NCLEX Practice Questions 500+

The nurse is preparing a client for nonemergency surgery. The nurse should:

verify the client understands the informed consent form. The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary.

According to Erikson's theory of development, chronic illness can interfere with which stage of development in an 11-year-old child?

Industry versus inferiority

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?

Multiple myeloma is more common in middle-aged and older clients. The median age at diagnosis is 60 years. It is twice as common in blacks as it is in whites. It occurs most often in black men.

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching?

"I will have to take vitamin B12 shots up to 1 year after surgery." After a total gastrectomy, a client will need to take vitamin B12 shots for life. Dietary B12 is absorbed in the stomach, and the inability to absorb it could lead to pernicious anemia.

A client has been diagnosed with hypothyroidism. Which statement by the client would demonstrate appropriate teaching by the nurse?

"I will increase fiber and fluids in my diet."

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse?

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction?

"Brain damage may occur if the molding does not resolve quickly." Caput succedaneum is common after the use of a vacuum extractor to assist the client's expulsion efforts. This edema may persist up to 7 days. Vacuum extraction is not associated with cephalohematoma. Maternal lacerations may occur, but they are more common when forceps are used. Neonatal intracranial hemorrhage is a risk with both vacuum extraction and forceps births, but it is not a common finding.

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents:

"Do you give the baby a bottle to take to bed?" In a young child, the eustachian tube is relatively short, wide, and horizontal, promoting drainage of secretions from the nasopharynx into the middle ear. Therefore, asking if the child takes a bottle to bed is appropriate because drinking while lying down may cause fluids to pool in the pharyngeal cavity, increasing the risk of otitis media.

Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture?

"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on."

Which instruction should a nurse give a client with prostatitis who is receiving co-trimoxazole double strength?

"Drink 6 to 8 glasses of fluid daily while taking this medication." The client must drink 6 to 8 glasses of fluid daily to prevent renal problems, such as crystalluria and stone formation. If the drug is effective, symptoms should improve within a few days. Sore throat and sore mouth are adverse effects; the client should report them to a physician right away. The drug causes photosensitivity, but the client should use a PABA-free sunscreen; PABA can interfere with the drug's action.

The 17-year-old client with a diagnosis of bulimia nervosa is hospitalized. The client weighs 5 lb (2.26 kg) less than her ideal weight for her height. She tells the nurse, "I do not have a problem. I am not really underweight." The nurse should respond by saying:

"Even though your weight is almost ideal for your height, purging and using laxatives are harmful to your body."

A nurse assessing the heart rate and rhythm of an 8-year-old child hears a murmur that's barely audible even in a quiet room. The child's heart rate is 80 beats/minute. The nurse should document her assessment findings as:

"Heart rate regular, grade I murmur auscultated." A grade I murmur is barely audible in a quiet room; a grade II murmur is faint but clearly audible.

While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response?

"I'm sorry, I can't disclose client information."

The nurse meets with the client and his wife to discuss depression and the client's medication. Which comment by the wife would indicate that the nurse's teaching about disease process and medications has been effective?

"It is important for him to take his medication so that the depression will not return or get worse."

A birthing couple informs the nurse that they would like to have the placenta after the baby is born. What is the nurse's best response?

"Let me check about how to go about doing this."

While assessing a neonate at 4 hours after birth, the nurse observes an indentation with a small tuft of hair at the base of the neonate's spine. The nurse should document this finding as what finding?

A small tuft of hair and an indentation at the base of the neonate's spine is termed spina bifida occulta. This condition usually occurs between the L5 and S1 vertebrae with failure of the vertebrae to completely fuse. There are usually no sensory or motor deficits with this condition. Spina bifida cystica includes meningocele, myelomeningocele, and lipomeningocele. Meningocele is characterized by a saclike protrusion filled with spinal fluid and meninges. Usually, this condition is associated with sensory and motor deficits. Myelomeningocele is characterized by a saclike protrusion filled with spinal fluid, meninges, nerve roots, and spinal cord. With myelomeningocele, there are usually sensory and motor deficits.

