills. This client has symptoms of thrombosis and must be evaluated urgently. This action must be taken first to ensure proper diagnosis. Think like a nurse: Triphasic birth control pills have constant or changing estrogen concentrations and varying progestin concentrations throughout the cycle. The nurse should inform the client about the dangerous side effects of birth control pills using the mnemonic ACHES; A - abdominal pain (severe); C - chest pain; H - headaches (severe); E - eye disorders; and S - severe leg pain or lower leg swelling. Signs and symptoms of deep vein thrombosis (DVT) require prompt evaluation and treatment.

The nurse provides care for a child client with suspected sickle cell disease. Which laboratory result does the nurse expect to be increased in sickle cell disease? 1. Hemoglobin level. 2. Hematocrit level. 3. White blood cell count. 4. Reticulocyte count.

4. Reticulocyte count. - These counts are elevated in children diagnosed with sickle cell disease because the lifespan of their sickled red blood cells is shortened. Think like a nurse: The nurse should mentally review the pathophysiology of sickle cell disease. This disease causes red blood cells to assume a sickle shape, which alters oxygen-carrying capacity and enhances the ability of the cells to become trapped in capillaries, causing pain. The sickling of the red blood cells enhances the lysis of circulating red blood cells. In response to red blood cell destruction, the body accelerates the process of creating new replacement cells, which are released into the bloodstream before maturity. Because of the disease process, the laboratory result most likely to validate the disease would be a high reticulocyte count.

The nurse prepares a teaching plan for a client with open-angle glaucoma. Which information will the nurse emphasize with the client? 1. Limit eye movements. 2. Wear protective eyewear in sunlight. 3. Instill mydriatic eye drops every 4 hours. 4. Schedule periodic tonometer readings.

4. Schedule periodic tonometer readings — The client with open-angle glaucoma should have tonometer or eye pressure measurements one or two times a year. Normal intraocular pressure is 10 to 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; and pain, headache, nausea, and vomiting.

The nurse assesses a client's hearing by performing the Weber test. The nurse notes that the sound lateralizes to the client's right ear. Which interpretation does the nurse make? 1. Nystagmus will require further evaluation. 2. Conductive hearing loss in the left ear. 3. This is a normal finding to document. 4. Sensorineural hearing loss in the left ear.

4. Sensorineural hearing loss in the left ear. - During the Weber test, the sound from the vibrating tuning fork is heard equally in both ears by bone conduction. If the client has a sensorineural type of hearing loss in one ear, the sound is heard in the other ear.

The nurse provides care for a client with suspected scabies. The nurse expects which assessment finding? 1. Small circular patches of redness on the top of the head. 2. Vesicles or pustules with thick honey-colored crust. 3. Small pink bumps with a raised surface on the chest and limbs. 4. Several wavy or straight thread-like lines beneath the skin.

4. Several wavy or straight thread-like lines beneath the skin. — Several wavy or straight thread-like lines beneath the skin are caused by the female mite that burrows beneath the skin to lay eggs.

An infant is prescribed amoxicillin trihydrate 20 mg oral suspension every 8 hours by mouth. Which instruction will the nurse provide to the client 's parent? 1. Administer after feeding and burping. 2. Protect the medication from sunlight and warmth. 3. Add the medication to the child 's formula and allow it to stand for 5 minutes. 4. Shake the medication before giving it.

4. Shake the medication before giving it. — The medication particles are not totally dissolved in a suspension. The medication needs to be shaken before preparing a dose. Think like a nurse: For a client with a newly prescribed medication, focus instructions on the medication 's administration procedures, therapeutic effects, and adverse effects. Include instructions to shake amoxicillin to ensure delivery of the prescribed dose needed to treat the client 's condition. For the infant client, it is essential to instruct the parents to never mix a medication with formula or food unless specifically instructed to do so. This can alter the medication 's action, the client might not consume the entire dose, or the client may begin refusing the food or formula.

The nurse provides care to a client who is comatose. Which observation requires intervention by the nurse? 1. Feet rest against a board at the foot of the bed. 2. Pillow under the calves, elevating the legs. 3. Capillary refill time of the great toe is 3 seconds. 4. Skin over the ischial tuberosities appears blanched.

4. Skin over the ischial tuberosities appears blanched. — The absence of normal red tones in the skin indicates tissue ischemia due to reduction of blood flow. This area should not be massaged, but the client does need to be repositioned to take the body weight off of this area. Think like a nurse: Since 2016, the term pressure injury is used to describe what was formerly referred to as pressure ulcer. Clients who are bedfast and chairfast should be considered at risk for developing pressure injuries. As part of routine and ongoing care, the nurse should inspect all the skin upon admission as soon as possible (but within 8 hours). Inspect the skin at least daily for signs of pressure injury, especially nonblanchable erythema; and assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows, and beneath medical devices. The nurse should assess for changes in skin temperature, skin tone, and tissue consistency when assessing a client with darkly pigmented skin. Also, moistening the skin will aid the nurse in identifying color changes.

A client receives IV theophylline for an acute respiratory problem. Which observation alerts the nurse to withhold the medication and notify the health care provider? 1. Hypertension. 2. Unresponsiveness. 3. Polyuria. 4. Tachycardia.

4. Tachycardia. — Tachycardia is an adverse effect of theophylline. Theophylline levels above 20 mcg/L (111 µmol/L) are considered toxic. After long-term use, clients may tolerate a higher blood concentration. Other adverse effects include hypotension, nausea, and vomiting.

The nurse receives a phone call from a client at 29 weeks ' gestation who is experiencing heartburn throughout the day. Which suggestion does the nurse provide to the client to assist with heartburn? 1. Instruct the client to lie on her left side for 30 minutes after each meal. 2. Suggest the client add two slices of bacon to her breakfast meal. 3. Recommend the client drink two 16-ounce glasses of water with each meal. 4. Tell the client to eat six to eight small meals per day.

4. Tell the client to eat six to eight small meals per day. - The nurse should suggest that the client eat small, frequent meals throughout the day to facilitate gastric emptying and decrease heartburn. Think like a nurse: Slowed gastric emptying combined with relaxation of the esophageal sphincter and pressure from the enlarging uterus allows reflux into the esophagus, which causes heartburn during pregnancy. To reduce heartburn during pregnancy without hurting the fetus, the client is advised to eat slowly; avoid fried, spicy, or fatty foods; and avoid any foods that seem to cause relaxation of the lower esophageal sphincter and increase the risk of heartburn. Over-the-counter antacids will also help relieve symptoms, but the client should first consult with the health care provider.

An older adult client has a medical history that includes hypertension. A public health nurse visits this client regularly. Which finding does the nurse expect for this client? 1. Temperature 99.5°F (37.5°C), pulse 110 beats/min, respirations 32 breaths/min, blood pressure 140/80 mm Hg. 2. Temperature 98.6°F (37°C), pulse 78 beats/min, respirations 16 breaths/min, blood pressure 120/80 mm Hg. 3. Temperature 99.8°F (37.7°C), pulse 90 beats/min, respirations 20 breaths/min, blood pressure 150/90 mm Hg. 4. Temperature 96.8°F (36°C), pulse 80 beats/min, respirations 20 breaths/min, blood pressure 160/90 mm Hg.

4. Temperature 96.8°F (36°C), pulse 80 beats/min, respirations 20 breaths/min, blood pressure 160/90 mm Hg. - The temperature is usually lower in the older adult client due to a decrease in the basal metabolic rate. The BP is expected with a history of hypertension, particularly since there is no indication the client is being controlled with an anti-hypertensive.

The nurse provides care for clients on the medical and surgical unit. Which observation requires intervention by the nurse? 1. The health care provider prepares to insert the needle for a lumbar puncture at the level of the posterior iliac crest. 2. As the nurse leaves the client 's room, the nurse removes gloves and then the gown, folding the gown inside out. 3. The unlicensed assistive personnel (UAP) feeds a client while the client 's neck and head are flexed slightly forward. 4. The LPN/LVN repositions a client in Buck traction by first removing the traction weights.

4. The LPN/LVN repositions a client in Buck traction by first removing the traction weights. - Skeletal traction weights should never be removed without a health care provider prescription to do so, including when repositioning the client. Such an action would be painful for the client and would interrupt the line of pull. Think like a nurse: Traction (to pull) is based on simple mechanical principles. To apply traction effectively, there must be something to pull against, which is an effort to pull in the opposite direction. Buck traction is an example of running traction, in which the pulling force is in one direction and the patient 's body acts as countertraction. Traction should be continuous and not interrupted, even during client movement such as turning. Removing the weight could induce muscle spasms.

The charge nurse makes rounds on the psychogeriatric unit. Which situation requires immediate intervention by the charge nurse? 1. The dietary aide removes a full breakfast tray untouched by a client with major depression who is still in bed wearing night clothing. 2. The unlicensed assistive personnel (UAP) makes the bed while a client 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 client with bipolar disorder who is refusing to take prescribed medication. 4. The UAP places personal care items in reach of a client with Alzheimer disease and then leaves to fill the wash basin with water.

4. The UAP places personal care items in reach of a client with Alzheimer disease and then leaves to fill the wash basin with water. - The client with Alzheimer disease is at risk for choking on inedible items such as soap, lotions, and caps of sample bottles. Think like a nurse: Persons with Alzheimer disease face safety challenges. In working with this population, the nurse should scan the immediate surroundings for potential safety hazards. Preventing choking hazards is a priority. Depending on the client 's stage of Alzheimer disease, the nurse can determine the level of supervision required. Another important safety measure is to watch the temperature of water and food. It may be difficult for the person with dementia to tell the difference between hot and cold.

The nurse makes rounds on the medical unit to assess the care given by the unlicensed assistive personnel (UAP). Which observation requires an intervention by the nurse? 1. The UAP places the fingers of one hand on the wrist of a client in order to evaluate the respirations. 2. The UAP prepares to take a blood pressure in the left arm of a client recovering from a right mastectomy. 3. The UAP weighs a client on a standing scale while the client is balanced on crutches. 4. The UAP prepares to take an oral temperature on a client recovering from a rhinoplasty.

4. The UAP prepares to take an oral temperature on a client recovering from a rhinoplasty. - Rhinoplasty compromises the ability of the client to breathe through the nose due to the packing in both nostrils. If the client has to keep the mouth closed for an oral temperature measurement, the client cannot breathe. Think like a nurse: The nurse should evaluate and monitor the UAP's competency periodically. This will ensure the provision of high-quality and safe client care. Given that the client is unable to breathe through the nose due to the packing in both nostrils, the nurse should inform the UAP during the handoff report how the temperature can be taken (e.g., via the axilla). If the UAP is unfamiliar with caring for clients with rhinoplasty, the nurse should encourage the UAP to ask questions.

The nurse provides care for an adolescent client 1 day after insertion of Harrington rods. Which observation best indicates that the pain medication is effective? 1. The adolescent verbalizes the pain has decreased. 2. The adolescent refuses the pain medication. 3. The adolescent becomes agitated with visitors in the room. 4. The adolescent uses the incentive spirometer when requested.

4. The adolescent uses the incentive spirometer when requested. — Using the incentive spirometer indicates that the client can breathe without pain. "Decreased" is not a measurable outcome. It is not clear whether the pain medication is effective (has reduced the pain to goal level) or not.

The clinic nurse examines the fingernails of a new client who presents with pallor and reports fatigue, weakness, and dyspnea on exertion. Which assessment finding is of the most concern the nurse? 1. There are multiple small pits in the nail plate. 2. There are 1-mm-wide horizontal depressions in the nail plates. 3. The nail plate is concave, curving up from the nail-bed and appearing spoon-shaped. 4. The angle between the nail plate and the proximal nail fold is straightened to 180 degrees.

4. The angle between the nail plate and the proximal nail fold is straightened to 180 degrees. — This finding indicates early clubbing, a sign of hypoxia, a priority. With early clubbing, the nail base is also spongy upon palpation. There is normally a 160-degree angle between the nail plate and proximal nail fold, and the nail shape is normally convex. Straightening or flattening beyond 180 degrees indicates late clubbing.

The home health nurse is conducting a home safety assessment in the home of an older adult client who lives alone. Which observation made by the nurse requires follow up and teaching? (Select all that apply.) 1. The cleaning supplies are left unlocked under the kitchen sink. 2. The testing supplies for diabetes management are left on the kitchen counter. 3. The client purchases non-childproof caps that are easy to open for medications. 4. The bottom drawer on the client's nightstand is broken and will not stay closed. 5. The client has a weekly laundry service that delivers clean laundry inside the front door.

4. The bottom drawer on the client's nightstand is broken and will not stay closed. -The client may trip over the nightstand drawer when getting out of bed, which creates a risk for falls. This observation would require follow up and teaching by the nurse. 5. The client has a weekly laundry service that delivers clean laundry inside the front door. - The client may trip over laundry baskets or bags, which creates a risk for falls. This observation would require follow up and teaching by the nurse. Think like a nurse. A priority when planning care, including teaching needs, is client safety. An older adult client, who lives alone in the home, is at risk for falling. The nurse must carefully assess the environment, and plan care, to decrease this client's risk. A drawer that will not stay closed along with laundry bags in a walkway both increase this client's risk for falling. The nurse must address these issues as they impact the client's safety. The other situations do not represent a safety risk for the older adult client who lives alone in the home.

The nurse performs an assessment on a 42-year-old client. Which observation does the nurse expect to find? 1. The client's cognitive skills are beginning to decline. 2. The client is seeking to explore relationships. 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. — At 42 years old, the client is moving into Generativity vs. Stagnation. This stage is one in which self-questioning occurs, as the client reappraises the past and discards unrealistic goals. The client may choose to move in a new direction or re-focus on previously set goals. Think like a nurse: It is important for the nurse to understand the physical and psychosocial milestones across the lifespan. This information will enable the nurse to relate to the client and identify client needs. The nurse can apply the information appropriately, even if there is a big gap in age between the client and the nurse; this ability aids the nurse in critical thinking and clinical judgement. A client approaching middle age may question the direction of life and decide whether adjustments should be made to achieve identified goals and plans. This is considered a normal developmental process for someone of this age.

The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe? 1. The client is experiencing delusions of messianic grandeur. 2. The client believes that the world is ending on a specific date. 3. The client is experiencing persistent pain after the resolution of herpes zoster. 4. The client is experiencing blindness without an identified physical cause.

4. The client is experiencing blindness without an identified physical cause. - Conversion disorder is diagnosed when the client presents with neurologic symptoms such as blindness, deafness, or paralysis that cannot be explained by medical evaluation. Think like a nurse: The nurse understands that a conversion reaction is the development of a neurologic symptom without an identifiable reason. The client demonstrating blindness as a conversion reaction will have intact optic cranial nerve function, but will be blind. Additionally, a client diagnosed with a conversion reaction may report muscle paralysis, again, without an identifiable cause.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are: pH 7.53, PaO2 72 mm Hg, PaCO2 32 mm Hg, and HCO3- 28 mEq/L. Which conclusion about the client should the nurse make? 1. The client has acidotic blood. 2. The client is probably over reacting. 3. The client is fluid volume overloaded. 4. The client is probable hyperventilating.

4. The client is probable hyperventilating - The patient is experiencing respiratory alkalosis due to hyperventilation

The nurse provides care for a client after a left below-the-knee amputation. Which observation by the nurse requires immediate follow-up? 1. The client eats about half the food on the meal tray. 2. The client expresses an inability to concentrate when reading a book. 3. The client's pulses are palpable above the operative site. 4. The client reports persistent pain after receiving pain medication.

4. The client reports persistent pain after receiving pain medication. — Persistent pain after receiving pain medication may indicate a complication related to circulation, inflammation, or infection. This finding requires immediate follow-up by the nurse. Think like a nurse: Pain re-assessment is expected after the administration of pain medicine. Typically, the client should be re-assessed 30 minutes after parenteral pain medications and 60 minutes after an oral pain medication. Guidelines for pain management include the use of non-opioid therapies to the extent possible, identifying and addressing co-existing mental health conditions (e.g. depression, anxiety, PTSD), focusing on functional goals and improvement, and engaging clients actively in their pain management.

The home health nurse is planning to visit four clients who live within 3 miles of each other. Which client does the nurse visit first? 1. The newborn who is 20-hours-old, is being breastfed, and has not had a stool since birth. 2. The newborn who has a respiratory rate of 60 breaths/min when crying. 3. The client who is at 30 weeks' gestation, has gestational diabetes mellitus (GDM), and has a blood sugar of 78 mg/dL (4.3 mmol/L). 4. The client who is at 34 weeks' gestation with twins and is reporting intermittent low back pain.

4. The client who is at 34 weeks' gestation with twins and is reporting intermittent low back pain. - Many twins or higher multiples are born prematurely because the uterus becomes overly distended. Intermittent low back pain is a sign of labor. This client should be assessed first. - Meconium, the first stool of the newborn, may be passed anytime within 12 to 24 hours. Think like a nurse: The home care nurse who provides care for maternal/newborn clients has to make decisions that are the best for the mother and baby. When reviewing the list of clients to be seen, the nurse needs to mentally ask, "Which client situation is the most acute and requires immediate assessment?" Of the clients to be seen, the one that could potentially have the most risk is the client who is pregnant with twins experiencing low back pain. For some clients, lower back pain is the first sign that the client is in labor. The nurse must also consider that a multiple gestation places this client in a high risk category. Based on this data, the nurse must prioritize care for the pregnant client at 34 weeks' gestation.

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics and has tenting of the skin. 2. The client with an ileostomy from a recent abdominal surgery. 3. The client who requires intermittent gastrointestinal suctioning. 4. The client with kidney disease and a 12-year history of diabetes mellitus.

4. The client with kidney disease and a 12-year history of diabetes mellitus. - Causes of fluid volume excess: decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid loss, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium.. - Fluid volume deficit: the client taking diuretics and has tenting of the skin, the client with an ileostomy from a recent abdominal surgery and the client who requires intermittent gastrointestinal suctioning.

The nurse prepares to complete an initial assessment for a client who has an indwelling urinary catheter. Which observation indicates to the nurse a need for intervention? 1. The client's urinary drainage bag contains amber-colored urine. 2. The client's urinary drainage tubing does not contain a dependent loop. 3. The client's urinary drainage system is positioned below the level of the bladder. 4. The client's urinary drainage bag is secured to the client's sheet.

4. The client's urinary drainage bag is secured to the client's sheet. - The client's urinary drainage bag should be properly secured to the client's thigh (not the bed linen) to prevent catheter movement, which increases the risk for catheter-associated urinary tract infections. Think like a nurse: An indwelling urinary catheter may be placed for a variety of reasons. Prior to inserting this device, the nurse should review the physiology of the urinary system and the purpose for the catheter. Because the device is inserted into the body, there is a high risk for urinary tract infection, so the nurse is careful to perform the procedure using sterile technique. Once inserted, the catheter should be secured to the client's leg to prevent accidental dislodging and injury. And to ensure that urine flows unobstructed, the collection device needs to be placed lower than the level of the bladder. Clients with an indwelling urinary catheter are always placed on input and output measurements.

The nurse supervises the newly licensed nurse during the insertion of a vascular access device (VAD) on an older adult client. The client has a history of type 2 diabetes mellitus, diastolic heart failure, and a right mastectomy 15 years ago. The client has a BUN of 24 mg/dL (8.57 mmol/L), a blood pressure of 92/60 mm Hg, and a heart rate of 96 bpm. Which observation concerns the nurse? 1. The nurse inflates a blood pressure cuff to 46 mm Hg prior to insertion of the VAD. 2. The nurse places warm towels over the left forearm prior to insertion of the VAD. 3. The nurse strokes the left arm distal to proximal prior to the insertion of the VAD. 4. The nurse cleans the right hand with an antiseptic solution prior to insertion of the VAD.

4. The nurse cleans the right hand with an antiseptic solution prior to insertion of the VAD. — The client had a right mastectomy and the use of the right arm should be avoided. Also, even though the hand is often recommended, there is increased risk of hematoma and infiltration with an older adult client.

The nursing manager observes a graduate nurse conduct a physical examination on a newly admitted client. Which action made by the graduate nurse requires an immediate intervention by the nursing manager? 1. The nurse uses the ball of the hand to palpate for tactile fremitus. 2. The nurse depresses the client's tongue slightly off center when using a tongue depressor to inspect the uvula. 3. The nurse uses a stethoscope to palpate the client's abdomen, with fingers moving over the edge of the diaphragm. 4. The nurse completes inspection of the client's thorax for cardiac assessment and then begins auscultation.

4. The nurse completes inspection of the client's thorax for cardiac assessment and then begins auscultation. — The correct sequence during cardiac assessment is inspection, palpation, and then auscultation. Think like a nurse: The nurse needs to mentally review the correct order of processes before conducting a physical assessment. The nurse will need to consider what each process will do to the area being assessed. When assessing the client's thorax during the cardiac assessment, the order of assessment should be inspection, palpation, and auscultation. The nurse should palpate before auscultating heart sounds. However, when assessing the abdomen, the order becomes inspection, auscultation, and palpation. Palpating the abdomen prior to auscultation can change the characteristics of, or stimulate, bowel sounds.

The office nurse manager observes client and nurse interactions to assess staff education needs. The nurse administers iron dextran intramuscularly (IM) to the client with iron deficiency anemia. Which action alerts the manager to an education need? 1. The nurse adds 0.2 mL of air to the syringe after withdrawing the medication from the container. 2. The nurse pulls the skin to one side of the injection site and holds it while injecting the medication. 3. The nurse waits 10 seconds after injecting the medication before removing the needle. 4. The nurse penetrates the deltoid muscle site and injects the medication slowly and smoothly.

4. The nurse penetrates the deltoid muscle site and injects the medication slowly and smoothly. - Iron dextran needs to be injected into a large muscle, if this route is used. IV administration is preferred. The deltoid would be too small for this medication. Ensuring an air-lock clears excess medication from the needle and prevents the irritating iron dextran medication from leaking into the subcutaneous tissues and skin surface, either on injection or upon withdrawal of the needle.

A nurse driving home from work observes a car go off the road into a shallow embankment. Which client does the nurse advise the arriving paramedics to transport to the hospital first? 1. A crying infant restrained in a rear-facing child safety seat. 2. The restrained front seat passenger who has a laceration to the right side of his head. 3. The restrained rear seat adult passenger who has a deformity of the right forearm and who reports pain at the site. 4. The restrained driver who has faint discoloration around the umbilicus and reports abdominal pain.

4. The restrained driver who has faint discoloration around the umbilicus and reports abdominal pain. — Ecchymosis around the umbilicus or in either flank indicates retroperitoneal bleeding and is an emergency. This client takes priority for transport to the hospital. Think Like A Nurse: The nurse realizes that clinical judgement and critical thinking is driven by the integrated processes of nursing. To determine which client is the priority, the nurse should first assess the status of airway-breathing-circulation (ABCs) due to the emergent threat to life related to abnormal findings. In this scenario, all clients appear to be conscious and are not experiencing any issues with breathing. The client bleeding from the head has a superficial laceration, which is not life threatening. However, the client with abdominal ecchymosis is most likely experiencing bleeding from internal injuries. This is the priority client for emergency care.

The nurse provides care for the client diagnosed with septic shock. Which observation most concerns the nurse? 1. The peripheral pulses are strong and bounding and the 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 intravenous catheter.

4. There is blood at a venipuncture site and around an intravenous catheter. - The bleeding is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem. Sepsis is the most frequent cause of DIC. Like a nurse: Disseminated intravascular coagulation (DIC) is an adverse effect of septic shock. This complication causes bleeding, which would occur at the intravenous catheter insertion site. Early signs of shock include full and bounding pulses and a rapid respiratory rate. Signs that shock is progressing include cool, clammy, and pale skin.

The clinical nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristic as improvement in the manifestations of psoriasis? Select all that apply. 1. Presence of striae. 2. Palpable radial pulses. 3. Absence of any ecchymosis on the extremities. 4. Thinner and decrease in number of reddish papules. 5. Scarce amount of silvery white scaly patches on the arms.

4. Thinner and decrease in number of reddish papules. 5. Scarce amount of silvery white scaly patches on the arms.

The nurse discovers an older adult client on the floor of the waiting room in the outpatient clinic. The client is unconscious and not breathing but has a pulse. Which action does the nurse implement next? 1. Lift the back of the client's neck and check the airway. 2. Move the lower jaw backward and push the tongue to the side. 3. Turn the client's head to one side and shake the client firmly. 4. Tilt the client's head back and lift the chin.

4. Tilt the client's head back and lift the chin. — This opens the airway. The nurse should place a hand on the client's forehead, applying backward pressure. The nurse should place the fingers of the other hand under the client's chin and lift forward. Think like a nurse: The nurse understands that the first step of cardiopulmonary resuscitation (CPR) is to determine client responsiveness by tapping or shaking the client's shoulder and asking, "Are you okay?" If the client does not respond, the nurse knows to check for breathing while simultaneously performing a carotid pulse check for at least 5 seconds, but for no more than 10 seconds. For the pulseless client, the nurse understands the importance of high-quality CPR and early defibrillation if the client's cardiac rhythm is ventricular fibrillation or pulseless ventricular tachycardia.

