NCLEX PRACTICE Q

An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch? A. Cover the adolescent's legs with blankets. B. Report this finding to the health care provider (HCP) immediately. C. Reposition the adolescent's legs. D. Lay the adolescent flat to aid circulation.

A. Cover the adolescent's legs with blankets. In spinal cord injury, temperature regulation is lost below T3. Body temperature must be maintained by adjusting room temperature or bed linens, such as covering the client's legs with blankets. Coolness of the extremities is an expected finding. Therefore, it is not necessary to notify the HCP immediately. Repositioning the client's legs does not alleviate the temperature regulation problem and could be harmful, considering the client's diagnosis. Moving the legs before the spine is stabilized could lead to further cord damage. Laying the client flat will not increase the warmth to the legs and feet.

Which information should the nurse include when providing discharge instructions to a client with psoriasis? A. Avoid applying creams after bathing. B. Trim fingernails regularly. C. Scrub vigorously when bathing to remove scales on skin. D. Use a washcloth when bathing.

B. Trim fingernails regularly. Clients with psoriasis are likely to experience itching. Trimming nails will help to prevent damage to the client's skin caused by scratching. Applying creams after bathing may help to reduce itching. Scrubbing vigorously when bathing should be avoided, as it can cause bleeding. Using a washcloth on skin is considered to be too harsh and should be avoided.

Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: A. electrical burns of the hands and arms causing arrhythmias. B. burns to the head, face, and airway resulting in hypoxia. C. chemical burns on the chest and abdomen. D. secondhand smoke inhalation.

B. burns to the head, face, and airway resulting in hypoxia. Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained? A. fewer bruises than on admission B. development of an increase in mobility C. decreased cardiac dysrhythmias D. fewer muscular spasms

B. development of an increase in mobility This plan of care will help limit bone demineralization and reduce osteoporotic pain, thus promoting increased activity. The other choices are not reflective of osteoporosis.

The nurse is caring for an unconscious client recovering from anesthesia. Which position would the nurse place the client in? A. supine with head-tilt, chin-lift B. prone with head turned to the side C. left lateral recumbent D. reverse Trendelenburg

C. left lateral recumbent In an unconscious client, the muscles controlling the tongue commonly relax, causing the tongue to obstruct the airway. When this situation occurs, the nurse would use the head-tilt, chin-lift maneuver to cause the tongue to fall back into place. But since the client recovering from anesthesia is at risk for vomiting and aspiration, the left lateral recumbent would be the best option.

After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which complication? A. denial of the pregnancy B. low-birth-weight infant C. cephalopelvic disproportion D. congenital anomalies

D. congenital anomalies Additional teaching is needed when the parent says that adolescents are at greater risk for congenital anomalies. Although adolescents are at greater risk for denial of the pregnancy, lack of prenatal care, low-birth-weight infant, cephalopelvic disproportion, anemia, and nutritional deficits and have a higher maternal mortality rate, studies reveal that congenital anomalies are not more common in adolescent pregnancies.

The nurse is preparing to administer oral digoxin to a child and notes that the child has nausea, has vomited, and has a pulse rate of 45 beats per minute. What is the appropriate nursing action? A. Hold the digoxin and notify the physician of possible toxicity. B. Give the medication and document findings. C. Hold the medication until the child has stopped vomiting. D. Let the child and parents know vomiting and bradycardia are expected with this drug.

A. Hold the digoxin and notify the physician of possible toxicity. Bradycardia and vomiting are symptoms of digoxin toxicity. The medication should be held and physician notified.

Which pressure point areas should the nurse monitor for an unconscious client positioned on the right side (see figure.) Select all that apply. A. ankles B. ear C. greater trochanter D. heels E. shoulder

A. ankles B. ear C. greater trochanter E. shoulder Pressure points in the side-lying position include the ears, shoulders, ribs, greater trochanter, medial or lateral condyles, and ankles. The sacrum, occiput, and heels are pressure point areas affected in the supine position.

A 10-year-old with a history of recent respiratory infection has swelling around the eyes in the morning and dark urine. What question should the nurse ask first? A. "Has the child had a rash and fever?" B. "Has the child had a sore throat?" C. "Does the child have any allergies?" D. "Does the child drink lots of liquids?"

B. "Has the child had a sore throat?" In conjunction with the child's history of recent respiratory infection and report of dark urine, swelling around the eyes should lead the nurse to suspect acute glomerulonephritis. Therefore, the nurse should ask about a recent sore throat because a child with glomerulonephritis typically would have had a sore throat in the past 10 days. Drinking lots of liquids is unrelated to the periorbital edema.

A client is brought in by police to a mental health clinic for admission for bipolar disorder. During the initial phase of the client's treatment, which interventions would benefit the client in the manic phase of bipolar disorder? Select all that apply. A. Encourage the client to avoid extraneous environmental stimuli. B. Provide the client with frequent, small meals in the form of finger foods. C. Encourage the client to complete solitary activities such as puzzles. D. Request that the client attend group therapy sessions. E. Communication with the client should be clear and direct.