What data indicates to the nurse that placental detachment is occurring?

An abrupt lengthening of the cord

An 86-year-old client with dementia is being discharged after treatment for a hip fracture. In reviewing the notes, the nurse identifies that the sole care-giver at home is an adult daughter with a moderate intellectual disability. Which is the most important action the nurse should ensure is in place before discharging the client home?

An immediate home visit is arranged with the visiting nurse service and the social worker.

Which measure would be most effective for the client to use at home when managing the discomfort of rhinoplasty 2 days after surgery?

Apply ice compresses.

What should a nurse do when administering pilocarpine?

Apply pressure on the inner canthus to prevent systemic absorption.

A client is admitted to the emergency department following an overdose of barbiturates. What should the nurse do first?

Assess ventilation and assist ventilation as needed.

A client with Tourette syndrome is seen in an outpatient clinic. The client has multiple tics occurring several times per day. The nurse notices that the client has a difficult time completing tasks such as activities of daily living (ADLs). In which of the following ways can the nurse best help this client?

Break down tasks into small achievable steps

A client with a personality disorder is upset and calls the nurse a "stupid cow." Which of the following is the most effective initial response by the nurse to this client's behavior?

Calmly discuss the inappropriateness of displacing anger to others.

Which meal would be appropriate for the child with osteomyelitis to choose?

Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs, cheese, meat, fish, and beans are the best sources of these nutrients.

The nurse is caring for a client with bipolar disorder who was recently admitted to an inpatient unit and is experiencing a manic episode. What is a priority nursing intervention for this client?

Closely monitor the client's eating and sleeping habits.

The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into the infant's diet at age:

Solids should be introduced at 6 months. Full-term infants use up their prenatal iron stores within 4 to 6 months after birth. Milk contains insufficient iron.

A client has been receiving oxytocin to augment her labor. The nurse notes that contractions are lasting 100 seconds. Which immediate action should the nurse take?

Stop the oxytocin infusion

A nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess:

Hegar's sign. When performing a vaginal or rectovaginal examination, the nurse may assess Hegar's sign (softening of the uterine isthmus) between the 6th and 8th weeks of pregnancy.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High-protein

The nurse is reviewing a client's prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth?

History of postpartum hemorrhage (PPH)

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?

IgE. Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

A client needs to be transferred to the oncology unit for further care. Which of the following information is necessary to include in the transfer report?

Current client assessment. The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained.

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

Elevated ST segment

After completing a shift, a nurse realizes that documentation on a client was not completed before leaving the unit. Which of the following actions by the nurse is most appropriate?

Enter the information tomorrow stating it is a late entry.

A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics?

Fidelity.

Which of the following involves charting information about the client and client care in chronological order?

Narrative charting. Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities. The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place her and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

The nurse should dispose of a used needle and syringe by:

Placing uncapped, used needles and syringes immediately in the universal precaution container in the client's room.

After being examined by a forensic nurse in the emergency department, a rape victim is prepared for discharge. Because of the nature of the attack, this client is at risk for post-traumatic stress disorder (PTSD). Which symptoms are associated with PTSD? Select all that apply.

Recurrent, intrusive recollections or nightmares Sleep disturbances Difficulty concentrating Clients with PTSD typically experience recurrent, intrusive recollections or nightmares, sleep disturbances, difficulty concentrating, chronic anxiety or panic attacks, memory impairment, and feelings of detachment or estrangement that destroy interpersonal relationships. Gingival and dental problems are associated with bulimia. Flight of ideas and unusual talkativeness are characteristic of the acute manic phase of bipolar disorder.

A two-year-old child has tested positive for tuberculosis (TB), and has been started on rifampin. The child's parents ask the nurse if there is any important information they should know about this medication. What important adverse effect should the nurse inform these parents about?