One day after a coronary artery bypass graft (CABG), the nurse discovers a client sitting in a chair. The client is cool and pale, and responds only to loud verbal stimuli. Which action does the nurse perform first? 1. Perform a cardiac assessment. 2. Review documentation for abnormal findings. 3. Administer oxygen per nasal cannula. 4. Transfer the client back to bed with assistance.

4. Transfer the client back to bed with assistance. - The cool, pale client experiencing decreased levels of consciousness (LOC) needs to be reclining in bed to increase perfusion to the heart. The client's status indicates that the nurse must have assistance in moving the client. Transient changes in level of consciousness (LOC) can be due to hypotension. The client needs to be reclining in bed to increase perfusion to the heart. The nurse checks neurological function every 2 to 4 hours, in addition to conducting focused cardiac assessments. After caring for the client's immediate physiological needs, the nurse will review any relevant information. The first action is to transfer the client to a reclining position in bed to increase perfusion to the heart. The client may not need oxygen, but the nurse would assess and implement after transferring the client back to bed with assistance.

The nurse provides care for a client with a fear of flying. The client is taking a job that will require frequent long-distance travel. Which intervention is best for the nurse to recommend to the client? 1. Asking the health care provider for a prescription for lorazepam. 2. Suggesting insight-oriented therapy. 3. Calling the crisis hotline prior to a flight. 4. Using systematic desensitization.

4. Using systematic desensitization. — Systematic desensitization enables the client to encounter a phobic object gradually while using relaxation techniques. This will enable the client to be successful in the new role. Think like a nurse: The nurse needs to carefully analyze the client's situation and help determine a method of treatment that specifically meets the client's needs. The client's ability to fly will affect the client's success with a new job. The client needs a method of dealing with the phobia in a timely manner. One appropriate technique used to overcome a phobia is called systematic desensitization. This is where the phobia is broken down into separate parts and the individual is exposed to the parts in progression. For this client, this may mean going to an airport, going through security, sitting in the waiting area, entering an airplane, sitting in a seat, and then staying for an entire flight.

The unlicensed assistive personnel (UAP) reports that a client scheduled for surgery has a temperature of 102.5°F (39.1°C). Which action will the nurse take first? 1. Document the finding in the medical record. 2. Notify the health care provider immediately. 3. Administer acetaminophen per rectum, as prescribed. 4. Verify the temperature measurement.

4. Verify the temperature measurement. - The nurse should first verify the client's temperature to ensure accuracy before intervening. By doing so, the nurse prevents unnecessary intervention should the reported finding be in error. Think like a nurse: The nurse recognizes that an elevated temperature in a client being prepared for surgery can be an issue. The client could have an infection, which would need to be managed before the surgery. Prior to contacting the health care provider about the elevated temperature and plans for the surgery, the nurse should validate the measurement. Should the measurement be valid, the surgery will most likely be postponed, and the client will undergo testing to determine the source of the infection and receive treatment.

The nurse on the burn unit orients new staff to infection control issues. Which measure is most important to emphasize for this particular type of unit? 1. Wear gowns, gloves, masks, as well as shoe and hair covers. 2. Ensure that no equipment is shared between clients. 3. Assign clients diagnosed with infection to private rooms with negative-pressure air flow. 4. Wash hands using a thorough and consistent approach.

4. Wash hands using a thorough and consistent approach. — Correct and consistent handwashing is the single most effective technique for preventing infection transmission on burn units. This is the priority measure for the nurse to communicate. Think like a nurse: The nurse recognizes that any client with impaired skin integrity is at an increased risk for infection. Handwashing, in all settings, is the first line of defense against the transmission of microorganisms. When providing care to a client with a burn injury, hand hygiene should be performed according to established protocols. This includes washing the hands both before and after each instance of client contact and wound care.

The nurse prepares to teach a client recovering from a spinal fusion on how to move from a supine to standing position at the left side of the bed with a walker. Which direction by the nurse is appropriate? 1. Raise the head of the bed to sit straight up, bend the knees, and swing the legs to the side and then to the floor. 2. Rock the body from side to side, going further each time until enough momentum is built up to be lying on the right side, and then raise the trunk towards the toes. 3. Reach over to the left side rail with the right hand, pull the body onto the left side, bend the upper leg so the foot is on the bed, and push down to elevate the trunk. 4. With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress.

4. With the left elbow as a pivot, grasp the mattress edge with the left hand and push on the mattress with the right hand above the left elbow, and then slide the legs over the side of the mattress. — Using the arms maintains spinal alignment and prevents injury. Think like a nurse: The nurse forms a mental view of what needs to be done, paying particular attention to client safety and preventing injury. The nurse considers that spinal fusion is a complicated surgery and requires special post-operative care to maintain the incision and prevent rotation of the vertebra within the surgical site. The first action by the nurse is to assess the client's physical and psychological ability to implement the teaching. Once ability is determined, the client is coached to use the arms and the legs to move the body into position for standing. The nurse observes the client's ability to change position while protecting the surgical site.

The nurse administers insulin glulisine by subcutaneous injection to a client diagnosed with diabetes mellitus (DM). Which time after the injection will the nurse expect the greatest risk for hypoglycemia to occur? 1. 60 minutes 2. 30 minutes 3. 15 minutes 4. 12 minutes

60 Minutes - As insulin glulisine peaks, hypoglycemia risk is greatest. Insulin glulisine reaches its peak concentration 60 minutes after subcutaneous administration. Think like a nurse: The nurse needs to recall the purpose and mechanism of action of the prescribed medication. The nurse needs to be acutely aware that insulins have different onsets, peaks, and lengths of effectiveness, in order to be prepared for client reactions. For this client, the prescribed insulin will peak 1 hour after administration. The nurse needs to observe the client at this time to evaluate for signs of a hypoglycemic reaction, which includes lethargy, slurred speech, and cold, clammy skin. Specific knowledge regarding insulins is a safety consideration for the client.

The health care provider prescribes cefdinir 190 mg in oral suspension every 12 hours. The label reads 125 mg/5mL. How many milliliters does the nurse administer for each dose? (Round at the end of the equation. Record your answer using one decimal place. )

7.6 mL Ratio/Proportion: 190/x mL = 125/5 mL 5 ×190 = 125 mL 950/125 = 7.6 x = 7.6 mL Dimensional Analysis: x mL = 5 × 190/125 = 950/125 = 7.6 x mL = 7.6 Alternate Method: 125mg/5 mL = 25mg/mL 190mg/25mg = 7.6 mL

A client is prescribed IV penicillin G potassium 5 million units every 6 hours. The medication vial contains 3 million units/50 mL. How many milliliters will the nurse provide to the client in a single dose? (Round at the end of the equation. Record you answer using a whole number.)

83 mL 3,000,000/50 mL = 5,000,000/x 3,000,000x = 250,000,000 x = 83.88 or 83 mL ALTERNATE: (5/3) x 50 1.66667 x 50 = 83.33 or 83 mL

The charge nurse on the medical unit reviews the health care provider's prescriptions for four newly admitted clients. Which prescription does the nurse question? 1. A computed tomography (CT) scan for a client who has suspected intracranial bleeding. 2. A bone imaging study for a client diagnosed with multiple myeloma. 3. A chest x-ray for a client who has a positive tuberculin skin test. 4. An upper GI tract endoscopy for a client diagnosed with cirrhosis.

A bone imaging study for a client diagnosed with multiple myeloma - Every contrast medium has a risk for causing reactions, so the benefit versus risk of harm to the client should be considered. Multiple myeloma involves overproduction of plasma cells, with resultant destruction of bone and of bone marrow products. If a bone scan is done, false-negative results will occur. This means that the client would be exposed to potential harm with no benefit. Multiple myeloma is unique as a neoplastic condition in that it is better detected with a plain radiograph than with a nuclear scan.

The outpatient clinic nurse administers a tuberculin skin test (TST) to four adult clients. The nurse anticipates which client will likely demonstrate a false-positive response to the TST? 1. A client who received a herpes zoster (shingles) vaccine last week. 2. A client who received a bacille Calmette-Guerin (BCG) vaccine 1 month ago. 3. A client who regularly takes corticosteroid medication. 4. A client who was recently diagnosed with AIDS.

A client who received a bacille Calmette-Guerin (BCG) vaccine 1 month ago - Clients who receive a BCG vaccine, which prevents against the development of tuberculosis (TB), may demonstrate a false-positive response to a TST.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? 1. An inflammation of the dermis only. 2. A skin infection of the dermis and underlying hypodermis. 3. An acute, superficial infection of the dermis and lymphatics. 4. An epidermal and lymphatic infection caused by Staphylococcus.

A skin infection of the dermis and underlying hypodermis. - Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. - Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics.

The nurse provides care for a client receiving 40 drops per minute of 0.9% sodium chloride. The IV set delivers 10 drops per mL. If the nurse begins infusing 1000 mL of IV fluid at 1200, how many milliliters of fluid will be remaining at 1530? (Record your answer rounding to the nearest whole number.)

ANSWER: 160 mL - 40 drops per min./10 drops per ml = 4 ml/min - 3.5 hrs x 60 mins = 210 mins - 210 mins x 4 ml/min = 840 ml - 1000 minus 840 = 160 ml at 330 pm

One minute after delivery, the newborn's heart rate is 124 beats/min, central color is pink, hands are blue, and moderate flexion of upper and lower extremities is noted. The infant cries vigorously and grimaces in response to nasal suctioning. Which Apgar score does the nurse assign to the newborn? 1. 6 2. 7 3. 8 4. 9

ANSWER: 7 — The 10-point Apgar scoring system is used to evaluate a newborn's physical condition physical condition after delivery at 1-minute and 5-minute intervals. The newborn's Apgar score is 7. A heart rate above or equal to 100 is scored at 2 points. For a pink body with blue extremities, which is normal at birth, 1 point is assigned. Some flexion of extremities is scored at 1 point. For a vigorous cry, 2 points are assigned. A score of 1 point is assigned for grimacing in response to nasal or oral suction, stroking the back along the spine, or tapping the soles of the feet.

The nurse assesses the client diagnosed with seizures, migraines, and type 1 diabetes mellitus (DM). Which client statement requires follow up by the nurse? (Select all that apply.) 1. "I see fireflies around my head." 2. "I can't seem to wake up today." 3. "My hands won't stop shaking." 4. "I usually give myself the insulin." 5. "I usually sleep after a seizure."

ANSWERS: 1, 2, 3 EXPLANATION: 1. "I see fireflies around my head." — This client statement requires follow up by the nurse. Flashing lights may indicate aura before the seizure or a migraine. 2. "I can't seem to wake up today." — This client statement requires follow up by the nurse. Hypersomnia or fatigue may indicate hyperglycemia, an adverse effect of poorly managed type 1 DM. 3. "My hands won't stop shaking." — This client statement requires follow up by the nurse. Tremors may be associated with hypoglycemia, an adverse effect associated with type 1 DM. Think like a nurse: The client with seizures, migraines, and diabetes mellitus has significant nursing management needs, and symptoms of complications may overlap and cause confusion. Additionally, this client may be on multiple medications that also have interaction potential. The client's glucose must be tightly controlled. The brain is very sensitive to glucose levels and changes in stimulation of the central nervous system is avoided in the client with migraines or seizures.

The nurse provides care for a client 24 hours after an ischemic stroke. The nurse notes a BP of 222/128 mm Hg, a radial pulse of 92 beats/min, a respiratory rate of 22 breaths/min, a temperature of 98.9°F (37.2°C), and an oxygen saturation of 96%. Which actions are appropriate for the nurse to implement in this situation? (Select all that apply.) 1. Provide supplemental oxygen of 2 L/min by nasal cannula. 2. Contact the health care provider. 3. Administer intravenous labetalol as prescribed. 4. Place the client in high-Fowler position. 5. Increase intravenous flow rate to 100 mL/hr.

ANSWERS: 1, 2, 3 EXPLANATION: 1. Provide supplemental oxygen of 2 L/min by nasal cannula. - Supplemental oxygen may increase the oxygen reaching damaged brain tissue. Providing supplemental oxygen is done for clients diagnosed with a cerebral vascular accident (CVA) regardless of oxygen saturation or respiratory symptoms. 2. Contact the health care provider. - The health care provider should be notified of the client's current blood pressure, which is indicative of a hypertensive emergency. 3. Administer intravenous labetalol as prescribed. - Labetalol is among the list of IV medications used to treat hypertensive crises. It is given PRN. Think like a nurse: Hypertension after a stroke is common, as typical blood pressure regulatory mechanisms are impaired. For the client who experiences a stroke, avoidance of extremes in blood pressure (both hypotension and hypertension) is important. However, a slightly elevated blood pressure may be beneficial to restoring cerebral perfusion. Maintenance parameters for the client's blood pressure will be prescribed by the health care provider (HCP). Significant hypotension or a sudden decrease in blood pressure can cause decreased perfusion of vital organs. As such, for the client who requires interventions to decrease blood pressure, the nurse should proceed with caution. Gradual reduction of blood pressure is achieved by administering small doses of IV anti-hypertensive medication as prescribed. Supportive care may include oxygen administration. Notify the HCP of changes in the client's status.

The nurse provides care for the client in the post-anesthesia care unit (PACU). Which assessment finding requires the nurse to contact the health care provider (HCP)? (Select all that apply.) 1. The client experiences coarse, crowing respirations. 2. The client's respiratory rate is 10 breaths/min. 3. The client is disoriented and has oliguria. 4. The client is restless and shouting. 5. The client's core temperature is 94.8 ºF (34.89 ºC). 6. The client's blood pressure is 110/69 mm Hg.

ANSWERS: 1, 2, 3, 4, 5 1. The client experiences coarse, crowing respirations. — Coarse, crowing respirations require the nurse to contact the HCP. Stridor indicates laryngospasm, which is an emergent airway complication. 2. The client's respiratory rate is 10 breaths/min. — A respiratory rate of 10 breaths/min requires the nurse to contact the HCP. Hypoventilation related to anesthesia and opioids indicates an oxygenation complication. 3. The client is disoriented and has oliguria. — Disorientation with oliguria requires the nurse to contact the HCP. Oliguria is a sign of hypoperfusion and indicates a circulation complication. Disorientation deepens the nurse's concern about this client. 4. The client is restless and shouting. — Restlessness and shouting require the nurse to contact the HCP. The emergence of restlessness may be neurological or a sign of an impending and emergent oxygenation or perfusion issue. 5. The client's core temperature is 94.8 ºF (34.89 ºC). — A core temperature below normal requires the nurse to contact the HCP. Hypothermia can increase risks and increases oxygen consumption. Think like a nurse: The immediate post-operative period is critical for monitoring the client for serious complications. The priority assessment and management is focused on airway, breathing, and circulation (ABC). The initial assessment should cover all the major body systems and the operative wound. The nurse needs to be aware of signs of inadequate oxygenation (e.g. changes in mental status and behavior). The nurse should escalate the scenario to the next level to get the client evaluated by the surgeon or anesthesiologist.

The nurse reviews the results of a client's urinalysis. The client's urine is yellow in color and appears hazy. Specific information obtained includes: glucose negative, bilirubin negative, ketones negative, specific gravity of 1.025, pH 6.0, protein negative, occasional RBCs, and 20 to 30 WBCs/hpf (high power field). Which questions does the nurse ask the client based on this data? (Select all that apply.) 1. "Are you experiencing pain with urination?" 2. "How much water do you drink each day?" 3. "Have you ever had a urinary tract infection?" 4. "Are you experiencing urinary frequency?" 5. "Are you experiencing abdominal discomfort?" 6. "How many carbohydrates do you eat each day?"

ANSWERS: 1, 2, 3, 4, 5 EXPLANATION: 1. "Are you experiencing pain with urination?" CORRECT - The urinalysis results indicate that the client may be experiencing a urinary tract infection (hazy appearance with white blood cells present). The nurse should assess for symptoms of urinary tract infection (UTI). Some clients may experience asymptomatic bacteriuria, which in the absence of symptoms, should not be treated. The nurse may also consider urinalysis contamination (from nonsterile container or inadequate genital cleansing) if the client has no symptoms. Pain with urination would be a symptom of a UTI. 2. "How much water do you drink each day?" CORRECT - The client should drink adequate oral fluids to flush bacteria from the urinary tract. The client's current urine specific gravity is on the concentrated side, suggesting that the client may not be drinking enough fluids. This would place the client at higher risk for UTI. The normal urine specific gravity range is 1.010 to 1.030. The higher the number, the more concentrated the urine. 3. "Have you ever had a urinary tract infection?" CORRECT - Previous urinary trauma or infection increases the risk of a UTI. 4. "Are you experiencing urinary frequency?" CORRECT - Urinary frequency is a symptom of a UTI. 5. "Are you experiencing abdominal discomfort?" CORRECT - Abdominal pain or discomfort is a symptom of UTI. 6. "How many carbohydrates do you eat each day?" INCORRECT - This is not related to urinary tract problems or infections. The client has negative ketones and negative glucose, which does not support a diagnosis of diabetes mellitus. Think like a nurse: The urinalysis results indicate a possible urinary tract infection. Subjective data to support this possibility includes asking about pain with voiding and presence of urinary frequency or abdominal discomfort. The nurse should assess if the client has a history of urinary tract infections and ask for the amount of water and other fluids ingested throughout the day.

The home care nurse provides care for the client diagnosed with stage 3 heart failure (HF). Which measure is included in the plan of care? (Select all that apply.) 1. Instruct the client to check weight daily. 2. Educate the client on a low-sodium diet. 3. Review the prescription for daily digoxin therapy. 4. Institute a cardiac rehabilitation program. 5. Assess for adverse effects of an angiotensin converting enzyme (ACE) inhibitor. 6. Teach the client when to stop taking medications.

ANSWERS: 1, 2, 3, 4, 5 EXPLANATION: 1. Instruct the client to check weight daily. — This is appropriate to include in the plan of care. Daily weights can predict fluid retention and HF exacerbations. 2. Educate the client on a low-sodium diet. — This is appropriate to include in the plan of care. A low-sodium diet reduces fluid retention and decreases the risk of HF exacerbation. 3. Review the prescription for daily digoxin therapy. — This is appropriate to include in the plan of care. Digoxin decreases cardiac workload but should be monitored carefully. 4. Institute a cardiac rehabilitation program. — This is appropriate to include in the plan of care. Exercise may improve cardiac function and decreases the risk of HF exacerbation. 5. Assess for adverse effects of an angiotensin converting enzyme (ACE) inhibitor. — This is appropriate to include in the plan of care. ACE inhibitors are first-line medication therapy for HF, but they require careful assessment for adverse effects such as hyperkalemia (especially when administered with digoxin) and angioedema. Think like a nurse: Heart failure affects all body systems. Nursing care should focus on actions to reduce fluid retention, fatigue, and respiratory distress. Daily weights assess fluid balance. A low-sodium diet is appropriate to reduce accumulation of excess fluid. Digoxin is a cardiac glycoside that is used to decrease cardiac workload. Cardiac rehabilitation is appropriate once the client stabilizes. This program improves cardiac function and reduces the risk of exacerbations. ACE inhibitors are prescribed for heart failure. However, the client should be monitored for the development of adverse effects.

The nurse teaches parents of children prescribed atomoxetine. Which information does the nurse include in the teaching? (Select all that apply.) 1. "There is a low risk of dependence with this medication." 2. "Your child may take atomoxetine with or without food." 3. "Record your child's weight weekly." 4. "Offer your child fresh fruits and vegetables daily to prevent constipation." 5. "Atomoxetine should not be taken by children under 95 pounds." 6. "Risk of suicidal thoughts may occur in children taking atomoxetine."

ANSWERS: 1, 2, 3, 4, 6 EXPLANATION: 1. "There is a low risk of dependence with this medication." -Atomoxetin is prescribed for attention deficit hyperactivity disorder (ADHD). When compared with other medications available to treat ADHD, atomoxetine has a low risk for dependence. 2. "Your child may take atomoxetine with or without food." - This is correct information. 3. "Record your child's weight weekly." - Even though atomoxetine is not a stimulant, anorexia may occur, so parents should monitor their child's weight. 4. "Offer your child fresh fruits and vegetables daily to prevent constipation." - Atomoxetine may cause constipation. Increasing the intake of fresh fruits and vegetables (high in fiber) will help to alleviate this side effect. 6. "Risk of suicidal thoughts may occur in children taking atomoxetine." - Suicidal ideation is an adverse effect of atomoxetine that may occur. Parents should monitor their child's mood. Think like a nurse: Medication teaching supports adherence and ensures the maximum effect of the prescription. Atomoxetine, a medication used to treat attention deficit/hyperactivity disorder, has a low risk for dependence. This medication can be taken with or without food and weight should be monitored because of anorexic effects. Constipation and suicide ideation can occur when taking this medication and actions should be taken to prevent the development of both.

The nurse teaches a client how to obtain accurate blood pressure (BP) measurements at home. Which factors will the nurse include as causing a false high BP reading? (Select all that apply.) 1. Using a cuff that is too short. 2. Repeating assessments too quickly. 3. Positioning the brachial artery below the heart. 4. Using a cuff that is too wide. 5. Deflating the cuff too quickly.

ANSWERS: 1, 2, 3, 5 EXPLANATION: 1. Using a cuff that is too short. - A cuff that is too short may cause a false high reading. 2. Repeating assessments too quickly. - Repeating assessments too quickly may cause a false high systolic reading. 3. Positioning the brachial artery below the heart. - If the arm is positioned below heart level, it may cause false high reading. 5. Deflating the cuff too quickly. - Deflating the cuff too quickly may cause a false high diastolic reading, as the last sound may be missed. Think like a nurse: The nurse should ensure that the client has an appropriately sized blood pressure (BP) cuff. A cuff that is too short may cause a falsely elevated measurement. The client should place the arm at the level of the heart. If the arm is below the level of the heart, the reading will be falsely elevated. The client should release the pressure in the cuff slowly, as releasing it too fast may cause a falsely elevated diastolic measurement since the last sound may be missed.

The nurse provides teaching to the parents of a newborn. Which parent statement requires an intervention by the nurse? (Select all that apply.) 1. "Since our baby seems to prefer formula to breast milk, I will stop breastfeeding." 2. "We will feed our baby formula until my breast milk comes in." 3. "If our baby continues to suck after the feeding, we can use a pacifier to soothe our baby." 4. "We will not give our baby a pacifier, due to an increased risk of sudden infant death syndrome (SIDS)." 5. "I will call the health care provider's office if my baby does not have at least six wet diapers per day." 6. "I will not worry if our baby's bowel movements are sticky and black at first."

ANSWERS: 1, 2, 4 EXPLANATION: 1. "Since our baby seems to prefer formula to breast milk, I will stop breastfeeding." — The nurse should recommend that the parents not offer formula if breastfeeding. The newborn may become confused and refuse breast milk. 2. "We will feed our baby formula until my breast milk comes in." — Parents planning to breastfeed should not offer formula. The newborn will obtain nutrient-rich colostrum before the breast milk comes in. 4. "We will not give our baby a pacifier, due to an increased risk of sudden infant death syndrome (SIDS)." — Pacifier use is associated with a reduced risk of SIDS, not an increased risk. Think like a nurse: Newborn feeding is a priority for teaching. The mother should decide the feeding approach to use and follow it consistently. This means if the mother is breastfeeding, formula should not be introduced. Pacifiers are encouraged since they help soothe the newborn, and evidence suggests they help reduce the incidence of sudden infant death syndrome. Evidence of adequate nutrition and hydration in a newborn includes at least six wet diapers each day. Bowel movements that are sticky and black indicate passing of meconium, an expected type of bowel movement in a newborn.

The client diagnosed with sickle cell anemia is admitted to the hospital for a vaso-occlusive crisis. The nurse reviews admission prescriptions. Which prescriptions does the nurse question? (Select all that apply.) 1. Restriction of oral fluid intake. 2. Water aerobic therapy for joint pain. 3. High calorie, high protein diet. 4. Acetaminophen 10 mg/kg every 6 hours as needed for pain. 5. Oxygen via nasal cannula at 2 L/min.

ANSWERS: 1, 2, 4 EXPLANATIONS: 1. Restriction of oral fluid intake. - In vaso-occlusive crisis, IV and oral fluids are the primary treatment to reduce blood viscosity. The nurse needs to question this prescription. 2. Water aerobic therapy for joint pain. - In vaso-occlusive crisis, activity is limited to decrease oxygen needs, which prevents further sickling. The nurse needs to question this prescription. 4. Acetaminophen 10 mg/kg every 6 hours as needed for pain. - Vaso-occlusive crisis is characterized by severe pain. A combination of opioid and nonopioid therapy are used for management of mild to moderate pain, whereas opioid analgesics are used for severe pain. The nurse needs to question this prescription. Think like a nurse. Treatment of this disorder includes fluids to reduce blood viscosity and improve circulation. The altered shape of the red blood cells affects oxygen-carrying capacity. As such, activity should be limited or restricted. The client will experience severe pain and should be prescribed opioid analgesics.