A. Encourage the client to avoid extraneous environmental stimuli. B. Provide the client with frequent, small meals in the form of finger foods. E. Communication with the client should be clear and direct. Symptoms of poor judgment and hyperactivity relate to the characteristics of mania. The client's environment should have low levels of stimulation and should also be free of hazards that the client could use to injure self or others. Providing small, frequent meals that can be eaten with their fingers will help to provide nourishment to the manic client. Communication should be clear and direct to minimize conflict and client frustration. Manic clients would find group therapy too stimulating and they could become a distraction to other clients. Activities for the manic client should focus on reducing frustration and conflict. A puzzle would not be a recommended activity.

A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and does not respond to verbal or tactile stimuli. Which nursing intervention is a priority? A. providing therapeutic communication and emotional stimulation B. providing a safe and supportive environment for the client C. assessing the client's nutritional and hydration status D. orientating the client to the unit and immediate surroundings for safety

C. assessing the client's nutritional and hydration status Priority is placed on immediate physical needs over psychosocial needs. In this situation, nutritional needs are the priority for a client in a catatonic state. Providing therapeutic communication, emotional stimulation, and a safe, nurturing, supportive environment and orienting the client to the environment are all appropriate actions, but the client's immediate physical needs must be met first.

The health care provider prescribes metoclopramide hydrochloride for the client with hiatal hernia. The nurse should assess the client to determine which expected outcome? A. Increase tone of the esophageal sphincter. B. Neutralize gastric secretions. C. Delay gastric emptying. D. Reduce secretion of digestive juices.

A. Increase tone of the esophageal sphincter. Metoclopramide hydrochloride increases esophageal sphincter tone and facilitates gastric emptying; both actions reduce the incidence of reflux.Other drugs, such as antacids or histamine receptor antagonists, may also be prescribed to help control reflux and esophagitis and to decrease or neutralize gastric secretions.Metoclopramide hydrochloride is not effective in decreasing or neutralizing gastric secretions and does not delay gastric emptying.

The client has been diagnosed with septic arthritis in a hip joint. Which outcomes are desired from a client-focused teaching plan? Select all that apply. A. Report pain that is severe enough to limit activities. B. Discuss how to take prescribed medications. C. Describe how the application of a heating pad set on "high" readily resolves edema. D. Describe the septic arthritis physiologic process. E. Explain the importance of supporting the affected joint. F. Describe how to use ambulatory aids and assistive devices.

A. Report pain that is severe enough to limit activities. B. Discuss how to take prescribed medications. D. Describe the septic arthritis physiologic process. E. Explain the importance of supporting the affected joint. F. Describe how to use ambulatory aids and assistive devices. The nurse should determine that a client with rheumatoid arthritis can describe the septic arthritis physiologic process and knows how to relieve pain using pharmacologic and nonpharmacologic interventions. Prolonged immobility and limited activity may promote formation of a deep vein thrombosis and possibly subsequent pulmonary emboli. The client should also understand the importance of supporting the affected joint, weight-bearing and activity restrictions, and how to use ambulatory aids and assistive devices safely to promote recovery of normal function. The local application of heat and cold to an injured body part can provide therapeutic benefits; however, "high" heat may cause a thermal injury and further promote edema formation. The client should inform the health care provider (HCP) about pain that is not relieved by the current management plan.

When caring for an oncology client receiving cisplatin and experiencing nausea and mouth sores, which nursing interventions are best to improve the client's diet? Select all that apply. A. Schedule high-nutrient shakes between meals. B. a large lunch with a nutritious snack for dinner. C. Offer small, frequent, light meals 5-6 times daily. D. Encourage a favorite meal of pizza and wings. E. Administer oral anesthetic 15 minutes prior to meals. F. Offer cool drinks and foods as tolerated.

A. Schedule high-nutrient shakes between meals. C. Offer small, frequent, light meals 5-6 times daily. E. Administer oral anesthetic 15 minutes prior to meals. F. Offer cool drinks and foods as tolerated. Optimal nutrition includes a balance of protein, carbohydrate, and only a small amount of fat. A client on cisplatin commonly has additional side effects of nausea and oral sores. Changes in the plan of care include high-nutrient shakes to compensate for low oral intake. Eating smaller, light meals commonly cooler in temperature as opposed to hot meals are better tolerated. Offering an oral anesthetic prior to meals decreases discomfort in the eating process. Large meals that are spicy and high in fat are discouraged.

A client recovering from spinal surgery needs to be repositioned in bed. Which action should the nurse take to ensure the client and nurse's safety? Select all that apply. A. Turn the client's head, upper body, torso, and lower extremities simultaneously. B. Place a pillow between the knees. C. Turn the client's shoulders first, followed by the hips. D. Have the client cross the arms over the chest. E. Raise the bed to a comfortable working height.