Rifampin and its metabolites will turn urine, feces, sputum, tears, and sweat an orange color. This is not a serious adverse effect. Rifampin may also cause GI upset, headache, drowsiness, dizziness, visual disturbances, and fever. Liver enzyme and bilirubin levels increase because of hepatic metabolism of the drug. Parents should be taught the signs and symptoms of hepatitis and hyperbilirubinemia such as jaundice of the sclera or skin.

A nurse meets his/her neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts?

Share the feedback with the nursing colleague directly.

A charge nurse enters a client's room and observes a physician instructing another nurse on how to insert a central line into the client's neck. The nurse is holding the cannula and inserting the line. What would be the appropriate response by the charge nurse?

Stop the procedure and inform the nurse that he/she is practicing outside of a nurse's legal scope of practice.

A client has been hospitalized with a diagnosis of myasthenia gravis. A friend is visiting the client during lunch. The nurse enters the room after the client recovered from choking on lunch. What should the nurse do next?

Tell the client to swallow when her chin is tipped down on her chest.

A client is admitted to the hospital for diagnostic testing to rule out colorectal cancer. Which intervention should the nurse include on the plan of care?

Test all stools for occult blood.

A registered nurse (RN) is supervising an unlicensed assistive personnel (UAP). Which principle would the nurse follow when delegating tasks?

The RN delegates a task based on the UAP's skill set

A client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

The client uses a mirror to inspect the skin.

A client is being admitted with a nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with a:

The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised.

A 4-year-old child is admitted for a cardiac catheterization. Which is most important to include as the nurse teaches this child about the cardiac catheterization?

The most important aspect of teaching a preschooler is to have the family members there for support. Preschoolers are able to understand information that is individualized to their level.

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from social work or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship?

The mother's fear that the staff do not respect her

A client who fell through ice and was submerged for longer than 1 minute is admitted to the emergency department with hypothermia and near-drowning. At which point will the nurse best be able to determine the client's outcome status?

The neural or hemodynamic status of the client cannot be determined until the client is warmed.

A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse?

The nurse should listen attentively and provide realistic verbal reassurance.

Which use of restraints in a school-age child should the nurse question?

To substitute for observation

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions?

With true labor, the contractions are felt first in the lower back and then the abdomen. They gradually increase in frequency and duration and do not disappear with ambulation, rest, or sleep. In true labor, the cervix dilates and effaces. Walking tends to increase true contractions. False labor contractions disappear with ambulation, rest, or sleep. False labor contractions commonly remain the same in duration and frequency. Clients who are experiencing false labor may have pain, even though the contractions are not very effective.

A nurse is assessing a client who is receiving clozapine. The nurse reviews the medical record. What should the nurse do next?

Withhold the clozapine, and notify the health care provider (HCP). Because clozapine can cause tachycardia, the nurse should withhold the medication if the pulse rate is greater than 140 bpm and notify the HCP. Giving the drug or telling the client to exercise could be detrimental to the client.

A client has been taking furosemide for 2 days. The nurse should assess the client for:

a decreased potassium level.

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first?

albuterol nebulizer

A nurse is assessing a 15-year-old girl who has lost 30 lb (13.6 kg) over 3 months. What other finding is the nurse likely to assess?

amenorrhea.

To prepare the community for the possible threat of anthrax, a nurse must teach that:

anthrax can infect the integumentary, GI, and respiratory systems.

To prevent back injury, the nurse should instruct the client to:

avoid prolonged sitting and standing.

When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem?

blindness secondary to gonorrhea

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value?

serum creatinine

During labor, a low-risk multigravid client in active labor has begun pushing, and the fetal head is beginning to crown. To prevent perineal lacerations during the birth, the nurse should:

stretch the perineal tissues with sterile gloved fingers. Sterile gloves should always be worn by birth attendants to prevent infection to the laboring client and the fetus. Stretching the perineal muscles can decrease the incidence of tearing or lacerations.