The nurse provides care to a client with an external fixator device to stabilize a fractured femur. Which assessment findings concern the nurse? (Select all that apply.) 1. Pain distal to the injury that is not relieved by opioid analgesics. 2. Paresthesia distal to the area of injury. 3. Reports of pain at pin insertion sites. 4. Toes on affected leg edematous and cool to touch. 5. Weak pedal pulse strength in affected leg.

ANSWERS: 1, 2, 4, 5 EXPLANATION: 1. Pain distal to the injury that is not relieved by opioid analgesics. CORRECT- Unrelenting pain is a characteristic of compartment syndrome. 2. Paresthesia distal to the area of injury. CORRECT- Parethesia is a characteristic of compartment syndrome. 3. Reports of pain at pin insertion sites. INCORRECT - Pain at the pin insertion sites is not a characteristic of compartment syndrome. 4. Toes on affected leg edematous and cool to touch. CORRECT- Cold and edematous extremity are characteristics of compartment syndrome. 5. Weak pedal pulse strength in affected leg. CORRECT- An alteration in pulse strength in the affected extremity is a characteristic of compartment syndrome. Think like a nurse: An external fixator is a metallic device composed of metal pins inserted into the bone and attached to external rods to stabilize the fracture while it heals. Neurovascular assessment is the main focus in clients with an external fixator. This includes monitoring for the color, temperature, capillary refill, peripheral pulses, paresthesia, and edema on the affected extremity. Motor function should be evaluated at frequent intervals (e.g., dorsiflexion and plantar flexion), unless contraindicated. Both sides should be assessed and compared. The nurse should note that partial or full loss of sensation is a late sign of neurovascular impairment. The client receives venous thromboembolism (VTE) prophylaxis, unless contraindicated.

The nurse provides care to a client newly diagnosed with schizophrenia who is prescribed chlorpromazine 25 mg PO tid. Which client statement indicates to the nurse a correct understanding of the medication administration instructions? (Select all that apply.) 1. "It is important that I brush my teeth three times a day." 2. "It may take 6 weeks for my medication to work." 3. "I can have a glass of wine with dinner each night" 4. "I am driving myself home today and to work tomorrow." 5. "I need to have blood drawn regularly for a few months." 6. "I should not be concerned if my urine turns pink."

ANSWERS: 1, 2, 5, 6 EXPLANATION: 1. "It is important that I brush my teeth three times a day." — Dry mouth is an adverse effect of chlorpromazine, so it is important to maintain good oral hygiene. 2. "It may take 6 weeks for my medication to work." — It can take at least 6 weeks before the client notices improvement in symptoms. 5. "I need to have blood drawn regularly for a few months." — There is a risk of leukopenia in the first 3 months, and this necessitates lab work. 6. "I should not be concerned if my urine turns pink." — Pink urine is an expected side effect of chlorpromazine. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. The nurse should keep in mind that chlorpromazine is also used to control nausea and vomiting and to relieve prolonged hiccups.

A client receives furosemide for heart failure. Which response indicates to the nurse that the medication is effective? (Select all that apply.) 1. Three pound weight loss in 24 hours. 2. Increased thirst and dry mouth. 3. Increased ease in breathing. 4. Dizziness and light-headedness. 5. Painful and swollen finger joints. 6. Muscle weakness and cramping.

ANSWERS: 1, 3 EXPLANATION: 1. Three pound weight loss in 24 hours. — Weight loss indicates diuresis, which is a desired effect for furosemide, a diuretic. 3. Increased ease in breathing. — Crackles and shortness of breath indicate pulmonary congestion, whereas easier breathing shows improvement. This data indicates a desired effect of furosemide, a diuretic. Think like a nurse: In evaluating effectiveness of medications used to treat heart failure, the nurse should look for manifestations indicating an improvement of cardiac output, renal function, tissue perfusion, and activities of daily living. The client is informed to report to the provider sudden or steady gain in daily weight, such as 2 to 3 lbs (0.91 to 1.4 kg) in 24 hours or 5 lbs (2.3 kg) or more in 1 week. If taking digoxin, the client should be taught how to take their pulse rate for a full minute and be aware not to take digoxin if rate is less than 60 beats/minute. The client taking furosemide should be informed to notify the provider if the client experiences leg cramps, a sign of hypokalemia.

The nurse provides instructions to a client prescribed hydralazine as treatment after a hypertensive crisis. Which client statements indicate to the nurse that the teaching is effective? (Select all that apply.) 1. "I need to tell my health care provider if I lose my appetite." 2. "I need to have my blood drawn twice a week." 3. "I will take the prescribed medication with my breakfast." 4. "I will call my health care provider before taking ibuprofen." 5. "I will sit on the edge of my bed for 2 minutes before I stand up in the morning."

ANSWERS: 1, 3, 4, 5 EXPLANATION: 1. "I need to tell my health care provider if I lose my appetite." - Anorexia is a possible adverse effect of hydralazine. The health care provider should be notified if this occurs. 3. "I will take the prescribed medication with my breakfast." - Hydralazine should be taken with food to increase bioavailability of the medication. 4. "I will call my health care provider before taking ibuprofen." - The client needs to avoid over-the-counter medications unless directed by the health care provider. 5. "I will sit on the edge of my bed for 2 minutes before I stand up in the morning." - Orthostatic hypotension is a possible adverse effect of this medication. Sitting on the edge of the bed before standing up in the morning helps prevent this effect. Think like a nurse: During client teaching, the nurse uses the teach-back method to evaluate the client's understanding. The nurse ensures the client understands the indications for hydralazine administration, as well as health management related to the hypertensive crisis. Dizziness, which is a potential adverse effect of hydralazine, may increase the client's risk for falls. Adverse effects such as fainting, tachycardia, edema, or chest pain require immediate care. Dietary recommendations include a low-sodium diet. Reinforce the importance of adhering to the prescribed medication regimen. Educate the client about health risks associated with poorly managed hypertension, including stroke and heart attack.

The nurse teaches a client diagnosed with Cushing Syndrome about the disease process. Which client statements indicate to the nurse that teaching is effective? (Select all that apply.) 1. "My diagnosis helps to explain why my bones are weak." 2. "I need to increase my daily caloric intake." 3. "My health care provider may prescribe a diuretic for me." 4. "I need to avoid people who have infections." 5. "I may have to take potassium supplements." 6. "I feel weak because the syndrome makes my blood glucose low."

ANSWERS: 1, 3, 4, 5 EXPLANATION: 1. "My diagnosis helps to explain why my bones are weak." CORRECT — Cushing Syndrome results from chronic exposure to excess corticosteroids. Excess corticosteroids adversely affect the bone structure, leading to weakening. 2. "I need to increase my daily caloric intake." INCORRECT - Weight gain is a common symptom of Cushing Syndrome. The client should decrease caloric intake. 3. "My health care provider may prescribe a diuretic for me." CORRECT— Edema of the lower extremities is common in Cushing Syndrome. A potassium-sparing diuretic may be prescribed. 4. "I need to avoid people who have infections." CORRECT— The client is at risk for an infection related to lowered resistance to stress and suppression of immune system caused by excessive corticosteroids. 5. "I may have to take potassium supplements." CORRECT— Hypokalemia commonly occurs in Cushing Syndrome. Potassium supplements are often prescribed. 6. "I feel weak because the syndrome makes my blood glucose low." INCORRECT - While weakness is a common symptom, clients diagnosed with Cushing Syndrome have hyperglycemia. The weakness is not being caused by hypoglycemia. Think like a nurse: A disease process such as Cushing Syndrome requires extensive teaching about the pathophysiological process, symptoms of the disorder, potential complications, and treatment. This disease develops after prolonged use of glucocorticoids. The effects of the syndrome on the body are caused by the steroid and include electrolyte imbalances, increased risk for infection, poor healing, fluid retention that manifests as peripheral edema, and changes in bone metabolism. Although it can develop as a primary condition, it most often occurs after the client has been prescribed long-term steroid use to treat another health problem.

The nurse teaches a client who is prescribed a reduced fat diet. The nurse determines that teaching is effective if the client makes which menu selections? (Select all that apply.) 1. Bran flakes and skim milk. 2. Avocado and peanut butter sandwich. 3. Canadian bacon and egg whites. 4. Baked tortilla chips and salsa. 5. Bologna sandwich and potato chips. 6. Water-packed tuna and a cola.

ANSWERS: 1, 3, 4, 6 EXPLANATION: 1. Bran flakes and skim milk. - Bran flakes are low in fat while skim milk contains no fat 3. Canadian bacon and egg whites. - Canadian bacon and egg whites are both low in fat. These are good substitutes for regular bacon and whole eggs. 4.Baked tortilla chips and salsa. - Baked tortilla chips and salsa are both low in fat. 6. Water-packed tuna and a cola. - Water-packed tuna is low in fat. While cola is high in carbohydrates, it is not a high-fat food. Think like a nurse: The nurse must apply the principles of teaching and learning to this scenario. This client is prescribed a low fat diet; therefore, the nurse must review the client's choices to determine if further education is required. Client choices indicating the need for more education include avocado and peanut butter along with bologna and chips. These food choices are all high in fat; therefore, the nurse would provide education regarding choices that are lower in fat when these menu options are chosen.

The nurse performs an assessment of a client diagnosed with Parkinson disease. The nurse expects to assess which symptoms? (Select all that apply.) 1. Tremors. 2. Diplopia. 3. Bradykinesia. 4. Slurred speech. 5. Respiratory distress. 6. Propulsive gait.

ANSWERS: 1, 3, 4, 6 EXPLANATION: 1. Tremors. CORRECT - Resting tremors that disappear with purposeful movements are expected for the client diagnosed with Parkinson disease. 2. Diplopia. INCORRECT - Diplopia is a finding that occurs with myasthenia gravis, not Parkinson disease. 3. Bradykinesia. CORRECT - Abnormally slow muscle movement and trouble initiating movement are common effects of Parkinson disease. 4. Slurred speech. CORRECT - Slurred speech is caused by the weakness and lack of coordination of muscles that occurs with Parkinson disease. 5. Respiratory distress. INCORRECT - Respiratory distress occurs with myasthenia gravis, not Parkinson disease. 6. Propulsive gait. CORRECT - A propulsive gait is expected for the client diagnosed with Parkinson disease. Instruct the client to walk erect, watch the horizon, and use a wide-based gait. Think like a nurse: Before assessing the client, the nurse should stop and recall the pathophysiological process of Parkinson disease and anticipate the symptoms. The nurse will use knowledge about the pathology of the disease and how the production of dopamine in the brain and the lack or absence of this neurotransmitter will affect motor function. During the assessment, the nurse should expect findings that reflect a change in musculoskeletal functioning. Some of these findings include difficulty with ambulation, slurred speech, and fine motor tremors.

The nurse provides care for a client who is prescribed levothyroxine. Which client statements indicate to the nurse a correct understanding of the medication therapy? (Select all that apply.) 1. "I will feel more energetic when this medication works." 2. "My blood TSH level will increase with this medication." 3. "I will take this medication on an empty stomach when I wake up." 4. "This medication contains both T3 and T4 hormones." 5. "This medication replaces the hormone I don 't produce."

ANSWERS: 1, 3, 5 EXPLANATION: 1. "I will feel more energetic when this medication works. " — Levothyroxine increases metabolism and cellular energy, which will likely cause the client to have more energy. This statement indicates a correct understanding of the medication therapy. 3. "I will take this medication on an empty stomach when I wake up. " — Food in the stomach may affect absorption of this medication. This statement indicates a correct understanding of the medication therapy. 5. "This medication replaces the hormone I don 't produce. " — Levothyroxine is a synthetic thyroid hormone that replaces the client 's lack of endogenous hormone. This statement indicates a correct understanding of the medication therapy. Think like a nurse: To evaluate the effectiveness of teaching, the nurse uses the teach-back method to assess the client 's understanding. Ideally, the client should understand the pathophysiology of the condition for which a medication is prescribed, as well as the therapeutic effects of the medication. In addition, the nurse should teach the client how to evaluate the therapeutic effectiveness of the medication, as well as guidelines for medication self-administration.

The nurse provides care for a client on the second day postpartum. The client begins to experience breast engorgement. Which actions are appropriate for the nurse to implement? (Select all that apply.) 1. Instruct the client to express some milk to relieve the distention. 2. Remove the client 's bra to relieve pressure from the sensitive breasts. 3. Apply ice packs to the breasts between feedings. 4. Decrease fluid intake for 24 hours. 5. Increase the frequency of breastfeedings.

ANSWERS: 1, 3, 5 EXPLANATION: 1. Instruct the client to express some milk to relieve the distention. - The mother can express milk to get the milk flow started and soften the areola. The client may use a breast pump or manually express milk. The client should wear a well-fitting bra for support and comfort. 3. Apply ice packs to the breasts between feedings. - Cold applications between feedings and heat just before feedings may help to reduce discomfort and engorgement. 5. Increase the frequency of breastfeedings. - The client should feed more often —every 1.5 to 2 hours. Think like a nurse: Before offering suggestions to address this client's symptoms, the nurse should review the physiologic changes that occur on the second day after delivery. The breasts are preparing to support the newborn with feeding. This means the ducts are producing milk, which causes the breast tissue to be engorged and tender. To help reduce the engorgement, the client can be instructed to express some of the milk from the breasts. Topical application of ice helps reduce the pain and swelling and will slow milk production. Increasing the frequency of feedings will help reduce the volume of engorgement, but will also stimulate additional milk production. The client needs to wear a well-fitting bra at all times. Because the client is producing milk, adequate oral fluid intake is required to ensure for a constant supply of breast milk to meet the newborn's nutritional needs.

The nurse prepares to administer amikacin to a client diagnosed with an enterococcal infection. Which client findings cause the nurse to question administration of the medication? (Select all that apply.) 1. Reports nausea and diarrhea. 2. Has an activated partial thromboplastin time (aPTT) value of 28 seconds. 3. Receives warfarin for atrial fibrillation. 4. Smokes one pack of cigarettes a day. 5. Receives hemodialysis three times weekly.

ANSWERS: 1, 3, 5 EXPLANATION: 1. Reports nausea and diarrhea. — Anti-infective medications can eradicate normal intestinal flora and le 3. Receives warfarin for atrial fibrillation. — Anti-infective medications can eradicate normal flora, reducing the amount of vitamin K produced by these bacteria. Amikacin is an aminoglycoside and can potentiate the action of warfarin. The nurse questions the administration of this medication based on this data. 5. Receives hemodialysis three times weekly. — Aminoglycosides are nephrotoxic and are contraindicated in clients diagnosed with kidney impairment because toxic levels are reached rapidly. The nurse questions the administration of this medication based on this data. Think like a nurse: The nurse should recall the Rights of Medication administration and apply knowledge about the classification and actions of the prescribed medication. The nurse will understand that the prescribed medication is an aminoglycoside antibiotic, which causes toxicity of the kidneys. For this reason, the nurse should question providing the medication to the client because of a risk for additional renal damage. Antibiotics in general destroy normal intestinal flora, causing nausea and diarrhea and interrupting the normal intestinal flora that helps maintain vitamin balance in the body. The medication should be questioned because of the client's existing symptoms, medical treatment, and current medication regimen.

A preschool-age client is recovering from a tonsillectomy and adenoidectomy. The client is discharged home with the parents. Which instruction will the nurse give to the parents? (Select all that apply.) 1. Monitor the child for continuous swallowing. 2. Encourage the child to deep breathe and cough every 2 hours. 3. Administer pain medication, such as acetaminophen, as needed. 4. Administer codeine elixir routinely for pain. 5. Monitor the child for restlessness and difficulty breathing.

ANSWERS: 1, 3, 5 EXPLANATIONS: 1. Monitor the child for continuous swallowing. — Frequent swallowing is a sign of bleeding. 3. Administer pain medication, such as acetaminophen, as needed. — The throat is sore after surgery and pain medication is needed regularly for the first few days. 5. Monitor the child for restlessness and difficulty breathing. — Restlessness or difficulty breathing is a sign of bleeding or airway obstruction. Think like a nurse: Post-tonsillectomy, the nursing interventions are focused on assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding. Discharge teaching may include reinforcing adherence with antibiotics, when to notify the health care provider (e.g., signs of difficulty breathing), and improving fluid and food intake. Water, apple juice, and grape juice, are well tolerated post-operatively. Soft foods such as applesauce, pudding, ice cream, sherbet, and yogurt are easy to swallow and will provide the client with nutrients. The nurse should instruct the client to avoid crunchy, hard foods and hot or spicy foods. The client may take pain medicine an hour before meals to reduce pain while eating.

The nurse supervises a novice nurse providing care to a client with new symptoms of a cerebrovascular accident (CVA). Which actions by the novice nurse cause the seasoned nurse to intervene? (Select all that apply.) 1. Administers to the client aspirin 325 mg by mouth. 2. Prepares the client for a CT scan. 3. Assigns the client a 0 score on the National Institute of Health stroke scale screen. 4. Measures the client's blood pressure. 5. Compiles a list of the client's home medications. 6. Reassures the client that all symptoms will resolve.

ANSWERS: 1, 3, 6 EXPLANATION: 1. Administers to the client aspirin 325 mg by mouth. — The client should have a CT scan first to determine whether the symptoms of the CVA are caused by ischemic changes or a cerebral hemorrhage. If the symptoms are caused by a hemorrhage, aspirin is contraindicated. Fibrinolytic therapy, and not aspirin therapy, should be considered if the stroke is not hemorrhagic in origin. 3. Assigns the client a 0 score on the National Institute of Health stroke scale screen. — If the client is demonstrating symptoms of a CVA, the National Institute of Health stroke scale screen cannot be 0. 6. Reassures the client that all symptoms will resolve. — The nurse cannot guarantee that all of the symptoms of the CVA will completely resolve. Think like a nurse: Before answering this question, recall the information within Benner's theory "From Novice to Expert." The novice nurse may have graduated from nursing school and passed the state board examination, but may still have learning needs. The client demonstrating symptoms of a stroke needs care to prevent additional cerebral ischemia or bleeding. This means that nothing should be provided to the client that may encourage bleeding. The nurse may not be experienced enough on the use of the stroke scale rating tool. And, the nurse is providing the client with false hope, which may hinder the recovery process. It is wise for the expert nurse to intervene to ensure for the client's safety, appropriate assessment, and realistic psychosocial support during this health crisis.

The nurse provides care for a client diagnosed with left-sided weakness and impaired speech. Which intervention is appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? (Select all that apply.) 1. Maintain the head of the bed less than 30 degrees. 2. Monitor blood pressure regularly. 3. Obtain medical history for risk factors. 4. Assist the client with frequent oral care. 5. Determine readiness for smoking cessation.

ANSWERS: 1, 4 EXPLANATION: 1. Maintain the head of the bed less than 30 degrees. - The UAP can assist the client to maintain the head of bed less than 30 degrees for optimal cerebral perfusion. Sitting upright is avoided as it decreases blood flow and oxygenation to the brain during this critical period, and this is balanced with avoiding lying flat, which increases intracranial pressure. 4. Assist the client with frequent oral care. - The UAP can assist the client with oral care. This is an appropriate intervention the nurse can assign. Think like a nurse: Before delegating care, the nurse needs to review the scope of practice of potential care providers. UAPs have the knowledge and training to complete routine tasks that have a predictable outcome on clients who are considered stable. Of all of the tasks that need to be completed for this client, the ones that the UAP can safely complete include positioning in bed and assisting with personal hygiene. The nurse retains the responsibility and accountability for all delegated tasks in addition to complete tasks that require assessment and teaching.

The nurse provides an albuterol nebulizer treatment to a client recovering from respiratory failure. Which finding does the nurse expect to observe after treatment? (Select all that apply.) 1. Increased productive cough. 2. Increased wheezes in upper lobes. 3. Decreased crackles in lower lobes. 4. Reports of decreased anxiety. 5. Bilateral hand tremors.

ANSWERS: 1, 4, 5 EXPLANATION: 1. Increased productive cough. — Bronchodilators can loosen secretions, helping the client expectorate them from the lungs. The nurse expects to observe an increased productive cough after the albuterol nebulizer treatment. 4. Reports of decreased anxiety. — Decreased oxygen causes anxiety and the client struggles to obtain enough air. Calmness should occur when the air passages are clearer or more dilated after the nebulized treatment. 5. Bilateral hand tremors. — Tremors are an expected side effect of albuterol and are not concerning. Think like a nurse: The nurse must differentiate between a medication's therapeutic effects, side effects, and adverse effects. Adverse reactions might include angina, hyper or hypotension, or metabolic acidosis. An unfortunate side effect of this bronchodilator is sympathomimetic actions, including tremors, central nervous system (CNS) stimulation, hyperactivity, sleeplessness, and anxiety. Albuterol opens the inflamed, irritated, narrowed air passages. This increases air inflow and widens airways, allowing mucus to be expectorated. Once the passages are opened, the surfaces are no longer rubbing and vibrating against each other as air passes, so wheezing stops.

The nurse conducts an educational session on wellness for community members. Which examples will the nurse include for tertiary health prevention? (Select all that apply.) 1. Teaching how to irrigate a new colostomy. 2. Providing a class on handwashing for a preschool class. 3. Informing a client that the infant can be immunized at the health department. 4. Arranging for a hospice nurse to visit with the family of a client with lung cancer. 5. Recommending that a spouse attend a bereavement group following a client 's death.

ANSWERS: 1, 4, 5 EXPLANATION: 1. Teaching how to irrigate a new colostomy. - The goal of tertiary health prevention is to prevent disability and complications of a condition. Teaching how to irrigate a new permanent colostomy is an example of tertiary level health prevention. 4. Arranging for a hospice nurse to visit with the family of a client with lung cancer. - The goal of tertiary health prevention is to prevent disability and complications of a condition. Arranging for a hospice nurse to visit with the family of a client with lung cancer is an example of tertiary prevention. 5. Recommending that a spouse attend a bereavement group following a client 's death. - The goal of tertiary health prevention is to prevent disability and complications of a condition. Recommending that a spouse attend a bereavement group following a client 's death is an example of tertiary level health prevention because it can help the spouse deal with loss in a healthy manner. Think like a nurse: Tertiary prevention includes actions to prevent the progression of negative consequences of chronic conditions, reduce disability, and minimize suffering, as well as preventing complications and deterioration (e.g., cardiac rehabilitation). Activities are directed at rehabilitation rather than diagnosis and treatment. An example would be a client with spinal cord injury learning how to use a wheelchair. Before teaching, the nurse should first assess the client 's baseline knowledge. The teach-back method is used to verify a client 's understanding. The nurse assesses a client 's risk and then screens the client for the condition.

A client diagnosed with a known history of substance abuse with opioids is recovering after a hysterectomy. Which actions will the nurse implement when providing care? (Select all that apply.) 1. Notifies the health care provider that the opioid prescription is twice the normal dose. 2. Determines what type and amount of opioids the client uses. 3. Administers opioids around-the-clock. 4. Uses physiological indicators of pain to confirm client's self-reported pain rating. 5. Provides nonopioid methods of pain relief.

ANSWERS: 2, 3 EXPLANATION: 2. Determines what type and amount of opioids the client uses. — The nurse should evaluate the medication prescription to avoid the opioid that was abused. 3. Administers opioids around-the-clock. — The medication should be provided around-the-clock to maintain a steady opioid level and prevent symptoms of withdrawal. Withholding opioids will lead to symptoms of withdrawal and should not be done. Think like a nurse: Many postoperative clients will experience acute pain, which should be treated with an opioid medication. The nurse needs to be aware of difficulty with pain management because of the client's history of opioid abuse. The prescribed medication should be provided around the clock to reduce the risk of withdrawal symptoms. The type of opioid medication that the client abused should be evaluated so that the same medication is not used to treat postoperative pain; using the same medication can result in poor pain management with safe doses of the medication.

The nurse provides care for a client diagnosed with migraine headaches. Which statement indicates to the nurse that the client understands migraine triggers? (Select all that apply.) 1. "I should take propranolol after the migraine begins." 2. "I should track the number of hours I sleep each day." 3. "Avoiding red wine, even at parties, is essential to prevention." 4. "I need a new favorite snack now that I can't eat cheddar cheese." 5. "Topiramate is taken before situations that cause migraines." 6. "Zolmitriptan will prevent migraines if I take a dose weekly."

ANSWERS: 2, 3, 4 EXPLANATION: 2. "I should track the number of hours I sleep each day." — Sleep deprivation is a migraine trigger. The client uses a journal to record food, sleep, and other common triggers or patterns. 3. "Avoiding red wine, even at parties, is essential to prevention." — Sulfites are used as preservatives in red wine and can cause migraines. In addition, alcohol increases blood flow to the brain and can cause dehydration, both known triggers. 4. "I need a new favorite snack now that I can't eat cheddar cheese." — Aged cheese contains tyramine, a migraine trigger. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. The client should be encouraged to ask questions. Migraine triggers vary among clients. The nurse should explore with the client specific triggers, such as the menstruation cycle, salty food, monosodium glutamate (MSG), alcohol, and weather changes.