A. Turn the client's head, upper body, torso, and lower extremities simultaneously. B. Place a pillow between the knees. D. Have the client cross the arms over the chest. E. Raise the bed to a comfortable working height. A client recovering from spinal surgery should be repositioned by using the logrolling process. When using this maneuver, the client is turned as one unit or the head, shoulders, spine, hips, and knees are turned simultaneously. A pillow is placed between the knees to keep the legs and hips from moving. The client should move the arms out of the way by crossing them over the chest. The bed should be raised to a comfortable working height for all care providers participating in the turn. When logrolling, the client's head, shoulders, spine, hips, and knees turn simultaneously. The shoulders should not be moved first, followed by other body parts. This is not the correct procedure to logroll a client.

The nurse on the inpatient obstetrical unit is caring for a 42-year-old gravida 3 para 2 female client at 36 weeks' gestation who presents with nausea, vomiting, headache, excessive thirst, and polyuria. 1230 Client admitted to the high-risk obstetrical unit after being seen in the health care provider's office with report of nausea, vomiting, headache, excessive thirst, and voiding large amounts of urine every hour. Based on an oral glucose tolerance test at 28 weeks' gestation, the client has been controlling elevated blood glucose levels with diet. Client states last meal was 2 hours ago. Client denies pain, contractions, or leakage of fluid and reports decreased fetal movement. Abdomen soft and non-tender. Fetal heart rate 125 beats/min with moderate variability. Fetal heart rate accelerations noted. No decelerations noted. No contractions noted on external uterine contraction monitor. Health care provider reports cervix was closed when client was seen in the office at 0900. Client is alert and oriented to person, place, and time. Vital signs: temperature, 98.9°F (37.2°C); heart rate, 64 beats/min; respiratory rate, 18 breaths/min; blood pressure, 114/70 mm Hg. Oxygen saturation 99% on room air. Client is 5 ft 3 in. (160 cm) and weighs 185 lb. (83.9 kg). Pre-pregnancy weight was 160 lb. (73 kg). LAB RESULTS Blood glucose level, nonfasting: 238 mg/dl (13.21 mmol/L) NORMAL GLUCOSE IS < 140 mg/dl at 2 hours after meal (< 7.8 mmol/L) Blood type: AB+ The nurse is reviewing the Nurse's Notes and laboratory results from 1230. Which assessment finding(s) requires follow-up by the nurse? Select all that apply. A. blood glucose level B. report of nausea and vomiting C. report of headache D. blood pressure reading E. report of excessive thirst F. fetal heart rate assessment G. report of frequent urination

A. blood glucose level B. report of nausea and vomiting C. report of headache E. report of excessive thirst G. report of frequent urination The report of nausea, vomiting, headache, excessive thirst, and polyuria in a pregnant client at 36 weeks' gestation is not normal and requires follow-up. A blood glucose level of 238 mg/dl (13.21 mmol/L) indicates hyperglycemia and requires follow-up. Nausea and vomiting may be a sign of hyperglycemia and requires follow-up. Headache may be a sign of hyperglycemia or other high-risk pregnancy conditions and requires follow-up. The client's report of thirst may be a sign of hyperglycemia and requires follow-up. A report of frequent urination may be a sign of hyperglycemia and requires follow-up. The client's blood pressure is 114/70 mm Hg and is within normal limits. A fetal heart rate baseline of 125 beats/min with moderate variability, presence of accelerations, and no decelerations indicates fetal well-being and is reassuring.

A client with acquired immunodeficiency syndrome is receiving zidovudine. Which laboratory value indicates an adverse reaction to zidovudine? A. red blood cell (RBC) count of 1.8 million/μl (1.8 million x 10 to the 12th/L) B. fasting blood glucose of 104 mg/dl (5.8 mmol/L) C. serum calcium level of 8.9 mg/dl (2.2 mmol/L) D. platelet count of 240,000/mm3

A. red blood cell (RBC) count of 1.8 million/μl (1.8 million x 10 to the 12th/L) Because anemia (characterized by a decrease in RBCs below 4.0 million/μl) (4.0 million x 10 to the 12th/L) is a major adverse effect of zidovudine, the nurse should monitor the client's RBC count and assess for signs and symptoms of decreased cellular oxygenation. Zidovudine doesn't affect the blood glucose level, serum calcium level, or platelet count and the values listed are within normal limits.

When a relief charge nurse posts assignments, a nurse notes that they are no longer assigned to a client whom the nurse has cared for the previous 2 nights. How should the nurse respond to this assignment? A. Tell the charge nurse that the nurse would like to continue with the same assignment. B. Ask the nurse if there's a reason there was a change to the assignment. C. Accept the assignment and discuss the situation with the charge nurse at a later time. D. Tell the charge nurse that the nurse feels they are the best person to care for this particular client.

B. Ask the nurse if there's a reason there was a change to the assignment. Asking the charge nurse if there's a reason why there was a change in the assignment is the most professional response. This response encourages communication and exchange of ideas. Although it's acceptable for this nurse to tell the charge nurse that they would like to continue with the same assignment or accept the assignment and discuss the change with the charge nurse at a later time, these responses don't give the nurse an opportunity to resolve the concerns. Telling the charge nurse that the nurse feels they are the best person to care for a particular client is too direct and could put the charge nurse in a defensive position.