When planning home care for a 3-year-old child with eczema, what should the nurse teach the mother to remove from the child's environment at home?

stuffed animals

A 12-year-old with asthma wants to exercise. Which activity should the nurse suggest to improve breathing?

swimming

The nurse is to check a client's gag reflex. The most effective technique for testing the gag reflex is to:

touch the back of the client's throat with a tongue blade.

Outcome statement is: a) Client will ambulate without a walker by 6 weeks b) Client will ambulate freely in house c) Client will not fall

A) Client will ambulate without walker by 6 weeks

Which nursing diagnoses would the nurse use for a client prone to falls: a) Deficient knowledge b) Risk for Injury c) Risk for disuse syndrome d) Risk for suffocation

B) Risk for Injury

The nursing action most appropriate for a client who has an infection and develops a fever of 99.8' F is to: a) Continue to monitor the patient's temp b) Administer an antipyretic

A) Continue to monitor the patient's temp

The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response?

"About one-third have an intellectual disability, but it is too early to tell about your child."

The client experienced female circumcision as a puberty ritual while living in Africa as a child. What condition should the nurse monitor the client as an adult: c) Chronic urinary tract infection d) Tendency for postpartum hemorrhage

C) Chronic Urinary Tract Infection

A client with acute pancreatitus has an abnormally low serum calcium level. During a bath the nurse cleans the client's face with a cloth, and the lips, nose, and side of the face. When documenting this information the nurse would state that the patient's facial twitching indicates the presence of: c) Chrostek's sign d) Bell's palsey

C) Chrostek's Sign

The nurse cares for a middle-aged client with a below-the-knee amputation. What statement indicates the need for further assessment of the client's body image?

"I hope I can handle having a prosthesis, but I am really wondering what my wife will think."

The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue?

"I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night."

During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction?

"Let your child eat any food he wants."

The nurse is explaining to a client and the client's family about what to expect immediately after electroconvulsive therapy (ECT) treatments. Which of the following statements would indicate to the nurse that the teaching was effective?

"My family member will likely experience some confusion and disorientation after the treatment." Clients typically experience some confusion and disorientation after treatment, but this generally recovers quite quickly. Clients are not heavily sedated after treatment. Muscle soreness is rare. Clients do not have immediate benefits after treatment; the typical course of treatment is 6 to 10 treatments.

A community health nurse is testing the theory of locus of control (LOC). Which of the following client's demonstrates the internal control concept of this theory: a) A client who takes an active role in all health decisions b) A client who allows the primary care provider to make all the decisions c) A client who does not make any decisions without his/her souse's input d) A client who relies on information from the local hospital for his.her health needs

A) A client who takes an active role in all health decisions

A patient complains of not having had a bowel movement since being admitted 2 days ago for multiple fractures of both lower legs. The patient is on bedrest and has skeletal traction. Which intervention would be the most appropriate nursing action: a) Administer an enema c) Ensure maximum fluid intake (3000 mL/day) d) Perform range of motion exercises to all extremeties

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A patient is receiving 3% NaCl solution for correction of hypoatremia. During administration of the solution, the most important assessment for the nurse is to monitor is: a) Lung sounds c) Peripheral pulses d) Peripheral edema

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A patient substained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear and edematous. The nurse identifies the stage of healing of these wounds as long: a) Inflammatory b) Proliferate d) Remodeling

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The RN should incorporate which instructions into the teaching plan for a client with a urinary diversion: b) Notify the physician if the stoma is deep pink and shiny c) Strands of blood appear in the urine d) Increase fluid intake

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The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take: a) Notify the patient's health care provider b) Give the prescribed PRN lorazepam (ativan) c) Start the prescribed PRN oxygen at 2 to 4 L/min

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When the body is subjected to invasion or trauma, the role of Europhiles is to: b) Release histamine into the circulation c) Produce specific antigens d) Phagocytize injurious agents

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When the nurse assesses dyspnea in a client with congestive heart failure, she assesses for other manifestations of fluid volume excess including: b) Peripheral Edema c) Increased hematocrit level d) decreased urine output