The client diagnosed with dehydration is treated with IV normal saline (NS). Which client responses noted by the nurse demonstrate a therapeutic effect of the NS? (Select all that apply.) 1. Crackles noted in the lungs. 2. Blood pressure increases. 3. The pulse rate decreases. 4. Urine output increases. 5. Hematocrit (HCT) level increases.

ANSWERS: 2, 3, 4 EXPLANATION: 2. Blood pressure increases. — Hypotension may indicate decreased fluid volume. An increase in blood pressure to normotensive is a therapeutic and expected response to the fluid infusion. 3. The pulse rate decreases. — An increased pulse may indicate decreased fluid volume as the heart pumps faster to maintain homeostasis. A decrease of heart rate to the normal range indicates therapeutic effectiveness of the intervention. 4. Urine output increases. — Urine output decreases with hypovolemia. A client with adequate hydration replacement should experience increased urination. Think like a nurse: The nurse must differentiate between a medication 's therapeutic effects, side effects, and adverse effects, in addition to monitoring for medication interactions. For the client who is prescribed IV fluid therapy for treatment of dehydration, the desired therapeutic outcomes include a reversal of dehydration-related signs and symptoms. Classic manifestations of dehydration include hypotension, tachycardia, and oliguria. In the dehydrated client, hematocrit may be elevated due to hemoconcentration. Adequate fluid volume is associated with a normal blood pressure and heart rate, as well as sufficient urine production. Auscultation of crackles in the lungs indicates potential fluid volume overload and must be corrected.

The nurse plans discharge care for the client diagnosed with recurrent cancer and lymphedema. Which client statements alert the nurse to a need for home health services? (Select all that apply.) 1. "I use this magnifying glass when I need to read small print. " 2. "Sometimes I don 't get to the bathroom in time." 3. "My hands always shake when I try to pick things up. " 4. "My dentures don 't fit so I don 't wear them, but I eat just fine. " 5. "I can 't feel a thing in my feet. It 's been that way for a while. " 6. "I 'm not able to get in the bathtub anymore. "

ANSWERS: 2, 3, 4, 5 EXPLANATION: 2. "Sometimes I don 't get to the bathroom in time." — A home health referral could benefit this client by assessing for durable medical equipment that might assist the client in using the bathroom. If incontinence is a problem, the client may need assistance with personal care. 3. "My hands always shake when I try to pick things up. " — This client may need assistance preparing meals, and managing medication administration. Home health care can provide accurately assess and provide appropriate referrals. 4. "My dentures don 't fit so I don 't wear them, but I eat just fine. " — Although the client says, "I eat just fine, " a dietary referral will ensure the client has the home resources and ability to eat a balanced diet. The fact that the dentures don 't fit may indicate the client has lost significant weight. 5. "I can 't feel a thing in my feet. It 's been that way for a while. " — A home health referral will determine if this client has safety needs in the home because of numbness in the feet. Slippery or uneven surfaces could be dangerous for this client. Think like a nurse: Referral for home health services requires assessment and documentation of the client 's needs. The nurse should collaborate with the case manager or social worker in determining which services may be required. Use standardized tools (e.g., Katz Index of Independence in Activities of Daily Living) to assess and document activities of daily living limitations that may be required.

The nurse prepares a client for a Holter monitor study. Which instructions will the nurse include when teaching the client about this study? (Select all that apply.) 1. Bathing and showering with the device on is permissible. 2. Trigger the event marker when pain or other symptoms occur. 3. Use a regular toothbrush instead of an electric toothbrush. 4. Keep a diary of activities, focusing on symptom occurrence. 5. Immediately report fast heart rate or difficulty breathing.

ANSWERS: 2, 3, 4, 5 EXPLANATION: 2. Trigger the event marker when pain or other symptoms occur. — The nurse should instruct the client to trigger the event marker on the device whenever pain or other symptoms occur. 3. Use a regular toothbrush instead of an electric toothbrush. — The nurse should instruct the client to avoid contact with electrical devices, such as shavers, toothbrushes, and electric blankets. 4. Keep a diary of activities, focusing on symptom occurrence. — The nurse should instruct the client to keep a diary of activities while wearing the Holter monitor to determine the heart 's response to daily activities. 5. Immediately report fast heart rate or difficulty breathing. — The nurse should instruct the client to immediately report symptoms such as fast heart rate or difficulty breathing. Think like a nurse: The nurse is aware that ambulatory cardiac monitoring can be used to determine if cardiac medications are working, to evaluate symptoms such as dizziness or palpitations, and to catch the heart 's intermittent conduction abnormalities. The client wearing a Holter monitor should engage in whatever activities are normally included in the daily routine, such as drinking coffee, exercising, working, and resting. This point should be emphasized by the nurse, as clients often behave differently when they know they are under observation. The client must record all episodes of chest pain, shortness of breath, palpitations, dizziness, or other bothersome symptoms so this can be correlated with the heart rhythm and rate.

The cardiac monitor of a client who is awake and alert and has a peripheral pulse shows ventricular tachycardia with a rate of 160 beats/min. Which actions are appropriate for the nurse to implement? (Select all that apply.) 1. Defibrillate using 200 joules. 2. Monitor blood pressure. 3. Alert the rapid response team. 4. Prepare to administer adenosine by slow IV push. 5. Obtain a 12-lead electrocardiogram as prescribed.

ANSWERS: 2, 3, 5 EXPLANATION: 2. Monitor blood pressure. — The nurse should monitor the client's blood pressure to determine whether the client is tolerating the rhythm. 3. Alert the rapid response team. — The nurse should alert the rapid response team to assist with the client's care. Evidence shows that rapid response teams help improve client outcomes when changes in condition occur. 5. Obtain a 12-lead electrocardiogram as prescribed. — The nurse should obtain a 12-lead ECG, as prescribed, to evaluate the client's cardiac conduction. Think like a nurse: Treatment of ventricular tachycardia with a pulse requires treatment of reversible causes. The nurse prepares for possible synchronized cardioversion. The client might require sedation prior to the procedure. The client's hemodynamic status should be monitored closely while promoting airway patency. The nurse is expected to draw a serum metabolic profile to verify if electrolyte imbalances caused the ventricular tachycardia. If the client becomes pulseless, the cardiac arrest team should be summoned (e.g., "call a code").

The nurse provides care for a client receiving doxycycline. The nurse is concerned if the client makes which statements? (Select all that apply.) 1. "I wear sunscreen when I work in the garden. " 2. "Currently I have a thick vaginal discharge. " 3. "I take the medication at 10:30 AM and 10:30 PM. " 4. "My husband and I use condoms for birth control. " 5. "Finishing all of the medication in the bottle is important. " 6. "I take an antacid immediately before going to bed. "

ANSWERS: 2, 3, 6 EXPLANATION: 2. "Currently I have a thick vaginal discharge. " — Doxcycline is an antibiotic, which can increase the risk for superinfection. Vaginal discharge may indicate a superinfection, which requires immediate treatment. 3. "I take the medication at 10:30 AM and 10:30 PM. " — 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. The nurse should find out what time the client usually goes to bed. 6. "I take an antacid immediately before going to bed. " — The client should not take antacids within 1 -3 hours of taking doxcycline to avoid absorption interference. Think like a nurse: Prior to administering a newly prescribed medication, teaching should occur that focuses on the mechanism of action, expected effects, any essential precautions, and side or adverse effects. This medication is an antibiotic, which can reduce the amount of naturally occurring flora in the body. The development of a superinfection is common, but needs to be reported and treated. Antacids interfere with the absorption of the medication and should not be taken near the same time. In addition, this antibiotic causes gastric distress and esophageal discomfort that is exacerbated when in the supine position. To reduce this effect, the medication should be taken well before the hour of sleep.

The nurse provides care to a client diagnosed with a pelvic fracture after a motor vehicle accident. The nurse notes that the client is agitated and attempting to get out of bed. The client has removed the IV and reports shortness of breath. The client's blood pressure is 90/58 mm Hg, respirations 28 breaths/minute, pulse 133 beats/minute, and O2 sat 78% on 3.5 L/minute of oxygen. Which action will the nurse perform? (Select all that apply.) 1. Administer normal saline 500 mL bolus. 2. Assess breath sounds. 3. Obtain arterial blood gases (ABG). 4. Begin cardiopulmonary resuscitation (CPR). 5. Continue to administer oxygen at 3.5 L/m via nasal cannula. 6. Establish vascular access.

ANSWERS: 2, 3, 6 EXPLANATION: 2. Assess breath sounds. — The client is responding to low oxygen levels; therefore, the nurse needs to assess to determine cause. 3. Obtain arterial blood gases (ABG). — The client is responding to low oxygen levels; therefore, the nurse draws an ABG to further assess the client. 6. Establish vascular access. — The nurse needs to reestablish IV access to administer medications. Think like a nurse: The client's symptoms indicate acute hypoxia, which may be caused by either a pulmonary or fat embolism. The nurse needs to intervene to ensure adequate oxygenation. Breath sounds should be assessed and arterial blood gases sent to help determine the cause for the symptoms. An intravenous access site is necessary for medication administration.

A client diagnosed with type 1 diabetes mellitus has a capillary blood glucose of 60 mg/dL (3.3 mmol/L) and reports hunger, sweating, tachycardia, and tremulousness. Which food choices does the nurse select that provide the client with 15 grams of an oral carbohydrate? (Select all that apply.) 1. 8 oz of regular soda. 2. Half cup of plain pasta. 3. Half cup of canned fruit. 4. 2 teaspoons of sugar. 5. 1 cup of whole milk. 6. 125 mL of apple juice.

ANSWERS: 2, 3, 6 EXPLANATION: 2. Half cup of plain pasta. — One-half cup of plain pasta contains 15 grams of carbohydrates. 3. Half cup of canned fruit. — One-half cup of canned fruit contains 15 grams of carbohydrates. 6. 125 mL of apple juice. — Apple juice in the amount of 125 milliliters contains 15 grams of carbohydrates. Think like a nurse: For the client who experiences hypoglycemia, food and drink should be offered only if the client is alert and speaking clearly. If the client demonstrates a decreased level of consciousness, introduction of food or oral fluids may result in aspiration. Sublingual administration of carbohydrates, including glucose gel or granulated sugar, is an available option for these clients. If the client is unconscious, glucose may be prescribed for administration via intravenous, intramuscular, or subcutaneous routes. For the alert client experiencing symptomatic hypoglycemia, the nurse administers only the necessary amount of carbohydrate, as excess carbohydrate administration causes rebound hyperglycemia. The quick carbohydrate dose is followed by a meal, sandwich, or protein-rich snack.

The nurse provides care for an antepartum client. Which factors, identified by the nurse on assessment, increase the risk of thrombosis? (Select all that apply.) 1. Vaginal birth. 2. Obesity. 3. Maternal age greater than 27 years. 4. Varicose veins. 5. Forceps use during delivery.

ANSWERS: 2, 4, 5 EXPLANATION: 2. Obesity. -Obesity is a risk factor for thrombosis. 4. Varicose veins. - Having varicose veins is a risk factor for thrombosis. 5. Forceps use during delivery. -Forceps use during delivery is a risk factor for thrombosis. Think like a nurse: The nurse is aware that pregnancy, labor, and delivery increase the risk of deep vein thrombosis (DVT), especially when the procedure is lengthy (which allows blood to pool) or when a vein sustains injury causing inflammation. Obesity increases pressure in leg veins and on the pelvic organs, resulting in increased blood stasis. Varicose veins allow blood pooling and clotting. Deliveries assisted by forceps are often prolonged, resulting in increased pressure on pelvic vessels, resulting in lower extremity venous pooling. Forceps can also cause vessel damage. Anyone who has given birth is at increased risk of DVT and pulmonary embolism for about 6 weeks due to hypercoagulation, vascular damage, and venous stasis from pressure in the pelvis.

The nurse provides care for a client who is preoperative for a discectomy/laminectomy. The client has a history of obesity and sleep apnea. The nurse administers diazepam 10 mg orally for pain reported as 9 out of 10 on a numerical pain scale. Which additional action is appropriate for the nurse to take? (Select all that apply.) 1. Administer narcotic analgesic as prescribed. 2. Perform frequent respiratory checks if the client is drowsy. 3. Ambulate the client to the bathroom to void. 4. Inform anesthesiology of administration of oral medication. 5. Reassess the client for pain level and anxiety.

ANSWERS: 2, 4, 5 EXPLANATION: 2. Perform frequent respiratory checks if the client is drowsy. — Benzodiazepines may exacerbate apneic episodes and the nurse must monitor the client closely. 4. Inform anesthesiology of administration of oral medication. — A client should remain NPO (nil per os, or nothing by mouth) prior to surgery, except for a sip of water with the medication. 5. Reassess the client for pain level and anxiety. — The nurse should reassess for pain using the numeric scale and anxiety at appropriate intervals. Think like a nurse: Nothing by mouth status is a routine intervention when preparing a client for surgery. Considering the client's pain level, oral medication was provided as appropriate with a sip of water. However, the client's condition and health history warrant additional interventions. Because the medication may exacerbate sleep apnea, the client's respiratory status should be frequently assessed. Effectiveness of the medication should be assessed in appropriate intervals.

When assessing an older adult client who is diagnosed with dehydration, the nurse expects to observe which clinical manifestations? (Select all that apply.) 1. Weight gain. 2. Tachycardia. 3. Moist mucous membranes. 4. Cold hands or feet. 5. Flattened neck veins.

ANSWERS: 2, 4, 5 EXPLANATION: 2. Tachycardia. - Tachycardia (heart rate greater than 100 beats/minute) is a sign of dehydration secondary to hypovolemia. 4. Cold hands or feet. - For the client who is dehydrated, peripheral vasoconstriction may cause the hands and feet to feel cold. 5. Flattened neck veins. - Flattened neck veins are a sign of hypovolemia and dehydration. By contrast, hypervolemia causes neck vein distention. Think like a nurse: Older adults are at increased risk for dehydration due to age-related changes such as decreased thirst sensation. They are also more sensitive to fluid status alterations and decreases in cardiac output, as their compensatory mechanisms are not as efficient in comparison to younger adults. In the older adult client, signs may be subtle, such as confusion or mood changes. Dehydration results in decreased cardiac output. The heart rate speeds up to compensate for decreased intravascular volume and decreased filling of the heart. If IV fluid replacement is prescribed, the nurse closely monitors the client for signs and symptoms of fluid volume overload, including changes in lung sounds (such as crackles or rhonchi), which may indicate pulmonary edema.

The nurse supervises an unlicensed assistive personnel (UAP). The nurse intervenes if the UAP fails to use airborne precautions with which client? (Select all that apply.) 1. Client diagnosed with whooping cough. 2. Client diagnosed with laryngeal tuberculosis. 3. Client diagnosed with infectious diarrhea. 4. Client diagnosed with chickenpox. 5. Client diagnosed with influenza. 6. Client diagnosed with measles.

ANSWERS: 2, 4, 6 EXPLANATION: 1. Client diagnosed with whooping cough. INCORRECT — Whooping cough is spread by contact with respiratory droplets, so airborne precautions are not necessary. 2. Client diagnosed with laryngeal tuberculosis. CORRECT — The client with laryngeal tuberculosis requires airborne precautions. The client should be in private room with negative-pressure airflow of at least six exchanges per hour via HEPA filtration. All staff should wear N95 respirator masks when providing care. 3. Client diagnosed with infectious diarrhea. INCORRECT — The client with infectious diarrhea requires contact precautions as the possible responsible organisms include Clostridium difficile, campylobacter, salmonella, shigella, and Yersinia. 4. Client diagnosed with chickenpox. CORRECT — Airborne precautions are required for the client with chickenpox. In addition to airborne precautions, contact precautions are also needed until lesions crust over. 5. Client diagnosed with influenza. INCORRECT — Droplet, not airborne, precautions are required for the client with influenza. 6. Client diagnosed with measles. CORRECT — Airborne precautions are required for the client with measles. Think like a nurse: Airborne precautions are indicated for clients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei. Diseases requiring airborne precautions include, but are not limited to, measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), disseminated herpes zoster, and Mycobacterium tuberculosis. All health care workers, including unlicensed assistive personnel (UAP), must wear a fit-tested NIOSH-approved N95 respirator when providing care for clients who require airborne precautions. Transport and movement of the client outside the client's room should be limited to medically necessary purposes only. The ideal room for airborne precautions should have 12 air changes per hour.

The nurse visits the home of a family whose mother died 2 months ago in a motor vehicle accident. Which observation causes the nurse the most concern? 1. A 3-year-old explains that mother is sleeping at grandmother's house. 2. A 6-year-old experiences enuresis and temper tantrums. 3. A 9-year-old states that no one will play with him. 4. A 12-year-old spends time away from home with friends.

ANSWERS: 3 EXPLANATION: 1. A 3-year-old explains that mother is sleeping at grandmother's house. INCORRECT - Infants and toddlers have no concept of death. The 3-year-old is behaving appropriately for the developmental level. 2. A 6-year-old experiences enuresis and temper tantrums. INCORRECT - Regressed behaviors are a common response to the death of a parent. 3. A 9-year-old states that no one will play with him. CORRECT - The inability to enjoy play is masked by this typical statement and is a hallmark sign of depression in children. 4. A 12-year-old spends time away from home with friends. INCORRECT - Spending time with friends is an expected early adolescence response to grief and is a way of coping with the loss. Think like a nurse: A child who is unable to enjoy playing may be experiencing depression which, in this situation, would be caused by the death of a parent. The child needs to be further assessed.

The clinic nurse instructs a client about an ambulatory electrocardiogram (ECG). Which client statements indicate to the nurse a need for additional education? (Select all that apply.) 1. "I will have to use a safety razor while the monitor is in place." 2. "I will keep a log of all of my activities during monitoring." 3. "I will wrap the device with plastic wrap before taking a shower." 4. "I will contact the health care provider if I experience lightheadedness." 5. "I will decrease my fiber during the monitoring."

ANSWERS: 3, 4, 5 EXPLANATION: 3. "I will wrap the device with plastic wrap before taking a shower." - The monitor cannot get wet so the client needs to avoid taking a bath or shower during monitoring. The nurse needs to provide additional education based on this statement. 4. "I will contact the health care provider if I experience lightheadedness." - If the client experiences dizziness, the client needs to document it in the event log along with pushing the event-marker button on the monitor. The client does not need to call the health care provider. This statement indicates that additional education is needed. 5. "I will decrease my fiber during the monitoring." - There is no reason to change diet while being monitored. This statement indicates that additional education is needed. Think like a nurse: Often called a Holter monitor, an ambulatory ECG is a portable device that is used to record a client's heart rhythm for 1 or 2 days. Just like a typical heart monitor, it has leads that attach externally on the torso. The client records symptoms by pushing a button on the device. This device is excellent for capturing episodic dysrhythmias or cardiac conduction abnormalities that only occur under certain circumstances. The client needs explicit instructions about using the device in order for it to be effective and worthwhile.

The nurse becomes concerned when which client makes the statement, "I've had leg spasms that kept me awake all night, and now I can't feel my hands and feet!"? (Select all that apply.) 1. A client with small cell lung cancer. 2. A client with stage IV breast cancer with metastasis to the bone. 3. A client with acute kidney injury and who has a urinary output of 4500 mL/24 hours. 4. A client with acute pancreatitis due to medication toxicity. 5. A client following surgery for removal of the thyroid gland.

ANSWERS: 3, 4, 5 EXPLANATION: 3. A client with acute kidney injury and who has a urinary output of 4500 mL/24 hours. - During the polyuric phase of acute kidney injury, calcium is excreted at a higher than normal rate, leading to hypocalcemia. 4. A client with acute pancreatitis due to medication toxicity. - Acute pancreatitis leads to hypocalcemia, as calcium is bound with fatty acids. 5. A client following surgery for removal of the thyroid gland. - The risk of damage to the parathyroid gland in thyroidectomy clients places them at risk for hypocalcemia. Think like a nurse: Leg spasms and paresthesias are symptoms of a low calcium level. The client with the polyuric phase of acute kidney injury is at risk for hypocalcemia because calcium is excreted in the urine output. Hypocalcemia occurs in acute pancreatitis because calcium binds to the fatty acids. With a thyroidectomy, the parathyroid glands can be damaged, which places the client at risk for hypocalcemia.

The nurse provides care for infants in the pediatric clinic. When teaching parents about developmental milestones, in which order does the nurse present the information? (Arrange developmental milestones in the proper order. All options must be used.) 1. Begins drooling 2. Responds to own name 3. Picks up bite sized pieces of cereal 4. Doll's-eye reflex disappears 5. Takes deliberate steps when standing

ANSWERS: 4, 1, 2, 5, 3 EXPLANATION: 4. Doll's-eye reflex disappears - Disappears at 2-3 months 1. Begins drooling - Begins at 4 months 2. Responds to own name - Happens at 6-8 months 5. Takes deliberate steps when standing - Starts at 9-10 months 3. Picks up bite sized pieces of cereal - Can do this at 11 months EXPLANATION: First, the infant loses the doll's eye reflex at 2 to 3 months of age and can follow a moving object briefly. At about 4 months of age, the infant begins drooling as the gums swell and teeth erupt. The infant responds to name by 6 to 8 months of age. The infant will take deliberate steps when held up or after pulling self up to a standing position at 9 to 10 months of age. Lastly, an infant will pick up bite-size pieces of cereal at 11 months and deliberately put them in the mouth.

The nurse supervises a nursing team that consists of nurses, LPN/LVNs, and unlicensed assistive personnel (UAP). A client experiences a generalized tonic-clonic seizure while in a standing position and is assisted to the floor. The nurse intervenes if which actions are observed? (Select all that apply.) 1. The LPN/LVN loosens the client's constrictive clothing. 2. The UAP places a pillow under the client's head. 3. The nurse suctions secretions in the buccal cavity. 4. The LPN/LVN places the client in the supine position. 5. The UAP restrains the client's extremities during the seizure. 6. The UAP closes the client's curtain until the situation resolves.

ANSWERS: 4, 5 EXPLANATION: 4. The LPN/LVN places the client in the supine position. - If possible, the client should be placed on one side with head flexed forward, as this position allows the tongue to fall forward and facilitates drainage of saliva and mucus. The nurse intervenes if supine positioning is observed. 5. The UAP restrains the client's extremities during the seizure. - Muscular contractions during seizures are strong, and restraint can cause injury to the client and to personnel. The nurse intervenes if this action is observed. Think like a nurse: It is essential for the nurse to be well-versed in recognizing a seizure when it happens (e.g. focal and absence seizure). It is important that the nurse notes the time the seizure starts. The nurse should collaborate with the team in identifying the underlying cause of the client' seizure. Although medication non-compliance and sub-therapeutic medication levels are among the most common causes of seizure presentations to the emergency department, clients should also be screened for underlying infectious or metabolic causes of seizure when indicated. In clients with therapeutic medication levels, fever, altered mental status (AMS), or other indication, laboratory and imaging studies should be considered.

The nurse assesses a client who gave birth to a baby 10 hours ago. Which findings are expected for this client? (Select all that apply.) 1. Elevated white blood cells (WBC) level. 2. Pulse oximetry reading of 96%. 3. Elevated neutrophils. 4. Temperature of 100.4°F (38°C). 5. Pulse rate of 102 beats/min.

ANSWERS: 1, 2, 3, 4 EXPLANATIONS: 1. Elevated white blood cells (WBC) level. - During the first 10 to 12 days after childbirth, values between 20,000/mm 3 (20×10 9/L) and 25,000/mm 3 (25×10 9/L) are common. 2. Pulse oximetry reading of 96%. - CORRECT- Pulse oximetry level should be within normal limits at this time 3. Elevated neutrophils. - CORRECT - Neutrophils are the most numerous white blood cells postpartum. 4. Temperature of 100.4°F (38°C). - CORRECT - During the first 24 hours, temperature can increase to 100.4°F (38°C) as a result of dehydrating effects of labor. Think like a nurse. Postpartum assessment of the client typically includes vital signs, pain level, epidural site inspection for infection, and a systematic head-to-toe review of systems. The acronym BUBBLE-EE (breasts, uterus, bowel, bladder, lochia, episiotomy/perineum, extremities, and emotions) can be a useful mnemonic. The nurse anticipates assisting the client with bowel and bladder elimination; promoting a balance of activity, rest, and exercise; assisting with self-care measures; educating about sexuality and contraception; promoting maternal nutrition; and supporting the client's choice of infant feeding method.

The nurse is preparing the client for a C3 to C4 laminectomy. Which client statement indicates to the nurse the client requires further instruction? (Select all that apply.) 1. "My pain will be completely gone when I wake up." 2. "I should not twist my back right after surgery." 3. "I will probably be incontinent after the surgery." 4. "I do not smoke so there will not be complications." 5. "It does not matter if I take herbal supplements."