A client with right lower quadrant pain is admitted to the emergency department with a white blood cell (WBC) count of 17.8/mm3. What should the nurse do next? A. Notify the healthcare provider. B. Assess vital signs. C. Prepare the client for surgery. D. Perform a complete abdominal assessment.

B. Assess vital signs. The client is presenting with signs of infection. Therefore, further assessment is needed so that the temperature can be monitored. Palpation of the abdomen should be avoided considering the client may have appendicitis. The nurse should report the elevated WBC count and prepare for surgery after the assessment is completed.

A 9-year-old is brought to the emergency department with extensive burns sustained in a restaurant fire. What is the nurse's most important intervention? A. Administer prescribed antibiotics to prevent superimposed infections. B. Conduct a wound assessment. C. Administer liquids orally to replace lost fluid. D. Administer frequent, small meals to support nutritional requirements.

B. Conduct a wound assessment. The most important aspect of care for a child with burns is wound management. The goals of wound care are to speed debridement, protect granulation tissue and new grafts, and conserve body heat and fluids. Antibiotics aren't always administered prophylactically. Fluids are administered I.V. to replace fluid volume according to the child's body weight. Enteral feedings, rather than meals, are initiated within the first 24 hours after the burn to support the child's increased nutritional requirements.

A nurse is assessing the intravenous catheter patency in an infant prior to establishing a saline infusion. The IV flushes well with normal saline, and there is no swelling at the site, but there is no blood return when aspirated. What action should the nurse take? A. Re-site the IV catheter to the other arm. B. Continue to use the catheter, and monitor response. C. Occlude the vein, and attempt to aspirate blood again. D. Attempt to adjust the placement of the current catheter.

B. Continue to use the catheter, and monitor response. Infants and children have small, fragile veins, making a lack of a blood return normal. The nurse can use the catheter despite the lack of blood return. The infusion of saline has a low risk for complications if the IV is not patent; if the solution to be infused was irritating or a vesicant, the nurse may need to take additional actions to ensure it is safe to use. Occluding the vein in an attempt to get blood return is not warranted in this case, and the nurse should not manipulate the catheter, because this risks displacement.

A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply. A. Remove all tubes and IV lines. B. Cover the body with a sheet. C. Notify the family. D. Transport the body to the morgue. E. Notify the chaplain.

B. Cover the body with a sheet. D. Transport the body to the morgue. The UAP can cover the body and transport it to the morgue. Deaths by gunshot wound are considered reportable deaths. All evidence in a reportable death, including tubes and IV lines, should remain intact until the coroner has been contacted. The health care provider (HCP) should be the one to notify the family. The nurse should be the one to notify the chaplain.

An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care? A. Empty the catheter drainage bag. B. Cover the client with warm blankets. C. Hang new bags of irrigation. D. Turn the client.

B. Cover the client with warm blankets. It is important for the nurse to cover this client with warm blankets because he is at high risk for hypothermia secondary to age, spinal anesthesia, placement in a lithotomy position in the cool operating room for 1.5 hours, instillation of 4,000 mL of room temperature bladder irrigation, and ongoing bladder irrigation. Spinal anesthesia causes vasodilation, which results in heat loss from the core to the periphery. The nurse will empty the catheter drainage bag and hang new bags of irrigation as needed, but the client's potential for hypothermia should be addressed first. The client will not be turned at this time.

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises would the nurse provide to the child and family? Select all that apply. A. Avoid foods high in folic acid. B. Drink plenty of fluids. C. Use cold packs to relieve joint pain. D. Report a sore throat to an adult immediately. E. Restrict activity to quiet board games. F. Wash hands before meals and after playing.

B. Drink plenty of fluids. D. Report a sore throat to an adult immediately. F. Wash hands before meals and after playing. Sickle cell anemia is an autosomal recessive genetic disease passed down through families in which red blood cells form an abnormal sickle or crescent shape. Fluids would be encouraged to prevent stasis in the bloodstream, which can lead to sickling. Sore throats and all other cold symptoms would be reported promptly because they may indicate an infection, which can precipitate a crisis (red blood cells sickle and obstruct blood flow to tissues). Children with sickle cell anemia would learn appropriate measures to prevent infection, such as proper hand-washing techniques and good nutrition. Folic acid intake would be encouraged to help support new cell growth; new cells replace fragile sickled cells. Warm packs would be applied to promote comfort and relieve pain; cold packs cause vasoconstriction. The child would maintain an active, normal life but would avoid excessive exercise, which can precipitate an attack. When the child experiences a crisis, the child will typically limit activity according to the pain level.

A premature infant in the neonatal intensive care unit is actively dying and on comfort care measures only. The infant is grimacing with a respiratory rate of 20 breaths/minute. The parents ask the nurse to administer an opioid analgesic. What should the nurse do first? A. Administer the opioid as prescribed by the healthcare provider. B. Ensure the parents know opioids can cause further respiratory depression. C. Contact the healthcare provider about the infant's respiratory rate. D. Stimulate infant to increase respiratory rate prior to administering the opioid.