ANSWERS: 1, 3, 4, 5 EXPLANATIONS: 1. "My pain will be completely gone when I wake up." — Postoperative pain is common. This client requires further instruction regarding this common phenomenon. 3. "I will probably be incontinent after the surgery." — Bowel or bladder incontinence would be an unexpected complication that might indicate spinal cord injury. This statement indicates the need for further instruction. 4. "I do not smoke so there will not be complications." — The client may still have complications, although the risks for many complications are reduced. This statement indicates the need for further instruction. 5. "It does not matter if I take herbal supplements." — The use of herbal supplements should be shared with the health care team as some herbs interfere with other treatments and medications. This statement indicates the need for further instruction. Think like a nurse: Although the client may be experiencing severe nerve pain generating from the C3-C4 site, the surgery, in time, will eliminate or decrease that pain. However, post-operative pain will still occur. The spine will need to be kept in proper anatomical alignment after a laminectomy until healing is complete.

The nurse determines that a client with malnutrition is at risk for pressure injuries. Which interventions will the nurse include in this client's plan of care to decrease this risk? (Select all that apply.) 1. Avoid the use of donut-type devices. 2. Massage bony prominences. 3. Elevate the head of the bed no more than 30 degrees. 4. Position flat when side lying. 5. Avoid prolonged periods of sitting in a chair.

ANSWERS: 1, 3, 5 EXPLANATIONS: 1. Avoid the use of donut-type devices. - Donut-type devices promote ischemia. 3. Elevate the head of the bed no more than 30 degrees. - Elevating the head of the bed no more than 30 degrees will decrease the chance of pressure injury development from shearing forces. 5. Avoid prolonged periods of sitting in a chair. - Prolonged sitting can lead to decreased blood flow and pressure injuries. Think like a nurse. To prevent pressure injuries, the National Pressure Ulcer Advisory Panel recommends that the nurse ensure that the client's heels are free from the bed. Additionally, the staff should use heel offloading devices or polyurethane foam dressings on individuals at high risk for heel pressure injuries. The nurse should inspect the skin upon admission as soon as possible (within 8 hours). Heel pressure injury can develop over a short period. When a client suffers from neuropathy (e.g., reduce leg sensation), the client may not feel pain on the injured heel. Persons at risk for pressure injury from malnutrition should be referred to a registered dietitian/nutritionist. Monitor a client's weight and adequacy of oral or enteral nutrition daily.

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? 1. Diarrhea 2. Hypermenorrhea 3. Abnormal bleeding 4. Abdominal distention

Abdominal distention - Clinical manifestations of ovarian cancer: abdominal distention, urinary frequency & urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor add the effects of urinary bladder and bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. - Abnormal bleeding often resulting from hypermenorrhea is associated with uterine cancer.

The nurse enters a client's room and finds that the wastebasket is on fire. After immediately assisting the client out of the room what is the nurse's next action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

Activate the fire alarm. - Followed by containing the fire and extinguishing it.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse determines that the client is receiving the therapeutic effect based on which results? 1. Prothrombin time of 12.5 seconds 2. Activated partial thromboplastin time of 60 seconds 3. Activated partial thromboplastin time of 28 seconds 4. Activated partial thromboplastin time longer than 120 seconds.

Activated partial thromboplastin time of 60 seconds - aPTT normal range is 30-40 seconds and since the aPTT should be 1.5-2.5 times the normal level, the client would be considered to be in the therapeutic range at 60 seconds. - Prothrombin time assesses response to Warfarin therapy

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of IV fluid increasing urine output to 25 mL/hr in the next hour. Daily laboratory results indicate that the BUN level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection

Acute kidney injury - Normal BUN: 10-20 mg/dL - Normal creatinine: 0.6-1.2 mg/dL (M) and 0.5-1.1 mg/dL (F). - The client is at risk for renal injury due to poor perfusion, hemolysis, low cardiac output or vasopressor medication therapy. Renal injury is signaled by increased BUN and creatinine levels.

A client has had an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? 1. Constipation 2. Abdominal Pain 3. An episode of diarrhea 4. Hematest-positive nasogastric tube drainage

An episode of diarrhea - Loperamide hydrochloride is an antidiarrheal used to manage acute and chronic diarrhea in conditions such as IBD. Loperamide can also be used to reduce the volume of drainage from an ileostomy.

The nurse provides care for an older adult client who had a stroke. Assessment findings include right-sided weakness, facial drooping, difficulty swallowing, and limited mobility. The nurse recognizes which sites are appropriate for use when assessing the client's temperature? (Select all that apply.) 1. Axillary. 2. Oral. 3. Tympanic membrane. 4. Rectal. 5. Temporal artery.

Answer: 1. Axillary. 3. Tympanic membrane. 5. Temporal artery. 1. Axillary. CORRECT- Axillary temperature measurement is safe, noninvasive, and appropriate for use with the client who has had a stroke. Oral and rectal temperature measurements are not the best option for this client, due to facial drooping and the client's potential difficulty with assuming a side-lying position, which is necessary for assessment of rectal temperature. 2. Oral. INCORRECT - Due to facial drooping and difficulty swallowing, the oral cavity is not the best site for temperature assessment in the client who has had a stroke. 3. Tympanic membrane. CORRECT- The tympanic membrane is an appropriate site for use in temperature assessment with the client who has sustained a stroke, as this site is easily accessible and does not require client repositioning. 4. Rectal. INCORRECT - Rectal temperature measurement is not ideal for the client who demonstrates limited mobility (including the client whose mobility is impaired due to a stroke), as maintaining a side-lying position may be challenging. Rectal temperature assessment provides no significant advantages over other routes of temperature assessment. 5. Temporal artery. CORRECT- The temporal artery is an appropriate site for measurement of temperature in the client who has had a stroke, as this route is safe and easily accessible. However, use of this method requires specialized equipment that may not be available to the nurse. Think like a nurse: For the client who has experienced a stroke or cerebrovascular accident (CVA), measurement of vital signs requires certain precautions. The nurse will avoid taking an oral temperature due to facial paralysis. Nerves that control facial muscles are damaged and it is not completely safe or accurate to obtain an oral temperature under these circumstances. If the stroke resulted in hemiplegia, blood pressure measurements are obtained on the unaffected side of the client's body. Changes in muscle tone make obtaining a blood pressure on the affected side inaccurate and unsafe.

The nurse discusses skateboard safety with a group of parents. Which statement is most important for the nurse to include? 1. "If your children are younger than 5 years of age, always observe them while they are skateboarding." 2. "Carefully check the surface where your child will be skateboarding." 3. "It does not matter what type of skateboard you get for your child." 4. "Instruct your child to keep as close to the curb as possible."

Answer: 2. "Carefully check the surface where your child will be skateboarding." Explanations: 1. "If your children are younger than 5 years of age, always observe them while they are skateboarding." INCORRECT - Children younger than 5 years of age should not skateboard. Developmentally, they have difficulty protecting themselves from injury. 2. "Carefully check the surface where your child will be skateboarding." CORRECT— The parents should check for holes, bumps, rocks, and debris that may cause an accident. 3. "It does not matter what type of skateboard you get for your child." INCORRECT - Skateboards are designed for various uses (slalom, freestyle, or speed). The parents should know how the child plans to use the skateboard. 4. "Instruct your child to keep as close to the curb as possible." INCORRECT - The child should never ride a skateboard in the street and should not be close to the curb. Think like a nurse: Bicycling, riding scooters, skateboarding, and inline skating are common activities of school-age children. Laws in some states require a helmet for riding bikes and scooters. In addition, when skating or skateboarding, school-age children should wear a helmet, knee pads, and elbow pads.

The nurse plans care for a client diagnosed with meningitis due to Haemophilus influenza. It is important for the nurse to include which intervention in the client's plan of care? 1. Place the client in isolation until cerebrospinal fluid culture results are normal. 2. Monitor vital signs and perform neurological checks every 6 hours. 3. Dim the room lights, turn off the television, and reduce the noise level. 4. Encourage oral fluids and administer intravenous fluids as needed.

Answer: 3. Dim the room lights, turn off the television, and reduce the noise level. Explanations: 1. Place the client in isolation until cerebrospinal fluid culture results are normal. INCORRECT - The client is placed on droplet precautions until 24 hours after culture-specific antibiotics are started. Some institutions may have varying guidelines, but ending isolation will not depend on the culture results. 2. Monitor vital signs and perform neurological checks every 6 hours. INCORRECT - The nurse assesses for increasing ICP and shock. Neurological checks are done frequently in acute meningitis, at least every 4 hours, and more frequently as indicated. Ideally, continual monitoring of vital signs is desired. 3. Dim the room lights, turn off the television, and reduce the noise level. CORRECT— Reducing environmental stimuli is essential to reducing complications. Meningeal irritation causes headache, light sensitivity, and seizures. 4. Encourage oral fluids and administer intravenous fluids as needed. INCORRECT - The client may be on fluid restriction due to increased ICP or may be neurologically unable to safely drink, but dehydration is carefully avoided by use of continuous, low-volume IV fluids. Think like a nurse: The client diagnosed with meningitis will be subject to isolation for a short period. The nurse's primary concerns are preventing increases in intracranial pressure and managing symptoms of meningitis, such as headache, photophobia, disorientation, and seizures. Fluid management, administration of prescribed medications (including anti-infective agents, steroids, and analgesics) are essential to this client's care. Non-pharmacological measures to promote a calm, peaceful environment are also important to avoid overstimulating the client.

The nurse provides discharge teaching to a client with multiple sclerosis. Which instruction is most important for the nurse to include? 1. Ambulate as tolerated every day. 2. Avoid overexposure to heat or cold. 3. Perform stretching and strengthening exercises. 4. Participate in social activities.

Answer: AVOID OVEREXPOSURE TO HEAT OR COLD 1. Ambulate as tolerated every day. INCORRECT— Although the client should be encouraged to ambulate as tolerated, this is not the most important instruction. 2. Avoid overexposure to heat or cold. CORRECT— Overexposure to heat or cold may cause damage related to the changes in sensation. Extremes in temperature can also exacerbate multiple sclerosis symptoms. 3. Perform stretching and strengthening exercises. INCORRECT— The client should be encouraged to participate in an exercise program that includes range-of-motion (ROM), stretching, and strengthening exercises, but this is not the most important instruction. 4. Participate in social activities. INCORRECT— The client should be encouraged to continue usual activities as much as possible, including social activities. However, this is not the most important instruction. Think like a nurse: Extremes in temperature can cause an exacerbation of symptoms in the client with multiple sclerosis. This is the most important area for the nurse to focus. Ambulation, exercise, and social activities are important; however, they do not help reduce the severity or exacerbation of symptoms.

A client weighing 45 lb is prescribed furosemide 4 mg/kg/day in four divided doses. Which amount in milligrams will the nurse administer to the client for one dose. (Round at the end of the equation. Record your answer using two decimal places.)

Answer: 20.45 mg Ratio/Proportion: 45 lbs/2.2 = 20.4545 kg 4mg x 20.4545 kg = 81.8181 mg/day 81.8181/4 = 20.4545 mg/dose

The nurse provides a client with a prescribed dose of hydrocodone for pain. Which findings related to the current prescribed pain medication cause the nurse to follow-up with the health care provider? (Select all that apply.) 1. Client reports pain is 8 out of 10. 2. Assesses respiratory rate as 8 breaths per minute. 3. Notes petechiae on the client's abdomen and forearms. 4. Notes potassium level is 3.4 mEq/L (3.4 mmol/L). 5. Notes urine output is 60 mL over the past 2 hours.

Answers: 1, 2, 3 Explanation: 1. Client reports pain is 8 out of 10. — A pain level of 8 out of 10 indicates pain that is unrelieved by the current medication prescription and requires follow-up by the nurse. The client may need an increased dose or change in pain medication. 2. Assesses respiratory rate as 8 breaths per minute. — A respiratory rate of 8 breaths per minute is a sign of over-sedation. The client's prescribed medication dose may need to be altered by the health care provider. 3. Notes petechiae on the client's abdomen and forearms. — Petechiae are a sign of an allergic reaction and should be reported to the health care provider. Think like a nurse: When providing care to a client who is prescribed opioid analgesics, the nurse needs to closely monitor the client for potential adverse drug reactions such as respiratory depression and allergic reaction. Naloxone should be readily available when administering opioid medications, as naloxone is prescribed to counteract the adverse reaction of respiratory depression. While monitoring the client for adverse reactions, the nurse must also assess for pain relief. This is typically done 30 to 45 minutes after the medication is administered. Unrelieved or worsening pain warrants further assessment and collaboration with the health care provider.

The nurse provides care for a client who had a transurethral resection of the prostate (TURP). The client has a three-way urinary catheter connected by gravity with continuous bladder irrigation (CBI) of normal saline. Which observations require the nurse to intervene? (Select all that apply.) 1. Temperature of 101.4°F (38.3°C). 2. Urinary output of 100 mL in 4 hours. 3. Fluid leakage around the catheter tubing. 4. Blood pressure of 112/76 mm Hg. 5. 230 mL of sanguineous fluid in the catheter bag. 6. Client reports pressure in the pelvis.

Answers: 1, 2, 3, 5 Explanation: 1. Temperature of 101.4°F (38.3°C). — An elevated temperature may indicate an infection, which is a complication of TURP. 2. Urinary output of 100 mL in 4 hours. — The client should produce at least 30 mL of urine per hour, so should have a minimum of 120 mL in 4 hours. In addition, the client will have the bladder irrigation fluid. 3. Fluid leakage around the catheter tubing. — Fluid leakage from the urethra around the catheter suggests a concern with the catheter. The nurse should assess for balloon inflation and proper positioning of the catheter. 5. 230 mL of sanguinous fluid in the catheter bag. — Hemorrhage is the greatest danger following TURP. While pink-tinged urine with occasional clots is expected, the client should not have sanguinous drainage, as it suggests hemorrhage. Think like a nurse: The nurse considers which findings are normal after a transurethral resection of the prostate (TURP) is performed and which findings indicate a complication. For any client, a fever over 101°F or urine output less than 30 mL per hour is a reason to notify the health care provider. Determining whether the client is bleeding will be difficult when the collection bag is full of urine, irrigation solution, and blood. The nurse is concerned when unmistakable, concentrated red blood is noted, indicating a site of hemorrhage. Decreased urine output can indicate hemorrhage, catheter blockage, or other complications.

The public health nurse visits an Asian American client who receives directly-observed therapy for tuberculosis. Which nursing actions demonstrate cultural competence when providing care to this client? (Select all that apply.) 1. Understanding the differences between the client 's and the nurse 's cultures. 2. Ensuring that the client understands why tuberculosis treatment requires Western medicine. 3. Understanding that different cultures hold different beliefs about health and disease. 4. Accepting the stereotypes based on the client 's culture. 5. Respecting the client 's values and beliefs.

Answers: 1, 2, 3, 5 Explanation: 1. Understanding the differences between the client 's and the nurse 's cultures. —A culturally competent nurse understands the differences between the nurse 's own culture and the culture of the client. 2. Ensuring that the client understands why tuberculosis treatment requires Western medicine. —The nurse who demonstrates cultural competence is able to recognize that the client may have different views about Western medicine and may not understand the importance of drug therapy in treating tuberculosis or may want to utilize therapies used in their own culture. 3. Understanding that different cultures hold different beliefs about health and disease. —A culturally competent nurse understands that different cultures hold different beliefs about health and disease, including the cause of disease. 5. Respecting the client 's values and beliefs. —A culturally competent nurse should respect the individual client 's culture and beliefs. Think like a nurse: Cultural competence includes recognizing that individuals and groups differ in terms of their beliefs, perceptions, and values. Moreover, cultural competence includes understanding that within a specific cultural group, not all members necessarily think alike. Presuming an Asian American client does not understand the relevance of Western medicine in the treatment of tuberculosis may constitute stereotyping. Rather than making assumptions based on ethnicity, the nurse 's role is to tactfully explore the client 's beliefs and preferences. The nurse then advocates for incorporating the client 's preferences into the plan of care whenever it is possible to safely do so. If the nurse seeks first to understand, then to teach and care, clients are often happy to explain their perspective.

The perioperative nurse is evaluating a group of clients for risk factors that may lead to postoperative complications. Which clients are at high risk for developing respiratory complications following surgery? (Select all that apply.) 1. A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago. 2. A 34-year-old smoker who underwent a left ankle repair 2 days ago. 3. A 60-year-old nonsmoker who underwent carpal tunnel surgery 3 hours ago. 4. A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago. 5. A 42-year-old nonsmoker who had a chest tube removed 2 hours ago.

Answers: 1, 2, 4 & 5 Explanation: 1. A 76-year-old nonsmoker who underwent an open cholecystectomy one day ago. - Aging increases the risk for respiratory complications, as mucociliary clearance ability diminishes with age. Following abdominal surgery, splinting and pain also may lead to shallow breathing, atelectasis, and decreased mucociliary clearance. 2. A 34-year-old smoker who underwent a left ankle repair 2 days ago. - Smoking increases the risk for postoperative complications, including respiratory problems, due to impaired mucociliary clearance. 4. A 48-year-old nonsmoker who had coronary artery bypass graft (CABG) surgery 48 hours ago. - Thoracic surgery leads to a decreased ability to cough and inhale deeply, and decreased mucociliary clearance. 5. A 42-year-old nonsmoker who had a chest tube removed 2 hours ago. - Lung trauma, including trauma due to procedures or surgery, increases the risk for developing respiratory complications. Think like a nurse: Risk factors for post-operative complications include increased age, history of smoking, certain surgical procedures, and lung trauma. The client post-cholecystectomy is of advanced age and is at risk. The client with a history of smoking is at risk for developing respiratory problems post-operatively. The client post-CABG is at risk because the incision location may hinder the ability to breathe deeply and cough. The client who had a chest tube recently removed is at risk because of lung trauma.

The nurse teaches a new parent about childhood immunizations for a 2-month-old client. Which immunizations does the nurse include in this teaching? (Select all that apply.) 1. Rotavirus. 2. Diphtheria, tetanus, pertussis. 3. Varicella. 4. Haemophilus influenzae type b. 5. Inactivated poliovirus. 6. Measles, mumps, rubella.

Answers: 1, 2, 4, 5 Explanation: 1. Rotavirus. CORRECT - Rotavirus vaccine (RV) is due at 2 months. 2. Diphtheria, tetanus, pertussis. CORRECT - Diphtheria, tetanus, pertussis (DTaP) vaccine are due at 2 months. 3. Varicella. INCORRECT - The varicella vaccine is due at 12 to 15 months and 4 to 6 years. 4. Haemophilus influenzae type b. CORRECT -Haemophilus influenzae type b (Hib) is due at 2 months. 5. Inactivated poliovirus. CORRECT- The inactivated poliovirus (IPV) vaccine is due at 2 months. 6. Measles, mumps, rubella. INCORRECT - Measles, mumps, and rubella (MMR) vaccine is administered at 12 to 15 months and 4 to 6 years. Think like a nurse: The Centers for Disease Control and Prevention (CDC) publishes a table that identifies when specific vaccinations should be received. A 2-month-old child should receive immunization against rotavirus, diphtheria, tetanus, and pertussis, Haemophilus influenzae , and poliovirus. Immunization against varicella and measles, mumps, and rubella are provided when the child is between 12 to 15 months of age, and then repeated when the child is 4 to 6 years of age.

The nurse manager reviews the medical records for clients receiving care on the unit. Which documentation entries require the completion of an incident report? (Select all that apply.) 1. "Client fell at 09:00 while getting out of bed. Client denied pain. No injuries noted. " 2. "Client reports 8/10 pain after receiving pain medication. Health care provider notified. " 3. "Levofloxacin 500 mg PO prescribed. Levofloxacin 750 mg PO administered." 4. "Vesicant medication infusing. Client 's IV site warm to touch, reddened, and swollen. " 5. "Client left facility before signing a leaving against medical advice form. "

Answers: 1, 3, 4, 5 Explanation: 1. "Client fell at 09:00 while getting out of bed. Client denied pain. No injuries noted. " — Falls, regardless of injury, require an incident report. 3. "Levofloxacin 500 mg PO prescribed. Levofloxacin 750 mg PO administered." — Medication errors require incident reporting. 4. "Vesicant medication infusing. Client 's IV site warm to touch, reddened, and swollen. " — Intravenous infiltration requires incident reporting. Also, vesicant medications can severely damage the client 's tissues. 5. "Client left facility before signing a leaving against medical advice form. " — All medical/legal occurrences require incident reporting. Think like a nurse: Reporting incidents, including medication errors, is now typically done electronically in most facilities. These reports may be used by the legal team to defend the health care agency against lawsuits. The report is considered confidential communication and cannot be subpoenaed by clients or used as evidence in lawsuits. In writing the report, the nurse must objectively describe the incident. No entry should be made in the client 's record about the existence of an incident report. The chart should, however, provide enough information about the incident so that appropriate treatment can be given. The agency may choose to do a root cause analysis for serious incidents.

After attending a presentation on sexually transmitted infections (STIs), an adolescent participant asks the nurse if the human papillomavirus (HPV) vaccination is necessary if a person is not sexually active. Which response will the nurse make to this adolescent? (Select all that apply.) 1. "Immunizations are recommended to provide immunity before exposure." 2. "The human papillomavirus vaccine reduces the risk of ovarian cancer as you get older." 3. "This vaccine is recommended for males and females at 11 -12 years of age." 4. "Use of condoms prevents the transmission of this sexually transmitted infection." 5. "The human papillomavirus vaccine is recommended after the first sexual experience." 6. "The human papillomavirus can cause cervical or penile cancer."

Answers: 1, 3, 6 Explanation: 1. "Immunizations are recommended to provide immunity before exposure." — Even though the person asking the question is not currently sexually active, receiving the vaccine before exposure is the goal of immunizations. 3. "This vaccine is recommended for males and females at 11 -12 years of age." — The HPV vaccine is recommended at 11 -12 years of age for males and females prior to sexual activity. 6. "The human papillomavirus can cause cervical or penile cancer." — It is correct that HPV can cause cancer in multiple locations, as well as genital warts. Think like a nurse: Teaching about the causes and risks associated with the human papillomavirus is appropriate during the adolescent years. It is during this time when sexual identity is being explored and clients of this age may experience their first sexual encounter. The clients need to understand the purpose of immunization for this virus is a precautionary measure against future disease processes. The vaccine is recommended regardless of the client's sexual experience. The vaccination is recommended for both genders and should be emphasized as such. The ideal age for receiving this vaccination is prior to having sexual encounters.

A client with a history of diabetes mellitus (DM) and asthma takes high-dose corticosteroids. Which dermatologic complications will the nurse assess in this client? (Select all that apply.) 1. Delayed wound healing. 2. Skin pigmentation changes. 3. Alopecia. 4. Erythematous plaques on legs. 5. Decreased subcutaneous fat over extremities.

Answers: 1, 4, 5 Explanation: 1. Delayed wound healing. CORRECT- Corticosteroids delay wound healing. 4. Erythematous plaques on legs. CORRECT- Erythematous plaques on the legs is related to diabetes mellitus. 5. Decreased subcutaneous fat over extremities. CORRECT- Decreased subcutaneous fat in the extremities is related to both diabetes mellitus and corticosteroids. Think like a nurse: Long-term steroid therapy may be prescribed for treatment of clients with various conditions, including chronic asthma or autoimmune disorders, such as lupus or rheumatoid arthritis. Both long-term systemic steroid therapy and Cushing syndrome result in multisystem effects of cortisol. Cortisol causes catabolism, altering the strength of tissues such as muscles and blood vessels. Collagen and elastic fibers in the epidermis are ruptured, resulting in decreased skin elasticity. While systemic steroid therapy does not typically cause changes in skin pigmentation, integumentary changes can include fragile skin, easy bruising, dry skin, acne, stretch marks, or infection. Topical corticosteroid cream misuse can cause integumentary effects such as skin thinning and telangiectasia

The nurse delegates tasks to the unlicensed assistive personnel (UAP). For which UAP action does the nurse intervene? (Select all that apply.) 1. Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy. 2. Reapplies the nasal cannula for a client who displaces the oxygen tubing. 3. Reports a decrease in a client's systolic blood pressure to the health care provider. 4. Reports an abnormal capillary blood glucose value to the nurse. 5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth.

Answers: 1. Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy. 3. Reports a decrease in a client's systolic blood pressure to the health care provider. 5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth. Explanation: 1. Decreases the flow rate of oxygen from 4 L/minute to 2 L/minute for a client being titrated off oxygen therapy. - Titrating an oxygen flow rate requires the nurse to assess the client's tolerance to a lower amount of oxygen. This action should only be done by the nurse. 3. Reports a decrease in a client's systolic blood pressure to the health care provider. - Only the nurse should report a change in client status to the health care provider (HCP). The HCP may want to provide new prescriptions, which the UAP cannot accept, since this is beyond the scope of practice. 5. Assists a healthy, multiparous, postpartum client to the bathroom for the first time following childbirth. - Since the client has just delivered, the nurse may need to provide teaching such as perineal cleansing. The nurse should assist the client to the bathroom to assess tolerance to activity and urine output. This task is not appropriate to delegate to the UAP. Think like a nurse: The nurse needs to consider the scope of practice of the UAP before deciding to intervene. The UAP may not administer or adjust prescribed therapies, such as oxygen. The UAP is responsible for following the chain of command and reporting any abnormal findings to the nurse. In considering whether the UAP may perform a task such as ambulation, the nurse considers whether the client is stable or whether the client has just experienced a change that may require assessment by the nurse. Just as the first set of vital signs upon admission or post-surgery should be performed by the nurse, the first ambulation to the bathroom post-delivery should also be done by the nurse.