B. Ensure the parents know opioids can cause further respiratory depression. The infant is actively dying and on comfort measures only, so the nurse's priority is the infant's and the parent's comfort. The nurse helps prepare the parents by making them aware of the effects of the opioid to ensure they are giving an informed request for this treatment. Once the parents indicate understanding, the nurse can provide the treatment. The respiratory rate is significantly lower than normal for a premature infant, which could be due in part to previous administration of opioids, so the parents should be made aware of this. However, the infant is showing some evidence of pain (grimacing), and the opioid is prescribed to treat this pain, so the nurse does not need to contact the healthcare provider. The nurse should not stimulate the infant, because doing so could cause more discomfort.

A client comes to the mental health clinic with suspected obsessive-compulsive disorder (OCD). The client explains that the compulsion to wash hands is interfering with employment. Which interventions are appropriate when caring for a client with OCD? Select all that apply. A. Do not allow the client time to carry out the ritualistic behavior. B. Support the use of appropriate defense mechanisms. C. Encourage the client to suppress anxious feelings. D. Explore the patterns leading to the compulsive behavior. E. Listen attentively but do not offer feedback. F. Encourage activities such as listening to music.

B. Support the use of appropriate defense mechanisms. D. Explore the patterns leading to the compulsive behavior. F. Encourage activities such as listening to music. Client care should focus on reducing associated anxiety, fear, and guilt. This can be accomplished by allowing the client to carry out ritualistic behavior until they can be distracted to some other activity. The client also should be encouraged to use appropriate defense mechanisms and express feelings of anxiety. Exploring patterns that lead to the compulsive behavior may also be effective. The nurse always should listen attentively to the client and offer feedback. Activities such as listening to music may divert the client's attention from unwanted thoughts.

The home health nurse is completing a screening for elder abuse during a client visit. Which findings would require action by the nurse? Select all that apply. A. The client who lives with family who is assuming more of their care responsibilities. B. The client who is frequently scheduling appointments with their primary care provider. C. A client on apixaban with multiple small bruises on their bilateral arms and legs. D. A client who reports having excessive sleepiness after their evening medications. E. A client who is less talkative recently and avoiding eye contact with the nurse.

B. The client who is frequently scheduling appointments with their primary care provider. D. A client who reports having excessive sleepiness after their evening medications. E. A client who is less talkative recently and avoiding eye contact with the nurse. The nurse responsible for knowing, screening, recognizing, and reporting elder abuse which can stem from negligent or intentional acts performed by a caregiver or other trusted individual that results in harm to a vulnerable elderly person. Clients making frequent appointments or trips to the ER, who reports having excessive sleepiness after their evening medications may be being abused and over-medicated, and who have become less talkative or avoid eye contact with you are often being abused. The client who lives with family who is assuming more of their care responsibilities is showing signs of improvement and independence. A client on apixaban which is an anticoagulant would be expected to have some small bruises on their body.

A 3-year-old child with cystic fibrosis is admitted to the hospital with bronchopneumonia. Identifying which factors would be most helpful in planning care for this child? Select all that apply. A. weight gain B. cough C. fever D. constipation E. dysuria

B. cough C. fever As a result of the infectious process and mucus accumulation, classic signs of pneumonia include fever and cough.Weight loss may occur in a child with cystic fibrosis because of the energy expenditure needed to fight the infection.Constipation is not a common manifestation of pneumonia. However, vomiting may occur, especially if the child is coughing frequently and has a lot of mucus. Dysuria is not associated with pneumonia.

The care team has determined that an infant being treated for congenital hypothyroidism is not responding adequately to treatment. What assessment findings would support this conclusion? Select all that apply. A. irritability B. fatigue C. sleepiness D. increased appetite E. diarrhea

B. fatigue C. sleepiness Signs of inadequate treatment are fatigue, sleepiness, decreased appetite, and constipation.

A client with prostate cancer is treated with a luteinizing hormone-releasing hormone agonist and antagonist goserelin. What symptom should the nurse instruct the client to expect while receiving this treatment? A. tenderness of the scrotum B. flushing C. loss of pubic hair D. decreased blood pressure

B. flushing Goserelin is used to decrease testosterone production in men to slow or stop the production of cancer cells. A common side effect is flushing or hot flashes. Changes in blood pressure, tenderness of the scrotum, and dramatic changes in secondary sexual characteristics should not occur.

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to A. cough as the cuff is being deflated. B. take a deep breath as the nurse deflates the cuff. C. hold the breath as the cuff is being reinflated. D. exhale deeply as the nurse reinflates the cuff.

B. take a deep breath as the nurse deflates the cuff. The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.

A primiparous non-breastfeeding client at 48 hours postpartum is to be given medroxyprogesterone before discharge. What information should the nurse include in the teaching plan before administering this medication? A. There is an increased risk of ovarian cancer with use of this drug. B. Amenorrhea is common during the first 6 months. C. Heavy menstrual bleeding may occur. D. The client may experience periods of increased energy.

C. Heavy menstrual bleeding may occur. As with other contraceptives that are progestin based, heavy menstrual bleeding may occur. Other adverse effects include rash, acne, alopecia, fluid retention, edema, and sudden loss of vision. Depression and weight gain have been reported. For clients taking this drug, the risk of endometrial or ovarian cancer is decreased. Amenorrhea has been reported in clients after receiving four injections 3 months apart for 1 year. Depression and loss of energy have been reported.

A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. What is the most important nursing goal at this time? A. Reduce the client's fear of pain. B. Support the client's wish to discontinue further therapy. C. Prevent feelings of isolation. D. Help the client overcome feelings of social inadequacy.

C. Prevent feelings of isolation. Terminally ill clients most often describe feelings of isolation because they tend to be ignored, they are often left out of conversations (especially those dealing with the future), and they sense the attitudes of discomfort that many people feel in their presence. Helpful nursing measures include taking the time to be with the client, offering opportunities to talk about feelings, and answering questions honestly.

Which information should the nurse include in a postoperative teaching plan for a client with a laryngectomy? A. Instruct the client to avoid coughing until the sutures are removed. B. Tell the client to speak by covering the stoma with a sterile gauze pad. C. Reassure the client that normal eating will be possible after healing has occurred. D. Instruct the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin.

C. Reassure the client that normal eating will be possible after healing has occurred. Normal eating is possible once the suture line has healed.Coughing is essential to keep the airway patent.Because the larynx has been removed, the ability to speak is lost.Swallowing is usually not affected nor is the ability to control oral secretions.

The nurse has received a change of shift report about clients. Which client should the nurse assess first? A. a client with chronic heart failure with right upper quadrant fullness B. a client in atrial fibrillation with a heart rate of 90 with a "fluttering" feeling C. client with peripheral artery disease (PAD) just returning from an angiogram D. a client who had coronary artery bypass surgery 2 days ago who reports having incisional pain of "3" out of "10"

C. client with peripheral artery disease (PAD) just returning from an angiogram It is important for the nurse to assess the client with PAD returning from an angiogram. It will be important to make baseline assessments on this client. A client with atrial fibrillation with a heart rate of 90 bpm is not an abnormal finding. A "fluttering feeling" is expected in a client with atrial fibrillation. A client with heart failure experiencing right upper quadrant fullness does not require urgent attention; the client might be experiencing signs and symptoms of hepatomegaly.

A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use? A. using the walker for support while rising from a chair B. adjusting the height of the walker so the arms aren't bent when the hands rest on the walker grips C. moving the walker, stepping with the affected leg, then stepping with the unaffected leg D. moving the walker, stepping with the unaffected leg, then stepping with the affected leg

C. moving the walker, stepping with the affected leg, then stepping with the unaffected leg The walker is designed to take the weight from the affected leg. Therefore, the nurse should instruct the client to move the walker, step with the affected leg, and then step with the unaffected leg. In this way, when the unaffected leg is lifted from the ground, the client's weight is partially supported by the arms on the walker. The arms should be flexed at the elbows at a 15- to 30-degree angle. When rising from a chair, the client should use the arms of the chair (not the walker) for support. The clients grasps the walker after rising from the chair. The same principle applies when sitting in a chair.

During the initial assessment, a client exhibits pressured speech. The client points to certain patterns on the wallpaper and says, "This is the writing about the tsunami. Thousands of people died because I read the writing. I should never have read the writing; it was my fault." Which would be central to the nurse's interventions? A. reduction of environmental stimuli B. challenging the client's personal space C. replying to the client with feedback about reality and the client's behaviors D. preparing the staff and the environment for escalation of behaviors

C. replying to the client with feedback about reality and the client's behaviors The client falsely believes that they are responsible for catastrophic events that are unrelated to them. The nurse must present reality in a nonjudgmental manner and validate the part of the delusion that is real. The nurse must also present that the client does not observe the part of the delusion the client is seeing. Reduction of environmental stimuli is important but is not central in the care of the delusional client. The priority would also not include preparing for escalation of behaviors because, if handled properly, the client should not escalate. The nurse should not invade the client's personal space and should use touch judiciously.

Which clinical manifestation would lead the nurse to suspect an infant has hydrocephaly? Select all that apply. A. depressed fontanel B. headache C. vomiting D. low pitched cry E. irritability F. pupillary changes G. bulging fontanel

C. vomiting E. irritability F. pupillary changes G. bulging fontanel Hydrocephaly is a block in the flow of cerebral spinal fluid. Hydrocephaly results in increased intracranial pressure (ICP). Vomiting, irritability, bulging fontanel, and pupillary changes are all signs of increased intracranial pressure in an infant. A depressed fontanel could be an indication of dehydration, not increased intracranial pressure. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the nurse or parent. A headache is an indication of increased ICP in a verbal child. A high-pitched cry is indicative of infants with increased intracranial pressure.