The nurse provides care for a client diagnosed with pneumonia and acute respiratory distress syndrome (ARDS). The client asks about the benefits of pulmonary rehabilitation. Which results of the rehabilitation program will the nurse include in the teaching? (Select all that apply.) 1. Improved exercise capacity. 2. Decreased anxiety. 3. Decreased depression. 4. Increased oxygen needs. 5. Decreased hospitalizations.

Answers: 1. Improved exercise capacity. 2. Decreased anxiety. 3. Decreased depression. 5. Decreased hospitalizations. Explanation: 1. Improved exercise capacity. - The program will help improve endurance and oxygenation. 2. Decreased anxiety. - Decreased anxiety is one of the major anticipated goals of the program. 3. Decreased depression. - Decreased depression is one of the major anticipated goals of the program. 5. Decreased hospitalizations. - Decreased hospitalizations is one of the major anticipated goals of the program. Think like a nurse: Recovery from acute respiratory distress syndrome (ARDS) could take time and requires pulmonary rehabilitation. This is partly because the fibrotic changes in the lung tissue may cause lasting damage, leading to chronic hypoxia. Exercise, diet, and health maintenance activities, such as influenza and pneumonia vaccination and avoiding contact with sick persons, are warranted. If the client requires home oxygen therapy, oxygen handling safety is reviewed with the client and caregiver. The nurse should use the teach-back method in all educational encounters, giving the client and caregiver an opportunity to ask questions.

The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.) 1. Remain with the client. 2. Contact the police to interview the client. 3. Administer prescribed lorazepam 1 mg orally. 4. Encourage client to describe the incident. 5. Provide privacy for the client. 6. Write down important information.

Answers: 1. Remain with the client. 3. Administer prescribed lorazepam 1 mg orally. 5. Provide privacy for the client. 6. Write down important information. Explanation: 1. Remain with the client. - Since the client is severely anxious, the nurse should remain with the client. Through use of therapeutic communication, the nurse should assist the client to clarify thoughts and feelings. 3. Administer prescribed lorazepam 1 mg orally. - Administering the prescribed lorazepam, an anti-anxiety medication, will help the client cope with the anxiety. 5. Provide privacy for the client. - Since the client is anxious, it is important to provide privacy from the activities in the ED, which may overstimulate the client. 6. Write down important information. - The client may have difficulty listening to and understanding information if anxiety is severe. Therefore, it is important for the nurse to write down essential information. Think like a nurse: The nurse understands that witnessing a traumatic event can be overwhelming to a client's psychological balance. For the client who observed such an event with a family member or friend, the client may demonstrate behaviors consistent with panic. The nurse needs to assess for client needs and plan client care accordingly. The client should not be left alone, and should be placed in an environment with limited stimulation in order to keep calm. Additionally, if the client is not able to understand instructions, the nurse will need to have information repeated or provided in another format. If the reaction to the stress is severe, a sedative may be prescribed to help reduce the effects of the stress on the body.

The nurse receives a report on clients who reside on the psychiatric unit. Which actions, if performed by the off-going nurse, require follow-up by the nurse? (Select all that apply.) 1. The nurse assessed a suicidal client every 15 minutes. 2. The nurse administered ziprasidone to a violent client. 3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal. 4. The nurse allowed a suicidal client to remain in street clothes. 5. The nurse initiated a signed PRN prescription for physical restraints.

Answers: 1. The nurse assessed a suicidal client every 15 minutes. 3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal. 4. The nurse allowed a suicidal client to remain in street clothes. 5. The nurse initiated a signed PRN prescription for physical restraints. Explanations: 1. The nurse assessed a suicidal client every 15 minutes. - The suicidal client must have one-on-one supervision at all times. The client could attempt suicide in a 15-minute interval. 3. The nurse placed a client in a dimly lit room after the client did not eat all of the provided meal. - Seclusion is never punitive. This intervention is only to be used to achieve the goal of client and others ' safety. 4. The nurse allowed a suicidal client to remain in street clothes. - All clothing and personal belongings are secured to minimize the potential for self-harm. Clients are placed in hospital gowns only. 5. The nurse initiated a signed PRN prescription for physical restraints. - Restraints are never a PRN prescription. The nurse uses alternative measures prior to the use of restraints (such as reorientation, family involvement, frequent assistance with toileting). Think like a nurse: The Joint Commission requires all health care providers to implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions. The scenario described offers several opportunities for the oncoming nurse to verify the clients ' plans of care, to reinforce adherence to protocol and procedure, and to ensure delivery of evidence-based practice. Situational crisis calls for the application of TeamSTEPPS ®, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety. This evidence-based framework aims to improve communication and collaboration among health care team members by promoting effective use of information, personnel, and resources for the purpose of achieving optimal client outcomes.

The nurse assesses a newborn immediately after birth. Which APGAR assessments cause the nurse to assign a score of less than 2 for an area? (Select all that apply.) 1. Weak cry. 2. Actively moving the arms and legs. 3. Body is pink, but extremities are blue. 4. Heart rate is 86. 5. Grimaces when a probe is placed into the nasal cavity.

Answers: 1. Weak cry. 3. Body is pink, but extremities are blue. 4. Heart rate is 86. 5. Grimaces when a probe is placed into the nasal cavity. Explanation: 1. Weak cry. — The baby should have a vigorous cry to receive a score of 2. 3. Body is pink, but extremities are blue. — The baby should be completely pink at birth to receive a score of 2. Blue extremities are not uncommon and are not a cause for great concern. The baby needs to be warmed. 4. Heart rate is 86. — The baby's heart rate should be over 100 to receive a score of 2. 5. Grimaces when a probe is placed into the nasal cavity. — The baby should actively move from the stimulation to receive a score of 2. Think like a nurse: The Apgar score is an assessment method to determine a newborn's physiologic response to extra-uterine life. The score is based upon observations of the newborn's cry, body color, heart rate, and activity when stimulated. To receive a maximum score of 2 for each of the parameters, the newborn should have a lusty cry, have pink skin color, have a heart rate within normal limits for a newborn, and actively avoid stimulation. The nurse needs to be aware that the first score is not expected to be a 10. As with all screening tools, the nurse knows that screening is helpful in recognizing real or potential problems, and the tool should be used appropriately and with discrimination.

The nurse provides care for the client diagnosed with esophageal cancer. Which goals does the nurse establish in the plan of care? (Select all that apply.) 1. Client will experience remission of the cancer. 2. Client will swallow liquids without aspiration. 3. Client will state an acceptable level of pain. 4. Client will maintain weight within normal range. 5. Client will agree to hospice consult.

Answers: 2, 3, 4 Explanation: 2. Client will swallow liquids without aspiration. - Risk for aspiration is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis. 3. Client will state an acceptable level of pain. - Pain is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis. 4. Client will maintain weight within normal range. - Risk for imbalanced nutrition is an appropriate nursing diagnosis for this client, and this is an appropriate goal for that diagnosis. Think like a nurse: Esophageal cancer impacts the client's ability to swallow. A nursing diagnosis that addresses the risk for aspiration is appropriate. Additionally, the client's nutritional status will be compromised due to the problem with swallowing. A nursing diagnosis that addresses weight management is essential. Pain management is an appropriate intervention because of the diagnosis and location of the pathology.

The nurse supervises the care of a client receiving enteral feedings through an NG tube. Which observations indicate to the nurse that the care being provided by the unlicensed assistive personnel (UAP) is appropriate for this client? (Select all that apply.) 1. Aspirates and measures the amount of the gastric aspirate. 2. Elevates the head of the bed 30 degrees. 3. Warms the feeding to room temperature. 4. Measures the pH of the gastric aspirate. 5. Infuses the intermittent feeding in 20 minutes. 6. Clamps the proximal end of the feeding tube at the end of the feeding.

Answers: 2. Elevates the head of the bed 30 degrees. 3. Warms the feeding to room temperature. 6. Clamps the proximal end of the feeding tube at the end of the feeding. Explanations: 1. Aspirates and measures the amount of the gastric aspirate. INCORRECT - Aspiring and measuring the amount of gastric aspirate verifies placement of the tube and should be performed by the nurse. 2. Elevates the head of the bed 30 degrees. CORRECT— Elevating the head of the bed prevents aspiration and indicates appropriate care by the UAP. 3. Warms the feeding to room temperature. CORRECT— Warming the feeding to room temperature prevents cramping and indicates appropriate care by the UAP. 4. Measures the pH of the gastric aspirate. INCORRECT - Measuring the pH of gastric aspirate should be performed by the nurse. 5. Infuses the intermittent feeding in 20 minutes. INCORRECT - The feeding should be infused over a minimum of 30 minutes. 6. Clamps the proximal end of the feeding tube at the end of the feeding. CORRECT— Clamping the proximal end of the feeding tube at the end of the feeding prevents air from entering the stomach and indicates appropriate care by the UAP. Think like a nurse: When supervising client care, the nurse first considers the scope of practice of the care provider. The unlicensed assistive personnel (UAP) is able to provide nasogastric tube feedings if the skill has been deemed appropriate and safe to provide to a stable client. However, the UAP cannot perform assessment or evaluation, such as checking the amount or pH of the gastric aspirate. The nurse then considers the safety of the actions provided by the UAP. When administering a nasogastric tube feeding, the head of the bed should be elevated to prevent aspiration. Warming the feeding to room temperature prevents gastric cramping and distress. And clamping the nasogastric tube at the conclusion of the feeding prevents air from entering the gastrointestinal tract. These actions are appropriate for UAP to perform.

The nurse provides care to a client diagnosed with iron-deficiency anemia. Which findings does the nurse anticipate as characteristic of this disorder? (Select all that apply.) 1. Autoimmune-related disease. 2. May occur with removal of duodenum. 3. Associated with chronic blood loss. 4. Most common type of anemia. 5. Lack of intrinsic factor.

Answers: 2. May occur with removal of duodenum. 3. Associated with chronic blood loss. 4. Most common type of anemia. Explanation: 2. May occur with removal of duodenum. — Removal of the duodenum results in the malabsorption of iron. 3. Associated with chronic blood loss. — Chronic blood loss causes a loss of iron. 4. Most common type of anemia. — More cases of iron-deficiency anemia occur than other types of anemia. Think like a nurse: There are many types of anemia. However, underlying causes of anemia typically fall into three main categories: acute blood loss, decreased red blood cell (RBC) production, and increased RBC destruction. Iron is needed to make hemoglobin, which is the component of the RBC that carries oxygen. The duodenum is the main site of iron absorption. If the client has undergone surgical removal of the duodenum (duodenectomy), iron supplementation will likely be needed. Because oral iron supplements are not well absorbed by the gastrointestinal tract, intravenous iron infusions may be prescribed.

The nurse teaches an adult female client with a family history of hypertension. Which recommendation does the nurse include in client education? (Select all that apply.) 1. Limit sodium intake to 2 grams or less daily. 2. Exercise at least twice weekly. 3. Avoid use of tobacco products. 4. Limit alcohol consumption to one serving per day. 5. Limit coffee consumption to two servings daily.

Answers: 1, 3, 4 Explanation: 1. Limit sodium intake to 2 grams or less daily. - Excessive sodium intake (greater than 2 grams daily) increases the risk for hypertension. 3. Avoid use of tobacco products. - Smoking or the use of other tobacco products increases the risk for hypertension. 4. Limit alcohol consumption to one serving per day. - Excessive alcohol intake is linked to hypertension. For adult females, no more than one serving of alcohol per day is recommended. Think like a nurse: Risk factors for the development of hypertension include excessive sodium intake, a sedentary lifestyle, use of tobacco products, and excessive alcohol intake. Sodium increases the amount of body fluid, which can cause a subsequent increase in blood pressure. A sedentary lifestyle encourages hemo-stagnation in the extremities, which weakens blood vessels. Tobacco and nicotine directly effect the blood vessels, causing constriction. Alcohol alters fluid balance, which affects all body systems.

A client newly diagnosed with emphysema is being discharged to home. Which client statement indicates to the nurse an understanding of the discharge instructions? (Select all that apply.) 1. "I need to get my annual influenza vaccine." 2. "I need to decrease my smoking to half a pack a day." 3. "I will sit while watching my grandson's soccer games." 4. "I should limit my fluid intake to 4 cups of water a day." 5. "I am signing up for tai chi at my local community center." 6. "I should eat three large meals each day."

Answers: 1, 3, 5 Explanation: 1. "I need to get my annual influenza vaccine." CORRECT — It is important to limit the risk for infection. Clients with emphysema are at high risk of infection and develop influenza-related complications, such as pneumonia, more easily. 2. "I need to decrease my smoking to half a pack a day." INCORRECT— The client needs to quit smoking completely. 3. "I will sit while watching my grandson's soccer games." CORRECT — It is important for this client to conserve energy when possible. 4. "I should limit my fluid intake to 4 cups of water a day." INCORRECT — Fluid intake should be increased to liquefy secretions. Four cups of liquid per day is not adequate. This client needs to drink more than the recommended daily intake of 8 cups. 5. "I am signing up for tai chi at my local community center." — It is important to practice relaxation and stress reduction techniques. Exercise also will help this client gain control of respiratory effort. 6. "I should eat three large meals each day." INCORRECT— The client should eat small, frequent meals. This helps prevent pressure on the diaphragm, which increases the work of breathing. Think like a nurse: Client education is an expected competency for every nurse. An essential first step is to assess the client's teaching and learning needs, including literacy issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level. Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method. Clients with emphysema should be informed on which warning signs to report to their provider (e.g., peak flow meter readings in the red zone).

The nurse administers an immunization to an adult client. Which observations made after the injection cause the nurse to immediately intervene? (Select all that apply.) 1. The client is clearing the throat and coughing. 2. The client has nasal drainage and sneezing. 3. The client is anxious and exhibits rapid breathing. 4. The client is feverish and sweating profusely. 5. The client reports dizziness upon standing. 6. The client has a diffuse rash across the trunk.

Answers: 1, 3, 5 Explanation: 1. The client is clearing the throat and coughing. - An anaphylactic reaction may begin with the client clearing the throat and coughing due to swelling in the airway. The nurse should assess the client for other signs of anaphylaxis and be prepared to intervene. 3. The client is anxious and exhibits rapid breathing. - Tachypnea and feelings of impending doom occur with anaphylaxis. This client needs immediate assessment and care. 5. The client reports dizziness upon standing. - Dizziness upon standing may be indicative of hypotension, which occurs with anaphylaxis and shock. The nurse should immediately assess this client's vital signs. Think like a nurse: A vaccination is used to immunize against a specific antigen. Some people may have an unknown allergy to the vaccine and develop symptoms of anaphylaxis, which include airway swelling, rapid heart rate, feeling of impending doom, and low blood pressure as a sign of developing shock.

The nurse evaluates a 5-day old newborn during a home visit. The neonate is being breastfed. Which assessments indicate to the nurse that breastfeeding is successful? (Select all that apply.) 1. Newborn appears relaxed after feeding. 2. Mother 's breast feels firm after feeding. 3. Newborn breastfeeds every 4 hours. 4. Newborn has 8 wet diapers in 24 hours. 5. An audible swallow is heard as the newborn sucks.

Answers: 1, 4, 5 Explanation: 1. Newborn appears relaxed after feeding. - The newborn should appear content after feeding. 4. Newborn has 8 wet diapers in 24 hours. - The newborn should have six to eight wet diapers every 24 hours after day 4. 5. An audible swallow is heard as the newborn sucks. - Audible swallowing should be present as the newborn sucks. Think like a nurse: While assessing the infant, the nurse should reflect on the developmental level of the infant and behaviors that indicate an adequate fluid volume and satiety. An infant who is restful and relaxed after breastfeeding is receiving enough nourishment. Adequate fluid balance is determined by the number of saturated diapers per day. Developmentally, the infant who is able to swallow without difficulty when being breastfed is most likely receiving adequate nutritional intake. Swallowing is also indicative of the presence of milk; if the infant sucks without swallowing, the infant should be moved to the other breast or breastfeeding session is stopped. Engorged breasts most likely indicate that frequency of breastfeeding should be increased to every 3 hours.

The nurse provides care to oncology clients. Which clients require further intervention from the nurse? (Select all that apply.) 1. The client receiving chemotherapy treatment for breast cancer who reports "always feeling tired." 2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest. 3. The client with bladder cancer reporting that "nothing tastes good" and who drinks four cans of nutritional supplement daily. 4. The client receiving radiation for lymphoma who reports there are handfuls of hair on the pillow every morning. 5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough. 6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid.

Answers: 2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest. 5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough. 6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid. Explanation: 2. The client receiving a chemotherapeutic alkylating agent intravenously via an implanted port with redness on the chest. — Alkylating agents can cause tissue necrosis if extravasation occurs. This client needs immediate intervention. 5. The client diagnosed with bone cancer who is receiving chemotherapy and is afebrile but has a productive cough. — Clients receiving chemotherapy may not have fever even though they are ill because of bone marrow depression. This client needs immediate intervention. 6. The client who reports frequent bouts of diarrhea but states the nausea is manageable with occasional sips of fluid. — This client is at great risk for dehydration due to frequent diarrhea and reduced oral intake. The nurse will intervene immediately. Think like a nurse: Clients with an implanted infusion port should be monitored closely for signs of central line-associated bloodstream infection (CLABSI). Due to immunosupression, the client receiving chemotherapeutic agents should be monitored for overt and covert signs and symptoms of infection. The nurse should check the client's complete blood count (CBC) result daily. Assess a client's hydration and ability to take adequate nourishment, which can be compromised due to nausea, vomiting, and diarrhea. All chemotherapeutic agents may potentially cause serious skin and mucus membrane damage if extravasated.

The nurse provides care to a client diagnosed with Paget disease. Which findings are anticipated by the nurse as characteristic of this disorder? (Select all that apply.) 1. A vitamin D deficiency. 2. An elevated serum alkaline phosphatase. 3. A pathologic fracture. 4. A loss of total bone mass and substance. 5. An abnormal remodeling and resorption of bone.

Answers: 2. An elevated serum alkaline phosphatase. 3. A pathologic fracture. 5. An abnormal remodeling and resorption of bone. 2. An elevated serum alkaline phosphatase. - An elevated serum alkaline phosphatase level occurs in advanced forms of the disease. 3. A pathologic fracture. - Pathologic fractures are the most common complication of the disease. 5. An abnormal remodeling and resorption of bone. - Abnormal remodeling and resorption of bone occurs, and the new bone is larger, disorganized, and structurally weaker. Think like a nurse: The nurse knows bone remodeling is an essential and continual process. In Paget disease, a localized area of bone does not correctly go through the cycle of bone breakdown and building, which results in odd and fragile bone formations. Paget disease has no known cause, and risk factors are not well understood, but the disorder may include a genetic component. While manifestations of Paget disease are often painful and interfere with daily living, some clients diagnosed with this disorder are asymptomatic. The same medications (but different doses) used for osteoporosis are used for treatment of clients with Paget disease. These medications slow bone turnover and help to lay down normal new bone.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.

Ask the client to extend the arms - Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing.

A client's medication record contains a prescription for setraline. To ensure safe administration of the medication, how should the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. PRN, when the client complains of depression

At the same time each evening - Setraline is generally administered once every 24 hours in the morning or evening, but evening administration is preferable, given drowsiness is a side effect. The medication can be administered without food, but with food if GI distress occurs.

Which medication, if prescribed for the client with glaucoma, should the nurse question? 1. Betaxolol 2. Pilocarpine 3. Erythromycin 4. Atropine sulfate

Atropine sulfate - Atropine sulfate is a mydriatic, cycloplegic and anticholinergic medication, contraindicated in clients with glaucoma since they dilate the pupil and can cause an increase in IOP.

The nurse is caring for a postoperative client who is receiving a demand dose hydromorphone via a PCA pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: 97.2 F orally, pulse 52 bpm, BP 101/58 mm Hg, RR 11, and SPO2 of 93% on 3L of O2 via nasal cannula. Which action should the nurse take first? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the HCP immediately. 4. Check the medication administration history on the PCA pump.

Attempt to arouse the client. - Since sleeping can lower the patient's vital signs, first arouse the client and reasses their vital signs, which may stabilize after they are awake. If the vital signs do not normalize, check the PCA pump history and then contact the HCP once all date is collected.

The nurse is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? 1. The development of insomnia 2. Audible expiratory wheezes 3. A baseline BP if 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after 2 doses of the medication. 4. A baseline resting HR of 88 BPM followed by a resting HR of 72 BPM after 2 doses of the medication.

Audible expiratory wheezes - Audible expiratory wheezes could be a sign of a serious adverse reaction indicating bronchospasm, which is an adverse effect of beta blockers, especially in clients with COPD or asthma. - Normal decreases in BP & HR are expected and insomnia is a mild side effect.

A client is being treated with Procainamide for a cardiac dysrhythmia. Following IV administration of the medication, the clients complains of dizziness. What intervention should the nurse take first? 1. Measure the heart rate on the rhythm strip. 2. Administer prescribed nitroglycerin strips. 3. Obtain a 12-lead electrocardiogram immediately. 4. Auscultate the client's apical pulse and obtain a blood pressure.

Auscultate the client's apical pulse and obtain a blood pressure - S/S of Procainamide toxicity include: confusion, dizziness, drowsiness, decreased urination, N/V, and tachydysrhythmias. Vital signs should be assessed first prior to attaching a 12-lead and nitroglycerin should not be administered because it would lower the patient's BP.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas

Bananas - Individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy as the result of a suspected cross-reaction between the food and the latex allergen.

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired. 2. Bed rest with the affected extremity kept flat. 3. Bed rest with elevation of the affected extremity. 4. Bed rest with the affected extremity in a dependent position.

Bed rest with elevation of the affected extremity. - Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. - A flat or dependent position of the leg would not achieve this goal and bed rest is recommended to prevent emboli and pressure fluctuations..

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding for the nurse's role regarding ensuring that each client's rights are respected? 1. Autonomy is the fundamental right of each and every client 2. A client's rights are guaranteed by both stated and federal laws 3. Being respectful and concerned will ensure that I'm attentive to my clients rights 4. Regardless of the clients condition, all nurses have the duty to value client rights

Being respectful and concerned will ensure that I'm attentive to my clients rights - The nurse needs to have respect and concern for the client.

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1. Infusion pump 2. Pulse oximeter 3. Cardiac monitor 4. Blood-warming device

Blood-warming device - Rapid transfusion of cold blood places the client at risk for cardiac dysrhythmias. A cardiac monitor and pulse ox help to monitor cardiac status, but do not aid in prevent dysrhythmias. An infusion pump would not be used given the blood needs to be infused rapidly, in addition not all infusion pumps are made to infuse blood.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours post-operatively, what type of drainage should the nurse expect. 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots

Bloody - After several hours it becomes serosanguineous and with proper chest tube function, should allow drainage of blood before it has the chance to clot in the chest or the tubing.

A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale, excessively tired, and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which lab result confirms the diagnosis? 1. Lumbar puncture showing no blasts cells. 2. Bone marrow biopsy showing blast cells. 3. Platelet count of 350,000 mm 4. White blood cell count of 4500 mm

Bone marrow biopsy showing blast cells. - An altered platelet count may occur, but may also occur from chemotherapy, thus does not confirm the diagnosis. A lumbar puncture may be done to check for the presence of blasts cells, suggesting central nervous system disease. The WBC may be normal, high or low.

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? 1. Watery diarrhea 2. Ribbon-like stools 3. Profuse projectile vomiting 4. Bright red blood and mucus in the stools

Bright red blood and mucus in the stools - A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw the knees into their chest. Vomiting may be present, but is not projectile. The bright red blood and mucus in the stools is described as currant, jelly-like stools.

A child has a fluid volume deficit. The nurse performs as assessment and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.035. 3. Capillary refill is less than 2 seconds. 4. Urine output is less than 1 mL/kg/hr.

Capillary refill is less than 2 seconds - Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.003 to 1.030, urine output of at least 1 mL/kg/hr, and adequate tear production.

A client with Chron's Disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion. 2. Checking the frequency and consistency of bowel movements. 3. Checking serum liver enzyme levels before and after the infusion. 4. Carrying out a Hematest on gastric fluids after the infusion is completed.

Checking the frequency and consistency of bowel movements. - Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, reducing the diarrhea.

A HCP prescribes an IV solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight. 2. Takes the temperature. 3. Takes the blood pressure. 4. Checks the amount of urine output.

Checks the amount of urine output - In hypotonic dehydration, electrolyte loss exceeds water loss. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine ouput is less than 1-2 mL/kg/hour, potassium chloride should not be administered.