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? A. an 84-year-old client with heart failure who's on telemetry and 2 L/minute of oxygen B. a 42-year-old client who has left lower lobe pneumonia and an I.V. line C. a 48-year-old client with chronic obstructive pulmonary disease with occasional atrial fibrillation D. a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line

D. a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if the client goes into atrial fibrillation, but this client isn't a priority at this time.

The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation? A. standard or routine precautions B. contact precautions C. airborne precautions D. droplet precautions

D. droplet precautions Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that HCPs wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms, and all heath care workers must wear respirators.

When coping becomes dysfunctional enough to require the client to be admitted to the hospital, the nurse expects that the client would be exhibiting what behaviors? A. objective and rational problem solving B. tension reduction activities and then problem solving C. anger management strategies with no problem solving D. minimal functioning with new problems developing

D. minimal functioning with new problems developing Minimal functioning, which can cause new problems to develop, is a reflection of dysfunctional coping. The ability to objectively and rationally solve problems demonstrates adaptive coping. Tension reduction activities demonstrate palliative coping. However, such activities alone do not solve problems; they must be followed by problem solving. Anger management alone may prevent new problems, such as violence toward oneself or others, but it does not solve problems directly. It is considered maladaptive coping.

A postpartum client has been ordered 500 mg of ampicillin oral suspension. The label reads ampicillin 125 mg/5 mL. How many milliliters would the client receive? Record your answer using a whole number.

20 500/125=4 4*5=20 ml

An oncology clinic nurse is reinforcing prevention measures for oropharyngeal infections to a client receiving chemotherapy. Which statement by the client indicates that teaching was successful? A. "I clean my teeth gently several times per day." B. "I replace my toothbrush every month." C. "I lubricate my lips with petroleum jelly." D. "I use an alcohol-based mouthwash every morning."

A. "I clean my teeth gently several times per day." The client demonstrates understanding when they state that they will clean their teeth gently several times per day. Frequent gentle cleaning of the mouth or rinsing reduces bacteria build-up in the oral cavity, thus reducing the risk for oropharyngeal infection. Changing the toothbrush each month reduces the bacteria in the mouth for the first few uses only. Petroleum jelly moistens the lips, but doesn't prevent breakdown of the mucous membranes or reduce the risk for oropharyngeal infection. Alcohol-based products cause drying of the mucous membrane, increasing the likelihood of oropharyngeal infection.

A nurse is preparing a 4-year-old child for surgery. Which is the best nursing intervention? A. Allowing the child to wear underwear if desired. B. Sharing the plan for pain control with the child. C. Ensuring that the child has only favorite foods for 24 hours. D. Explaining the surgery in detail.

A. Allowing the child to wear underwear if desired. Allowing the preschool-age child to make choices during the preoperative period helps to relieve fear and anxiety, so allowing a child to wear underwear during the preoperative period is most appropriate. Preschool-age children have short attention spans and active imaginations; sharing detailed explanations about the pain management plan or procedure may increase anxiety. Promising only favorite foods is unrealistic.

A primigravida states, "I think my water just broke." What should the nurse do? Select all that apply. A. Perform a nitrazine test to confirm that the membranes are ruptured. B. Monitor the fetal heart rate and pattern. C. Assess maternal temperature. D. Tell the client that birth will most likely occur within the next hour. F. Prepare the client for childbirth.

A. Perform a nitrazine test to confirm that the membranes are ruptured. B. Monitor the fetal heart rate and pattern. C. Assess maternal temperature. When membranes rupture, the nurse should immediately check fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. The nurse should also perform a nitrazine test to confirm that the membranes are ruptured. Maternal temperature should be assessed every 1 to 2 hours so infection can be identified early. Membranes may rupture any time during labor. In some cases, 24 hours may pass between rupture and onset of labor, so the nurse does not need to prepare for childbirth at this time.

The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess? A. amenorrhea and quickening B. uterine enlargement and Chadwick's sign C. a positive pregnancy test and a fetal outline D. Braxton Hicks contractions and Hegar's sign

A. amenorrhea and quickening Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective, but nonconclusive indicators — for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators, such as fetal outline on ultrasound confirm pregnancy.

The nurse administers a preoperative intramuscular medication at the ventrogluteal site. Into which muscle will the nurse inject the medication? A. rectus femoris B. gluteus minimus C. vastus lateralis D. gluteus maximus

B. gluteus minimus When using the ventrogluteal site, the nurse injects the medication into the gluteus minimus muscle.The rectus femoris muscle, which is located on the anterior aspect of the thigh, can be used for intramuscular injections.The vastus lateralis muscle is used for the vastus lateralis injection site.The gluteus maximus muscle is used for the dorsogluteal injection site.