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal Artesia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? 1. Incessant crying 2. Coughing at nighttime 3. Chocking with feedings 4. Severe projectile vomiting

Chocking with feedings - In esophageal Artesia with tracheoesophageal fistula, the esophagus terminates before it reaches the stomach ending in a blind pouch and a fistula is present that forms an unnatural connection with the trachea. Any child who exhibits the "3 Cs" - coughing and choking with feedings and unexplained cyanosis - should be expected to have tracheoesophageal fistula.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg

Clear mentation - An altered mental state is an early indication of fat emboli. Eupnea (normal breathing), not minimal dyspnea, is a good sign. Arterial oxygen levels should be between 80-100 mm Hg and oxygen saturation should be higher than 95%

An older client recently has been taking Cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations

Confusion - Cimetidine is a histamine-receptor antagonist. The most frequent central nervous system side effect is confusion, with less common side effects including headache, dizziness, drowsiness and hallucinations.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action should the nurse take in relation to the characteristics of the medication action? 1. Provide lubrication to the operative eye prior to giving the eye drops 2. Call the surgeon, as this medication will further constrict the operative pupil 3. Consult the surgeon, as their is not sufficient time for the dilative effects to occur 4. Give the medication as prescribed; the surgeon needs optimal constriction of the pupil

Consult the surgeon, as their is not sufficient time for the dilative effects to occur - Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication that is effective in 25-75 minutes, with accommodation that returns in 6-24 hours.

A client is prescribed a subcutaneous injection of heparin 5000 units every 6 hours. The medication is in a 5 mL multiple-dose vial containing 10,000 units/mL. Which amount of medication in milliliters will the nurse provide for each dose? (Round at the end of the equation. Record your answer using one decimal place.)

Correct Answer: 0.5 mL 10,000 units/1mL = 5000 units/x 10,000x = 5000 x = 0.5 mL

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution? 1. Osteoarthritis 2. Hypothyroidism 3. DM 4. Polycystic disease

DM - Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics (stimulant compounds which mimic the effects of endogenous agonists of the sympathetic nervous system). It should be used with caution in clients with impaired cardiac function, DM, hypertension, hyperthyroidism, or a history of seizures. In addition, the medication may increase blood glucose levels.

A parent brings her 4-month-old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to the infant? 1. Varicella & hepatitis B vaccine (HepB) 2. Diphtheria, tetanus, cellular pertussis (DTaP), measles, mumps, rubella (MMR) and inactivated polio virus (IPV). 3. MMR, Haemphhilus influenzae type b (Hib), and DTaP. 4. DTaP, Hib, IPV, pneumococcal vaccine (PCV), and rotavirus vaccine (RV).

DTaP, Hib, IPV, pneumococcal vaccine (PCV), and rotavirus vaccine (RV).

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding PN solution will accompany the diet prescription? 1. Discontinue PN 2. Decrease PN rate to 50 mL/hour 3. Start 0.9% NS at 25 mL/hour 4. Continue current infusion rate.

Decrease PN rate to 50 mL/hour - PN should be decreased gradually to prevent hypoglycemia. In addition, when a patient is on PN, they may become anorexic in addition to the fact that their digestive tract has not been producing the digestive enzymes that will be needed to process solid food.

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline in elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums.

Decreased oozing of blood from puncture sites and gums. - Platelets are necessary for proper blood clothing. - Increased H&H would occur in result of packed red blood cells. - An elevated temperature returning to normal would result from the infusion of granulocytes.

A child with B-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to prescribed? 1. Fragmin 2. Meropenem 3. Metoprolol 4. Deferoxamine

Deferoxamine - Exjade and Deferoxamine are antidotes for iron toxicity. Fragmin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a beta blocker used to treat hypertension.

Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL and a hematocrit level of 30%. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? 1. Begin the transfusion as prescribed. 2. Administer an antihistamine and begin the transfusion. 3. Delay hanging the blood and notify the HCP. 4. Administer 2 tablets of acetaminophen and begin the transfusion.

Delay hanging the blood and notify the HCP. - HCP needs to be contacted before any prescription medication can be provided.

The nurse provides care for a client diagnosed with spinal cord injury at the level of T1. The nurse notes profuse sweating, and the client reports a pounding headache and nasal stuffiness. In which order does the nurse provide care for this client? (Please arrange in order. All options must be used.) - Instruct the client about how to prevent autonomic dysreflexia: instruct about signs/symptoms and causes (full bladder, impaction, pressure on skin, cool draft) - Place the client in a sitting position: lowers blood pressure immediately - Check the Foley catheter tubing for kinks or obstruction: most common cause is distended bladder or constipation - Label the chart with a visible note about the risk for autonomic dysreflexia: ensures that staff is aware of risk - Monitor the blood pressure every 10-15 minutes: if emptying the bladder or removing the fecal mass does not decrease blood pressure, hydralazine hydrochloride (Apresoline) is administered IV

Determine how best to decrease client's blood pressure: (1) Place the client in a sitting position - Lowers blood pressure immediately (2) Check the Foley catheter tubing for kinks or obstruction - Most common cause is distended bladder or constipation (3) Monitor the blood pressure every 10-15 minutes - If emptying the bladder or removing the fecal mass does not decrease blood pressure, hydralazine hydrochloride (Apresoline) is administered IV (4) Label the chart with a visible note about the risk for autonomic dysreflexia - Ensures that staff is aware of risk (5) Instruct the client about how to prevent autonomic dysreflexia - Instruct about signs/symptoms and causes (full bladder, impaction, pressure on skin, cool draft)

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of Warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? 1. Prepare to administer the antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for a prothrimbin time (PT) and INR.

Draw a sample for a prothrimbin time (PT) and INR. - The results will provide information on how to best treat the client's condition (i.e. if an antidote such as Vitamin K or a blood transfusion is needed). An aPTT monitors the effects of heparin therapy.

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency? 1. Headache 2. Dysphagia 3. Constipation 4. Electrocardiographic changes

Electrocardiographic changes - Headache and dysphagia are not related to hypercalcemia and constipation is an early sign. Electrocardiographic changes include shortened ST segment and widened T waves.

The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and IBU is no longer effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of IBU. 2. Increase the frequency of IBU. 3. Encourage the child to lie on their left side. 4. Encourage the child to lie on their right side.

Encourage the child to lie on their right side - Splinting in the effected side may relief discomfort.

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 1. Fatigue 2. Weakness 3. Weight gain 4. Enlarged lymph nodes

Enlarged lymph nodes - Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area. 2. Coolness of the calf area. 3. Enlarged, hardened veins. 4. Palpable dorsal pedal pulses.

Enlarged, hardened veins. - Usually accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. Clients also sometimes experience pain with walking.

The clinic nurse reviews the record of a child just seen by a HCP and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

Exercise intolerance - Due to reduced cardiac output

While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: 1. Call the physician to reinsert the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection.

Grasp the retention sutures to spread the opening. - The other options would delay treatment and covering the site would block the airway.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Bradycardia and hyperactivity 2. Decreased respiratory rate and depth 3. Headache, restlessness, and confusion 4. Bradypnea, dizziness, and paresthesias

Headache, restlessness, and confusion - The respiratory rate and depth increases in an attempt to compensate. The client may experience: headache, restlessness, mental status changes, such as drowsiness and confusion, visual disturbances, diaphoresis, cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? 1. Hematocrit of 33% 2. Platelet count of 400,000 mm 3. WBC count of 6000 mm 4. BUN level of 15 mg/dL

Hematocrit of 33% - Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate RBC production in the bone marrow. Therapeutic effect is seen when the hematocrit reaches between 30% and 33%.

The nurse is conducting a teaching session with a client regarding their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1. My skin will have tiny red vesicles 2. The skin vesicles are caused by a virus 3. I have an autoimmune disease that causes blistering in the epidermis 4. The presence of red, raised papules and large plaques, covered by silvery scales will be present on my skin

I have an autoimmune disease that causes blistering in the epidermis - The client will have large, flaccid blisters (bullae) in the epidermis, leaving a thin covering of skin, which breaks easily, leaving large denuded areas of skin. On initial examination, clients may have crusted areas instead of intact blisters. - Option 1: eczema - Option 2: herpes zoster - Option 4: psoriasis

The nurse is caring for a 4-year-old child with HIV infection. The nurse should expect which statement that is aligned with the psychosocial expectations of this age. 1. Being sick is scary. 2. I know it hurts to die. 3. I know I will be healthy soon. 4. I know I am different than other kids.

I know it hurts to die. - A preschool age child begins to conceptualize the death process as involving physical harm. 1. An adolescent expresses fear, withdrawal and denial. 3. A child from birth to 2 years of age is unable to grasp the concept of illness and death. 4. A school-age child begins to understand that something is wrong.

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of club foot made at birth. Which statement by the parents indicates a meed for further teaching regarding this disorder? 1. Treatment needs to be started as soon as possible. 2. I realize my infant will require follow-up care until fully grown. 3. I need to bring my infant back to the clinic in 1 month for a new cast. 4. I need to come to the clinic every week with my infant for the casting.

I need to bring my infant back to the clinic in 1 month for a new cast. - Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3-6 months, surgery is usually indicated.

The nurse is providing discharge teaching for a client newly diagnosed with T2DM who has been prescribed metformin. Which client statement indicates the need for further teaching? 1. It is okay if I skip meals now and then. 2. I need to constantly watch for signs of low blood sugar. 3. I need to let my health care provider know if I get unusually tired. 4. I will be sure to not drink alcohol excessively while on this medication.

I need to constantly watch for signs of low blood sugar. - Metformin does not stimulate insulin release, so poses little risk for hypoglycemia, so is good for clients who skip meals. When used alone, metformin lowers the blood sugar after meal intake as well as fasting blood glucose. - Toxic side effects of metformin: somnolence, hyperventilation, myalgia, and malaise are signs of lactic acidosis.

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? 1. I should limit my fluids to 1 liter/day 2. I should use my treadmill to go for walks daily 3. I should follow a moderate-calcium, high fiber diet. 4. My alendronate helps to keep calcium from coming out of my bones.

I should limit my fluids to 1 liter/day - To prevent nephrolithiasis, 1-2 liters of fluids should be consumed daily. - Clients with hyperparathyroidism should engage in moderate physical activity, especially weight bearing exercise, to limit bone resorption and to prevent a spike in PTH which would occur in a low-calcium diet, clients should maintain a moderate calcium diet, which is also high in fiber, since calcium causes constipation. Alendronate is a biphosphate that inhibits bone resorption.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates the need for further instruction? 1. I should take hot baths because they are relaxing 2. I should sit whenever possible to conserve my energy 3. I should avoid long periods of rest because it causes joint stiffness 4. I should do some exercises, such as walking, when I am not fatigued

I should take hot baths because they are relaxing - The client should be encouraged to sit whenever possible to conserve energy, avoid hot baths, which exacerbate fatigue, schedule moderate, low impact exercise when not fatigued, and maintain a balanced diet. Long periods of rest should be avoided to prevent joint stiffness.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurses determines that further teaching is needed if the client makes which statement? 1. I will need to increase my insulin dosage during the first 3 months of pregnancy. 2. My insulin dose will likely need to be increased during the second and third trimesters. 3. Episodes of hypoglycemia are more likely to occur during the first 3 months or pregnancy. 4. My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding.

I will need to increase my insulin dosage during the first 3 months of pregnancy. - Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripherial sensitivity to insulin. - The remaining options are accurate and signify the client understands control of her diabetes during pregnancy.

The nurse in the health car clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? 1. I will record the number of movements or kicks. 2. I will need to lie flat on my back to perform the procedure. 3. If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours. 4. I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks.

I will need to lie flat on my back to perform the procedure. - The client should sit or lie quietly on her side. Lying flat on the back is unnecessary, can cause discomfort and presents a risk of vena cava (supine hypotension) syndrome. - The remaining 3 answers are correct.

A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level is 950 mg/dL. A continuous IV infusion if short-acting insulin is initiated, along with IV rehydration with normal saline. When the serum glucose level decreases to 240 mg/dL, which medication would the nurse expect to prepare? 1. An ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures

IV fluids containing dextrose - If correction of fluid and electrolyte imbalances occurs too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose levels fall between 250-300 mg/dL, the IV infusion rate is reduced and dextrose solution is added to maintain a blood glucose level of about 250 mg/dL or until the client recovers from ketosis.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements, such as, "I'm a failure. I can't do anything right." How should the nurse plan to respond to the clients statement? 1. Reassure the client that things will get better 2. Tell the client that this is not true and that we all have a purpose in life 3. Identify recent behaviors or accomplishments that demonstrate the client's skills 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings

Identify recent behaviors or accomplishments that demonstrate the client's skills - An effective plan of care to enhance the client's self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the clients past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Silence may be interpreted as agreement.

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1. Increased calcium level 2. Increased WBC 3. Decreased BUN level 4. Decreased number of plasma cells in the bone marrow

Increased calcium level - Findings indicative of multiple myeloma: increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An elevated WBC count may or may not be present.

A 10-year old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? 1. Injection of factor X 2. Intravenous infusion of iron. 3. Intravenous infusion of factor VIII 4. Intramuscular injection of iron using the Z-track method.

Intravenous infusion of factor VIII

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1. It connects the pulmonary artery to the aorta. 2. It is an opening between the right and left artia. 3. It connects the umbilical vein to the inferior vena cava. 4. It connects the umbilical artery to the inferior vena cava.

It connects the umbilical vein to the inferior vena cava.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test includes a phenylaline level of 1 mg/dL. The nurse reviews this result and makes which interpretation? 1. It is positive. 2. It is negative. 3. It is inconclusive. 4. It requires rescreening at 6 weeks.

It is negative - Normal levels are between 0-2 mg/dL. Toxic levels of phenylaline are greater than 20 mg/dL.

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

It promotes the fertilized ovum's normal implantation in the top portion of the uterus.

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which complication may be associated with use of this medication? 1. Itching 2. Euphoria 3. Drowsiness 4. Frequent urination

Itching - Azelaic acid is a tropical medication used to treat mild to moderate acne. Adverse affects: burning, itching, singing, redness of the skin, and hypopigmentation of the skin in clients who have a darker complexion.

A client arrives at the clinic for her first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2018. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12th, 2019 2. July 26th, 2019 3. August 12, 2019 4. August 26th, 2019

July 26th, 2019 - Subtract 3 months and add 1 year and 7 days to the first day of the last menstrual period.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states and intention to increase the intake of which food? 1. Milk 2. Chicken 3. Broccoli 4. Legumes

Legumes - Other foods high in thiamine include: nuts, whole-grain, cereals, and pork.

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition? 1. Limited range of motion in the affected hip. 2. An apparent lengthened femur on the affected side. 3. Asymmetrical adduction of the affected hip when the infant is placed supine with the knees and hips flexed. 4. Symmetry of the gluteal skinfolds when the infant is placed prone and the legs are extended against the table.

Limited range of motion in the affected hip. - Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

The nurse is analyzing the laboratory studies on a client receiving dantrolene. Which laboratory test would identify an adverse effect associated with the administration of this medication? 1. Platelet count 2. Creatinine level 3. Liver function test 4. BUN level

Liver function test - Dose related liver damage is the most serious adverse effect of this medication. To prevent damage, liver function test should be performed before and through-out treatment. For this reason, dantrolene is administered at the lowest effective dose for the shortest time possible.

A client has developed Hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected symptom? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant pain

Malaise - S/S: anorexia, nausea, right upper quadrant discomfort, weight loss, fatigue, malaise, and light or clay colored stools if conjugated bilirubin is unable to flow out due to obstructed bile ducts.

The nurse is caring for a client who is 1-day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-lying in the operative side. 2. On the nonoperative side with the legs abducted. 3. Side-lying with the affected leg internally rotated. 4. Side-lying with the affected leg externally rotated.

On the nonoperative side with the legs abducted. - Positioning depends on the surgical techniques used, the method of implantation, the prosthesis and the HCP's preference. However, abduction is maintained when the patient is supine or positioned on the nonoperative side. Internal/external rotation, addiction, or side-lying on the operative side is avoided to prevent displacement of the prosthesis.

A client with a gastric ulcer has a prescription for Sucralfate 1 gram by mouth 4 times daily. The nurse should schedule the medication for which times? 1. With meals and at bedtime. 2. Every 6 hours around the clock. 3. One hour after meals and at bedtime. 4. One hour before meals and at bedtime.

One hour before meals and at bedtime - Sucralfate is a gastric protectant, given 1 hour before meals to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation.

The nurse is assessing a HCP examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess? 1. Babinski's Sign 2. The Moro Reflex 3. Ortolani's Maneuver 4. The palmar-plantar grasp

Ortolani's Maneuver - In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's Maneuver is a test to assess for hip instability and can be done only before 4 weeks of age. To conduct the test, the examiner abducts the thigh and applies gentle pressure forward over the great tronchanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum.

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula. 2. Presence of a radial pulse in the left wrist. 3. Visualization of enlarged blood vessels at the fistula site. 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand.

Palpation of a thrill over the fistula - And auscultating of bruit. Visualization of enlarged blood vessels at the fistula site is a normal observation, but not an indication of patency.

While caring for a client with an internal cervical radiation implant, the nurse finds the implant in the client's bed. The nurse should take which initial action? 1. Call the HCP 2. Reinsert the implant into the vagina 3. Pick up the implant with gloved hands and flush it down the toilet. 4. Pick up the implant with long-handed forceps and place it in a lead container.

Pick up the implant with long-handed forceps and place it in a lead container

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? 1. Call the HCP 2. Place the tube in a bottle of sterile water. 3. Replace the chest tube system immediately. 4. Place a sterile dressing over the disconnection site.

Place the tube in a bottle of sterile water (below the level of the chest)

The nurse reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? 1. Wearing gloves when emptying the client's bed pan. 2. Keeping all linens in the room until the implant is removed. 3. Wearing a lead apron when providing direct care to the client. 4. Placing the client in a semi-private room at the end of the hallway.

Placing the client in a semi-private room at the end of the hallway. - A private room with a private bathroom is essential to prevent accidental exposure of other clients to radiation.

An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for symptoms indicative of human immunodeficiency virus (HIV) infection. The nurse assesses the infant, knowing that which infection is the most common opportunistic infection of children infected with HIV? 1. Meningitis 2. Gastroenteritis 3. Cytomegalovirus infection 4. Pneumocystis jiroveci pneumonia

Pneumocystis jiroveci pneumonia

The nurse teaches a new nurse about the prevention of acute respiratory distress syndrome (ARDS). Which action is the nursing priority in ARDS prevention? 1. Elective intubation for septic clients. 2. Adequate staffing in intensive care units. 3. Early mobility for clients with pneumonia. 4. Prevention of client aspiration.

Prevention of client aspiration — Aspiration is one of the most common causes of ARDS. Prevention of aspiration is a priority action to reduce the risk of ARDS.

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parents about the child's symptoms? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

Projectile vomiting - In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations include: projectile vomiting, irritability, hunger, crying, constipation, and signs of dehydration, including a decrease in urine output.

IV heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1. Vitamin K 2. Protamine Sulfate 3. Potassium Chloride 4. Aminocaproic Acid

Protamine Sulfate - Vitamin K is the antidote for Warfarin - Potassium Chloride is administered for hypokalemia - Aminocaproic Acid is the antidote for thrombolytic therapy.

A nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the HCP? 1. Stoma is beefy red and shiny 2. Purple discoloration of the stoma 3. Skin excoriation around the stoma 4. Semi-formed stool noted in the ostomy pouch

Purple discoloration of the stoma - Dusky, blush or purple color is associated with ischemia of the stoma. Stoma excoriation needs to be treated, but is not as urgent as purple discoloration of the stoma.

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing that which of the following results would indicate this type of anemia? 1. An elevated hemoglobin level 2. A decreased reticulocyte count 3. An elevated RBC count 4. Red blood cells that are microcytic and hypochromic

Red blood cells that are microcytic and hypochromic - Results of a CBC would show decreased hemoglobin levels with microcytic and hypochromic RBCs. RBC count would be decreased with a normal or slightly elevated reticulocyte count.

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take? 1. Report the observation to the HCP 2. Move the objects in the child's direct field of vision. 3. Teach the child how to visually scan the environment. 4. Provide additional lighting for the child during play activities.

Report the observation to the HCP - While this is normal for an infant or toddler, this is not normal for a 6-year-old, indicating the child is not progressing normally. Options 2, 3, & 4 delay necessary follow-up and treatment.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action? 1. Use alcohol in small amount only. 2. Report yellow eyes or skin immediately. 3. Increase intake of Swiss or aged cheese. 4. Avoid vitamin supplements during therapy.

Report yellow eyes or skin immediately. - Isoniazid is hepatotoxic, therefore the client is taught to report the S/S of hepatitis immediately.

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? 1. Test the urine for protein. 2. Reposition the infant frequently. 3. Provide a stimulating environment. 4. Assess blood pressure every 15 minutes.

Reposition the infant frequently. - Hydrocephalus occurs as a result of an imbalance of cerebrospianl fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma, resulting in head enlargement and increased intracranial pressure. In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back of the head.

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg and HCO3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Respiratory acidosis - Normal PaCO2: 35-45 mmHg. Since the client's pH is acidic (low pH) and PaCO2 is elevated at 58 mmHg, the lab values represent respiratory acidosis.

The client is admitted to the hospital with Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain in the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

Respiratory or gastrointestinal infection during the previous month - Many clients report a history of respiratory or gastrointestinal infection in the 1-4 weeks prior to the onset of neurological deficits related to Guillain-Barre syndrome. On occasion, the syndrome can be triggered by vaccination or surgery.

Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness

Restlessness - Toxicity of Oxybutynin produces central nervous system excitation, such as nervousness, restlessness, hallucinations, irritability, hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. - Drowsiness is a frequent side effect of the medication, but does not indicating overdose.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? 1. Remove the IV line 2. Run a solution of 5% dextrose in water 3. Run normal saline at a keep-vein-open rate 4. Obtain a culture if the tip of the catheter device removed from the client.

Run normal saline at a keep-vein-open rate - The IV tubing should be changed, but IV access should not be removed. After changing the transfusion tubing, normal saline should be administered.

The nurse has a prescription to give a client salmeterol (2 puffs) and beclomethasone dipropionate (2 puffs) by metered-dose inhaler. The nurse should administer the medication using which procedure? 1. Beclomethasone first and then salmeterol . 2. Salmeterol first and then Beclomethasone. 3. Alternating a single puff of each, beginning with the Salmeterol. 4. Alternating a single puff of each, beginning with the Beclomethasone.

Salmeterol first and then Beclomethasone - Salmeterol is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators should always be given first.

A hospitalized client has begun taking bupropion as an antidepressent agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright

Seizure activity - Seizure activity can occur in clients taking bupropion dosages greater than 450 mg daily. Weight gain is a occasional side effect and constipation is a common side effect. Orthostatic hypotension is not a side effect of this medication.

The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? 1. Semi-fowler's 2. Trendelenburg 3. Reverse Trendelenburg's 4. Flat, supine

Semi-fowler's - Client's who have undergone a crainotomy should have the head of the bed elevated 30-45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midlife neutral position. The client should not be placed on the side of the surgery. - The flat or Trendelenburg's position would increase intracranial pressure and the reverse Trendelenburg's position would not be beneficial or comfortable for the client.

Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: - Serum Calcium: 9.8 mg/dL - Serum Magnesium: 1.0 mEq/L - Serum Potassium: 4.1 mEq/L - Serum Creatinine: 0.9 mg/dL Which result should alert the nurse that the client is at risk for digoxin toxicity? 1. Serum Calcium 2. Serum Potassium 3. Serum Creatinine 4. Serum Magnesium

Serum Magnesium - Normal Calcium: 8.5-10.8 mg/dL - Normal Creatinine: 0.7-1.4 mg/dL - Normal Magnesium: 1.5-2.5 mEq/L - Normal Potassium: 3.5-5 mEq/L

The nurse is assigned to care for a client with cytomegalovirus retinitis and AIDS, who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication? 1. CD4+ T cell count 2. Lymphocyte count 3. Serum albumin level 4. Serum creatinine level

Serum creatinine level - Foscarnet is toxic to the kidneys, so the serum creatinine levels are monitored before therapy and 2-3 times per week during induction therapy, and at least weekly during maintenance therapy. - Foscarnet may also cause decreased levels of: calcium, magnesium, phosphorus, and potassium, thus the levels are measured with the same frequency.

A client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making the rounds at 1545 finds the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive with an increased pulse rate. The IV bag has 400 mL remains The nurse should take which action first? 1. Slow the infusion rate. 2. Sit the client up in bed. 3. Remove the IV catheter. 4. Call the HCP.

Slow the infusion rate. - The IV infusion rate should first be slowed, since 600 mL has infused in 45 minutes, followed by sitting the client up to aid with their difficulty breathing, before calling the HCP. The IV catheter should not be removed, since it may be needed for the administration of medication to resolve the complication.

A client is taking the prescribed dose of phenytoin to control seizures. Results of phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result? 1. Hypotension 2. Tachycardia 3. Slurred speech 4. No abnormal finding

Slurred speech - Therapeutic phenytoin level: 10-20 mcg/mL. At a level higher than 20 mcg/mL involuntary movement of the eyeballs (nystagmus) occur and at a level higher than 30 mcg/mL, ataxia and slurred speech occur.

A 6-year-old child has just been diagnosed with localized Hodgkin's disease with chemotherapy scheduled to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response? 1. It's very costly and chemotherapy works just as well 2. I'm not sure, I will discuss it with the HCP 3. Sometimes age has to do with the decision for radiation therapy 4. The HCP would prefer that you discuss treatment options with the oncologist

Sometimes age has to do with the decision for radiation therapy - Radiation therapy is usually delayed until a child is 8-years-old, whenever possible, to prevent retardation of bone growth and soft tissue development.

A client requests information on nonpharmacologic methods of birth control. In planning the client's care, which method is most effective and needs to be included when providing education? 1. Calendar method. 2. Coitus interruptus. 3. Basal body temperature evaluation. 4. Symptothermal method.

Symptothermal method — The symptothermal method combines cervical mucus evaluation and basal body temperature evaluation. Any time a method of birth control can be used in combination with another, the rate of effectiveness increases. Therefore, this method is the most effective.

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

Tachycardia - The early signs of HF include: tachycardia, tachypnea, produce scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress.

A client has a prescription for guaifenesin. The nurse determines that the client understands the proper administration of this medication of the client states that s/he will perform which action? 1. Take an extra dose if fever develops. 2. Take the medication with meals only. 3. Take the tablet with a full glass of water. 4. Decrease the amount of daily fluid intake.

Take the tablet with a full glass of water - Guaifenesin is an expectorant and should be take with a full glass of water to decrease the viscosity of secretions. Extra doses should not be taken. The client should contact the HCP if the cough last longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. The medication does not need to be taken with meals.

The nurse is providing instructions to a client newly diagnosed with DM who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching? 1. Inject the pramlintide at the same time you take other medications. 2. Take your prescribed pills 1 hour before or 2 hours after the injection. 3. Be sure to take the pramlintide with food so you don't upset your stomach. 4. Make sure you take your pramlintide immediately after you eat so you don't experience a low blood sugar.

Take your prescribed pills 1 hour before or 2 hours after the injection. - Pramlintide is used for clients with type 1 and 2 DM who use insulin and is administered before meals to lower blood glucose levels after meals, leading to less fluctuation during the day and better long-term glucose control. Because pramlintide delays gastric emptying, oral medications should be taken hour before or 2 hours after the injection.

A client has been discharged to home on PN. With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy? 1. Pulse and weight. 2. Temperature and weight. 3. Pulse and blood pressure. 4. Temperature and blood pressure.

Temperature and weight. - The clients temperature should be monitored as a means of detecting an infection. Their weight should be monitored as a measure of effectiveness of the nutritional therapy and/or to detect hypervolemia.

A client complains of fever, perineal pain, urinary urgency, frequency and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate exam for which characteristic of this disorder? 1. Soft and swollen prostate gland. 2. Swollen and boggy prostate gland. 3. Tender and edematous prostate gland. 4. Tender, indurated prostate gland that is warm to the touch.

Tender, indurated prostate gland that is warm to the touch - Systemic S/S include: fever with chills, perineal and low back pain, and signs of urinary tract infection which often accompany the disorder.

A client with Type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? 1. I should not exercise since I am taking insulin 2. The best time for me to exercise is after breakfast 3. The best time for me to exercise is mid- to late afternoon. 4. NPH is a basal insulin, so I should exercise in the evening

The best time for me to exercise is after breakfast - DM clients should exercise an hour after mealtime or after consuming a 10-15 gram carbohydrate snack and after checking their blood glucose level. - Since NPH is an intermediate acting insulin, which peaks 4-12 hours after administration, so afternoon exercise should be avoided.

The nurse performs a physical assessment on a client. Which location would the nurse palpate the client's brachial pulse?

The brachial pulse is found in the groove between the biceps and triceps muscle above the elbow at the antecubital fossa on the medial side of the arm.

The nurse is describing Paget's cognitive developmental theory to pediatric nursing staff. The nurse should tell the staff that which child behavior is characteristic of the formal operations stage? 1. The child has the ability to think abstractly. 2. The child begins to understand the environment. 3. The child is able to classify, order and sort facts. 4. The child learns to think in terms of past, present, and future.

The child has the ability to think abstractly (and logically). - Option 2 identifies the sensorimotor stage. Option 3 identifies the concrete operational stage. Option 4 identifies the preoperational stage.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida. 2. The client has a history of cardiac disease. 3. The clients hemoglobin level is 13.5 g/dL. 4. The client is a 20-year-old primigravida of average weight and height.

The client has a history of cardiac disease. - Factors of preterm labor: medical conditions, present and past obstetric problems, social and environmental factors, substance abuse, and multifetal pregnancy.

The nurse is caring for a client who is involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1. The informed consent does not need to be obtained 2. The informed consents should be obtained form the family 3. The informed consent needs to be obtained from the client 4. The healthcare provider will provide the informed consent

The informed consent needs to be obtained from the client - Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent, given they must be considered legally competent until they have been declared incompetent through a legal proceeding.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching? 1. The medication is an antibacterial. 2. The medication will help heal the burn. 3. The medication is likely to cause stinging every time it is applied. 4. The medication should be applied directly to the wound.

The medication is likely to cause stinging every time it is applied. - Silver sulfadiazine is a antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria and yeast. It is applied directly to the wound and does not cause stinging.

Describe the Paget's Formal Operational stage?

Theoretical, hypothetical, and counterfactual thinking. Abstract logic and reasoning. Strategy and planning become possible. Concepts learned in one context can be applied to another.

The nurse has given instructions to a client who has just been prescribed Cholestyramine. Which statement by the client indicates a need for further instruction? 1. I will continue taking vitamin supplements. 2. This medication will help to lower my cholesterol. 3. This medication should only be taken with water. 4. A high-fiber diet is important while taking this medication.

This medication should only be taken with water. - Cholestyramine is a bile acid sequestrant used to lower the cholesterol level. Due to its taste and palatability the use of flavored products or fruit juices can improve the taste. - Some side-effects of bile acid sequestrants include constipation and decreased bile absorption.

Salicyclic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations

Tinnitus - Symptoms of toxicity include: tinnitus, dizziness, hyperpnea, and psychological disturbances.

Which is the most common complaint associated with a client diagnosed with a disorder involving the inner ear? 1. Pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

Tinnitus - Symptoms range from mild ringing in the ear (which may not be audible during the day) to loud roaring in the ear, which can interfere with the client's thinking process and attention span.

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors with a lithium level of 2.5 mEq/L. The nurse plans care based on which representation of this level. 1. Toxicity 2. Normal 3. Slightly above normal 4. Excessively below normal

Toxicity - Normal therapeutic level: 0.6-1.2 mEq/L

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux

Urinary strictures - Bethanechol chloride can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall, since the medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Such elevation of pressure within the urinary tract could damage or rupture the bladder in clients with these condition.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses' station 2. Use an indirect light source and turn off the television 3. Keep the television and a soft light on during the night 4. Play soft music during the night and maintain a well-lit room

Use an indirect light source and turn off the television - Provisions of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television may add to the confusion and disorientation.

The nurse is evaluating the development level of a 2-year-old. Which does the nurse expect to observe in this child? 1. Uses a fork to eat. 2. Uses a cup to drink. 3. Notify the HCP. 4. Use a knife for cutting food.

Uses a cup to drink - By 3-4 years of age, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.

The nurse provides care for a client in the emergency department (ED). The nurse reviews the health care provider (HCP) prescription and notes that digoxin 1.25 mg PO has been prescribed to be given now. Which action by the nurse is appropriate? 1. Administer the medication as prescribed. 2. Validate the prescription with the HCP. 3. Ask the client if this is the usual daily dosage. 4. Ask another nurse if the dosage is appropriate.

Validate the prescription with the HCP - Verify the rights of medication administration. The nurse needs to clarify the prescription with the HCP. If this is a digitalizing dose, it is to be given in three divided doses over a 24-hour time frame. If it is a maintenance dose, it would usually be between 0.1 to 0.375 mg per day.

The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? 1. Ventrogluteal 2. Lateral deltoid 3. Rectus femoris 4. Vastus lateralis

Vastus lateralis

When a low-pressure alarm sounds on a ventilator. and a nurse is unable to determine the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen 2. Check the client's vital signs 3. Ventilate the client manually 4. Start CPR

Ventilate the client manually - Since the reason a potential sign of failing equipment or improper ventilation cannot be determined.

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1. Asystole 2. Atrial fibrillation 3. Ventricular fibrillation 4. Ventricular tachycardia

Ventricular fibrillation - V-fib is characterized by irregular undulations of varying amplitudes, has no measurable rate, no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves, the QRS complexes are wide and the ventricular rate is regular, but more than 140 BPM. The nurse interprets that the client is experiencing which dysrhythmia? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions (PVCs)

Ventricular tachycardia - V-tach is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds) and typically a rate between 140-180 impulses/minute.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in vitamins that may be lacking in a vegan diet? 1. Vitamin A 2. Vitamin B12 3. Vitamin C 4. Vitamin E

Vitamin B12 - Vitamin B12 is found in animal products, thus would be lacking in a vegan's diet

A client has a new prescription for metoclopramide. On review of the charts the nurse identifies that this medication can be safely administered with which condition? 1. Intestinal obstruction 2. Peptic ulcer with melena 3. Diverticulitis with perforation 4. Vomiting following cancer chemotherapy

Vomiting following cancer chemotherapy - Metoclopramide is a gastrointestinal stimulant and antiemetic which is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in treatment of vomiting after surgery, chemotherapy or radiation.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1. Sodium level: 140 mEq/L 2. Uric acid level: 4 mg.dL 3. WBC count: 3000 mm 4. BUN level: 10 mg/dL

WBC count: 3000 mm - The low WBC count reflects agranulocytosis - Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermatoligical effects.

The nurse has instructed the family of a client with a stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggest that the family understands the measures to use when caring for the client? 1. We need to discourage him from wearing eyeglasses 2. We need to place objects in his impaired field of vision 3. We need to approach him from the impaired field of vision 4. We need to remind him to turn his head to scan the lost visual field

We need to remind him to turn his head to scan the lost visual field - Homonymous hemianopsia is the loss of half of the visual field.

The nurse monitors the client receiving PN for complications of the therapy and should assess the client for which manifestations of hyperglycemia? 1. Fever, weak pulse, and thirst 2. N/V and oliguria 3. Sweating, chills and abdominal pain 4. Weakness, thirst, and increased urinary output.

Weakness, thirst, and increased urinary output. - Signs of hyperglycemia include: excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul respirations, diuresis, and coma

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? 1. Your type of pelvis has a narrow pubic arch. 2. Your type of pelvis is the most favorable for labor and birth. 3. Your type of pelvis is a wide pelvis, but it has a short diameter. 4. You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery.

Your type of pelvis is the most favorable for labor and birth. - Android pelvis (resembling a male pelvis) has narrow pelvic planes, making it unfavorable for labor. - Arthropod pelvis: has an adequate outlet, with a normal or moderately narrow pubic arch. - Platypelloid pelvis (flat pelvis): has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

Which of the following patients are at risk for developing Cushing's Disease? 1. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. 2. A patient taking glucocorticoids for several weeks. 3. A patient with a tuberculosis infection. 4. A patient who is post-opt from an adrenalectomy.

1. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted.

The nurse prepares a client for a skin biopsy. Which client statement will 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. Think like a nurse: Aspirin has anti-platelet properties. It blocks thromboxane A2 (produced by activated platelets and has prothrombotic) properties to prevent platelet aggregation. Long-term use of aspirin can cause bleeding, even during minor procedures such as a biopsy. The nurse should notify the health care provider of the client's aspirin use. It is also important to note that aspirin may be contained in some over-the-counter medications such as Pepto-Bismol. Medication reconciliation is an essential procedure that should be done when a client goes for a procedure.

The nurse provides care for clients in the gastroenterology clinic. In which order does the nurse rank these clients regarding the risk for developing colorectal cancer? (Arrange in order from greatest to least risk of developing colorectal cancer. All options must be used.) - 29-year-old Caucasian female, following a vegetarian diet, history of inflammatory bowel disease. - 37-year-old Caucasian male, high intake of red meats, great uncle diagnosed with colorectal cancer - 42-year-old African-American male, drinks two servings of alcohol daily, high intake of processed meats. - 45-year-old African-American female, smokes cigarettes, physically inactive

- 42-year-old African-American male, drinks two servings of alcohol daily, high intake of processed meats. - 45-year-old African-American female, smokes cigarettes, physically inactive - 37-year-old Caucasian male, high intake of red meats, great uncle diagnosed with colorectal cancer - 29-year-old Caucasian female, following a vegetarian diet, history of inflammatory bowel disease. - The nurse needs to be aware of the risk factors associated with specific diseases and conditions. When evaluating which client is at greatest risk, the nurse needs to add up the known risk factors for each client based on their personal and medical history. Keep in mind that risk factors can include issues that cannot be altered, such as gender or age. Likewise, some risk factors can be altered when associated with lifestyle choices, such as diet, smoking, and exercise. Think like a nurse: Risk factors for the development of colorectal cancer include African-American race, male gender, alcohol intake, diet high in red and processed meats, cigarette smoking, sedentary lifestyle, family history of the disorder, and a disease process that affects the intestines. After counting up the risk factors, the 42-year-old African- American client has the greatest risk, followed by the 45-year-old African-American female, 37-year-old Caucasian male, and, lastly, the 29-year-old Caucasian female.

An infant is admitted for pyloric stenosis and will be going to surgery. The parents have gone to get something to eat and the grandparents are with the child. When the nurse enters the room and prepares to insert a nasogastric (NG) tube, the grandparents say, "Don't you need consent for that?" Which response by the nurse is best? 1. "Thanks for reminding me. I will get the form and have you sign it before I go any further." 2. "Consent is not needed for inserting this type of tube in any patient." 3. "You sound worried. Let me explain how this tube works and why it is needed." 4. "This is in preparation for the surgery, and the consent for the surgery has been signed."

"You sound worried. Let me explain how this tube works and why it is needed." — This is an empathic response followed by education to address the grandparents' underlying concern. It is clear and conveys caring and respect. The consent-to-treatment forms signed when a client is admitted to a hospital give general consent to routine types of procedures or treatments. Routine usually implies noninvasive and low risk for injury, and it includes NG tube insertion.

A patient with Cushing's syndrome will be undergoing an adrenalectomy. Which of the following will be included in the patient's discharge teaching after the procedure? 1. Glucocorticoid replacement therapy 2. Avoiding avocadoes and pears 3. Declomycin therapy 4. Signs and symptoms of Grave's Disease

1. Glucocorticoid replacement therapy

A HCP prescribes 1 unit of packed red blood cells to infuse over 4 hours. The unit of blood contains 250 mL. The drop factor is 10 gtt/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Record your answer to the nearest whole number.

10 drops/minute Total Volume x Drop Factor/Time in Minutes = Drops per minute 250 mL x 10 gtt/240 minutes = 10.42 or 10 drops/min

The nurse is making initial rounds at the beginning of the shift and notes that the PN bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit? 1. 5% dextrose in water 2. 10% dextrose in water. 3. 5% dextrose in Lactated Ringer 4. 5% dextrose in 0.9% sodium chloride

10% dextrose in water - The client is at risk of hypoglycemia, so the solution with the highest glucose concentration is appropriate.

A healthcare provider's prescription reads potassium chloride 30 mEq to be added to 1,000 mL NS and to be administered over a 10 hour period. The label on the medication bottle reads 40 mEq/20mL. The nurse prepares how many mL of potassium chloride to administer the correct dose of medication?

15 mL Desired x mL/Available = mL/dose 30 mEq x 20 mL/40 mEq = 15 mL ALTERNATE: 40 mEq/20 mL = 2 mEq/mL 30/2 = 15 mL

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

2. Monitor liver function studies 3. Instruct the client to avoid alcohol 5. Instruct the client to avoid exposure to the sun - Ketoconazole is an antifungal medication - The medication is hepatotoxic, is administered with food and antacids should be avoided for 2 hours after taking the medication to ensure absorption. The client is instructed to avoid alcohol and exposure to the sun, due to increased photosensitivity.

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's WBC count was which value? 1. 2000 mm 2. 5800 mm 3. 8400 mm 4. 11,500 mm

2000 mm - Normal WBC Count range: 5,000-10,000 mm

The community health nurse obtains and evaluates laboratory test results for four clients. Which lab results most concern the nurse? 1. Urine culture and sensitivity with colonization of E. coli. 2. Urinalysis with leukocytes. 3. Elevated serum anti-streptolysin O (ASO) titer. 4. Cystourethrogram reveals vesicoureteral reflux.

3. Elevated serum anti-streptolysin O (ASO) titer. — This result indicates glomerulonephritis. The condition results in damage to glomerulus caused by an immunological reaction that results in proliferative and inflammatory changes within the glomerular structure. The infection can be a serious threat to the client's health.

The health care provider prescribes 2000 units of heparin per hour for a client with cardiac disease. The IV solution contains 20,000 units of heparin in 500 mL of 5% dextrose in water. The nurse sets the infusion to deliver how many mL per hour? (Record your answer rounding to the nearest whole number.)

ANSWER: 50 mL EXPLANATION: 2000 units/x mL = 20,000 units/500 mL 20,000 x = 1,000,000 x = 50 mL ALTERNATE: 20,000/2,000 = 10 500 mL/10 = 50 mL

The nurse provides care for a client diagnosed with Korsakoff psychosis. Which assessment finding does the nurse expect? 1. The client's blood pressure is 180/96 mm Hg. 2. The client has right-sided weakness. 3. The client has tinnitus. 4. The client invents elaborate, improbable events.

4. The client invents elaborate, improbable events. — This describes confabulation, which clients diagnosed with Korsakoff psychosis often demonstrate, in order to fill memory gaps.

The nurse assesses a client's electrocardiogram (ECG). How many heart beats per minute will the nurse record? (Record your answer using a whole number.)

79 BPM To determine the heart rate for a regular rhythm, count the number of small boxes between two R waves; 1500 divided by the number of boxes between two R waves equals the heart rate. 1500/19 = 79

A HCP prescribes regular insulin, 8 units/hr by continuous IV infusion. The pharmacy prepares the medication and then delivers an IV bag labeled 100 units of regular insulin in 100 mL NS. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many mL/hr to deliver 8 units/hr?

8 mL/hr Known amount of medication in solution/total volume of diluent = amount of medication per mm 100 units/100 mL = 1 unit/mL Doses per hour desired/concentration per mL = infusion rate 8 units/1 unit per mL = 8 mL/hr

The nurse receives telephone messages from clients receiving care in the outpatient clinic. Which message will the nurse return first? 1. Client with cold symptoms & an oral temperature of 103° F (39.4° C). 2. Client with a stage 2 pressure injury reporting that the dressing has come off. 3. Client with nausea who has vomited six times in the previous 24 hours. 4. Client complaining of leg pain after walking half a mile.

Client with nausea who has vomited six times in the previous 24 hours The client who is nauseated and has vomited six times in the previous 24 hours is at risk for a fluid volume deficit. The amount and character of the emesis needs to be assessed. Fluid volume deficit can impact circulation. Therefore, when using the ABCs (airway, breathing, circulation) for prioritization, the nurse returns this message first.

Describe the Paget's Concrete Operational stage?

Concepts attached to concrete situations. Time, space and quantity are understood and applied, but not as independent concepts.

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that s/he will immediately report which finding? 1. Impaired sense of hearing 2. Gastrointestinal side effects 3. Orange-red discoloration of body secretions. 4. Difficulty in discriminating the color red or green.

Difficulty in discriminating the color red or green - Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green.

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

Fluid overload - Precipitating factors: infection, dehydration, hypoxia, trauma, physical or emotional stress. Given dehydration is a risk factor patients should be encouraged to intake 1.5-2 times the daily requirement.

Cyclobenzaprine is prescribed to a client for muscle spasms. Which disorder, if noted in the patient record, would indicate a meed to contact the HCP about the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus

Glaucoma - Cyclobenzaprine has anticholinergic effects, so should be used with caution in clients with a history of urinary retention, glaucoma, and increased IOP. The medication should also only be used for a short time (2-3 weeks)

The nurse provides care for a client diagnosed with schizophrenia. Which problem does the nurse identify as being a priority for the client? 1. Acting-out behaviors. 2. Having difficulty forming relationships. 3. Acting in a compulsive way. 4. Having multiple personalities.

Having difficulty forming relationships. — The marked inability to trust others, a hallmark of schizophrenia, makes it difficult for the client to form relationships.

A client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability and generalized weakness 4. Headache, deteriorating LOC and twitching

Headache, deteriorating LOC and twitching

A week after kidney transplantation a client develops a temperature of 101 F, their BP is elevated and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1. Antibiotic therapy 2. Peritoneal dialysis 3. Removal of the transplanted kidney 4. Increased immunosuppression therapy

Increased immunosuppression therapy - Acute rejection most often occurs within 1 week of transplantation, but can occur anytime posttransplantation. Clinical manifestations include: fever, malaise, elevated WBC count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function.

The nurse is working with a client, who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

Inquiring about and examining the client's feelings for any that may block adaptive coping - The client must deal with feelings and negative responses before the client can work through the meaning of the crisis.

The nurse provides care to a client who requires wound care. When collecting a wound drainage specimen for culture, the nurse implements which step? 1. Administer a single dose of antibiotic medication 30 minutes before obtaining the specimen. 2. Remove the crusts or scabs with sterile forceps and then culture the site beneath. 3. Swab the area in which the largest collection of drainage is present. 4. Irrigate the wound with sterile water prior to obtaining the specimen.

Irrigate the wound with sterile water prior to obtaining the specimen - Irrigating the wound with sterile water or normal saline prior to collecting a drainage specimen is appropriate. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms.

The nurse is performing an assessment on a client who is 38 weeks' gestation and notes that the fetal heart rate is 174 BPM. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's HR. 3. Notify the HCP. 4. Tell the client that the fetal HR is normal.

Notify the HCP - 1st Trimester: 160-170 BPM - 2nd Trimester: 110-160 BPM - 3rd Trimester: if less that 110 or greater than 160 when the uterus is at rest, the fetus may be in distress.

A client with PN infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? 1. On their left side, with their head lower than their feet. 2. On their left side, with their head higher than their feet. 3. On their right side, with their head lower than their feet. 4. On their right side, with their head higher than their feet.

On their left side, with their head lower than their feet. - This position is used to minimize the effect of the air traveling as a bolus to the lungs, by trapping it in the right side of the heart.

The nurse in the labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration and intensity. What is the priority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin infusion closely.

Provide pain relief measures. - Preparation for an amniotomy and oxytocin infusion are treatments for patient's with hypotonic dysfunction. In addition, a patient with hypertonic uterine contractions would be encouraged to rest, not ambulate.

The nurse describes which positioning will be used on a client who is about to undergo a lumbar puncture? 1. Side-lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg position. 4. Side-lying with the legs pulled up and the head bent onto the chest

Side-lying with the legs pulled up (to the abdomen) and the head bent onto the chest - This position helps to open the spaces between the vertebrae, allowing for easier needle insertion by the HCP. The nurse remains with the client to help maintain the position throughout the procedure

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. Iron supplements will give me diarrhea 2. Meat does not provide iron and should be avoided 3. The iron is best absorbed of taken on an empty stomach 4. On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement

The iron is best absorbed of taken on an empty stomach - Or taking the supplement with a fluid high in ascorbic acid like tomato juice, which enhances absorption. Iron supplements usually cause constipation, not diarrhea.

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regime? 1. My ulcer will heal because these medications will kill the bacteria. 2. These medications are only taken when I have pain from my ulcer. 3. The medications will kill the bacteria and stop the acid production. 4. The medications will coat the ulcer and decrease the acid production in my stomach.

The medications will kill the bacteria and stop the acid production. - Triple therapy for H. pylori infection usually includes 2 antibacterial medications (clarithromycin and amoxicillin) and a proton pump inhibitor (esomeprazole).

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client in the cast. What is the most appropriate assessment for this client? 1. The need for sensory stimulation 2. The amount of home care support available 3. The ability to perform activities of daily living 4. The type of transportation available for f/u care

The need for sensory stimulation - The assessment should include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. The remaining options do not directly address psychosocial adjustment.

After performing an initial abdominal assessment on a client with N/V, the nurse should expect to note which finding? 1. Waves of loud gurgles in all 4 quadrants 2. Low-pitched swishing in 1 or 2 quadrants 3. Relatively high-pitched clicks or gurgled in all 4 quadrants 4. Very high-pitched, loud rushes especially in 1 or 2 quadrants

Waves of loud gurgles in all 4 quadrants - Normal bowel sounds are relatively high-pitched clicks or gurgled. Loud gurgles (borborygmi) indicate hyperperistalsis and are commonly associated with N/V. A swishing or buzzing sound represents turbulent blood flow associated with a bruit, which are not normal sounds. When the intestines are under tension, such as an intestinal obstruction, bowel sounds are very high-pitched and loud (hyperresonance).