The client presents to the clinic with severe anemia, and is a Jehovah's Witness with religious beliefs that prohibit the administration of blood products. Which concurrent medications does the nurse teach the client about when receiving blood products? Select all that apply. A. NSAIDs B. epoetin alfa C. aspirin D. levothyroxine E. ferrous sulfate

B. epoetin alfa E. ferrous sulfate The concurrent medication of ferrous sulfate to clients receiving epoetin alfa increases the likelihood of an optimal hematologic response. An adequate iron supply must be available for red blood cell production. When receiving blood products, NSAIDs, levothyroxine, and aspirin are not used as concurrent medications.

After the administration of t-PA, the assessment priority is to: A. Observe the client for chest pain. B. Monitor for fever. C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours. D. Monitor breath sounds.

Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.

The nurse is serving on the Quality Improvement Committee for the maternity unit. Quality improvement projects for this unit impacting safety and quality of care include which projects? Select all that apply. A. use of recycling bins on the unit B. infant identification system C. sibling and family visitation policies D. postpartum discharge instructions E. rooming in guidelines

B. infant identification system C. sibling and family visitation policies D. postpartum discharge instructions E. rooming in guidelines The use of recycling bins on the unit does not impact safety or contribute to the quality of care. The infant identification system is a safety practice. Nursing influences the type of system used and how monitoring and identification occur, which improves the quality of care. The sibling and family visitation policy can be an excellent project. Sibling policies regarding visitation can influence safety (safety of mother and infant by keeping children with colds/flus, infections away from the obstetrics unit). Nursing influences development of the policy utilized and implemented on a daily basis. Postpartum instructions represent an area where the skill level, quality, and quantity of instruction represent nursing contributions to care. The ability for a family to remain together during a hospital stay is important to families. The quality of the obstetrical experience can be enhanced or determined to be negative by this particular policy, one that is often looked at by these committees.

The nurse is assessing a 2-year-old child's development. What assessment finding would warrant further investigation by the nurse? A. constantly stating "no" to instructions B. requesting the same bedtime story every night C. having a vocabulary of 100 words D. building a small tower with 5 blocks

C. having a vocabulary of 100 words The favorite word of a two-year-old is "no." It is a way to exert their independence and test limits. Two-year-olds like repetition because it provides security, so reading the same book every night provides stability and comfort. They can build a block tower of 4-5 blocks. A two-year-old should have a vocabulary of 200 words, so a smaller vocabulary could indicate a development delay.

The nurse is preparing to administer an I.V. medication to an unconscious client. What is the best action by the nurse? A. Compare the client's name to the medication administration record. B. Compare the room number of the client to the medication administration record. C. Compare the client's ID on the wristband to the medication administration record. D. Compare the client's name and ID on the chart to the client's wristband.

D. Compare the client's name and ID on the chart to the client's wristband. The nurse should verify two identifiers. One way to do this would be to compare the client's name and ID number on the chart to the name and ID number on the client's wristband. Comparing the client's name with the medication administration record and comparing the client's ID on the wristband to the medication administration record only provides one verification of identification when two are needed. Comparing the room number is not best practice as the client in the room may not be the correct client.

A client with depression and behavioral changes is transferred from a local assisted living center to the emergency department. The nurse notes that the client cries out when approached. The nurse gains the client's confidence and begins the assessment, noticing some blood on the client's underwear. The client is otherwise stable. The nurse questions the client about the stain, and the client begins to cry, saying "don't tell, don't tell." The nurse suspects sexual abuse. Which action should the nurse take first? A. Notify the client's primary care physician of the findings. B. Notify adult protective services. C. Notify the client's family. D. Notify the rape crisis team.

D. Notify the rape crisis team. The nurse should first notify the rape crisis team to obtain evidence to be collected of possible rape and the suspicions to be confirmed. The primary care physician, adult protective services, and/or the ombudsperson should be notified next. The family should be notified if the client consents but not until the rape investigation is complete.

As part of the postpartum follow-up, a nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information which assessment would the nurse make? A. The client's behavior represents signs of postpartum depression. B. The client is acting abnormally and her physician needs to be notified. C. A home assessment is necessary to assure the well-being of the mother and the neonate. D. This is expected behavior for a client 3 to 7 days postpartum.

Normal processes during postpartum include the withdrawal of progesterone and estrogen and lead to the psychological response known as "the blues." Postpartum depression is a psychiatric problem that occurs later in postpartum and is characterized by more severe symptoms of inadequacy. Because the client's behavior is normal, notifying her physician and conducting a home assessment aren't necessary.

The young sister of a young adult client with leukemia asks, "Can you check my blood? When my sister got pneumonia, so did I. And I think I have this, too." Which of the following by the nurse would be inappropriate? A. Ask the client's health care provider to take a sample of the sister's blood. B. Explain to the sister that leukemia is not a communicable disease. C. Discuss the sister's concern with her parents. D. Tell the sister's parents about a group for siblings of clients with terminal illness.

A. Ask the client's health care provider to take a sample of the sister's blood. Taking a blood sample is an unnecessary, invasive procedure that would not directly address the sister's fear. Leukemia is not considered a communicable disease. Providing an explanation and alerting the parents to the sibling's concern and the resources available to assist siblings to deal with the terminal illness are all appropriate interventions.