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Which potential potassium order is safe for the nurse to implement: a) Add 20 mEq of KCL to 1,000 mL of IV fluid b) 10 mEq KCL IV over 1-2 min d) 10 mEq KCL SQ

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Which problem is most appropriate for the nurse to identify for the client with diarrhea: a) Alteration in skin integrity b) Chronic pain perception d) INeffective coping

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Normal Range for HCO3:

21-28 mEq/L

Normal Range for: PaCO2

35-45 mm Hg

Normal Range for pH:

7.35- 7.45

A client is attending classes on building positive relationships with significant others as well as learning skills to be open minded and respectful to those whose opinions are different. This client is focusing on which component of wellness: a) Physical b) Social c) Emotional d) Environment

B) Social

Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient's Stage III sacrel pressure ulcer: a) Administer the ordered PRN oral opoid 30 min before the dressing change b) Soak the old dressing with sterile saline a few minutes before removing them

A) Administer the ordered PRN oral opiod 30 min before the dressing change

The nurse is reviewing laboratory data for a patient who is receiving total parental nutrition. Which lab value should be immediately brought to the physicians attention: a) BUN of 60 c) Serum glucose 328 d) Potassium of 3.5

A) BUN of 60

On one of the first days working alone, the novice nurse must provide teaching on tracheotomy care to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to: a) ASk the nurse mentor to assist with the teaching after reviewing the procedure b) Read the policy and procedure manual before the teaching session c) Do the best the nurse can by remembering what was taught in nursing school d) ASk for a different assignment until the nurse feels comfortable with this one

A) ASk the nurse mentor to assist with the teaching after reviewing the procedure

A student nurse who claims to be very uncreative and dose not understand why it is necessary to assess and develop new ideas in the clinical area. The best response by the nurse educator is: a) Creativity allows unique solutions to unique problems b) Not all your answers are going to be from your textbook c) Creativity makes nursing fun d) You'll get bored if you don't learn to be creative

A) Creativity allows unique solutions to unique problems

A client has an open wound that is yellow and black. Using the RYB color code, which nursing intervention needs to occur first? a) Debride the area with wet-to-dry dressing b) Apply topical antibiotic ointment

A) Debride the area with wet-to-dry dressing http://www.slideshare.net/lezzoj/wound-dressing

A client recovering from abdominal surgery refuses analgesia, saying that he is "fine, as long as he dosen't move." Which nursing diagnosis should be a priority: A) Deficient Knowledge (pain control measures) b) Ineffective Health Maintenance

A) Deficient Knowledge (pain control measures)

A nursing activity that is carried out during the evaluation phase of the nursing process is: a) Determining if interventions have been effective in meeting patient's outcome b) Documenting the nursing care plan in the progress notes in the medical record c) Deciding whether the patient's health problems have been completely resolved d) Asking the patient to evaluate whether the nursing care provided was satifactory

A) Determining if interventions have been effective in meeting patient's outcomes

A patient complains of pain during circumfusion of the shoulder when the nurse moves the arm behind the patient which question should the nurse ask: a) Do you have difficulty in putting on a jacket b) Are you able to feed yourself without difficulty

A) Do you have difficulty in putting on a jacket

During a well-child visit, a mother tells the nurse that her 4- year old daughter typically goes to bed at 10:30 pm and awakens each morning at 7 am. She does not take a napin the afternoon. Which is the best response by the nurse: a) encourage the mother to consider putting her daughter to bed between 8 and 9 pm d) Reassure her that her daughter's sleep pattern is normal and that she has outgrown her need for an afternoon nap

A) Encourage the mother to consider putting her daughter to bed between 8 and 9 pm

The mother of a 1 month old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instructions should the nurse give this infants mother: a) Have the infant be seen by a physician b) Give the infant at least 2 ounces of juice every 2 hours

A) Have the infant be seen by a physician

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. Which statement made by the client, would indicate that this client needs further instruction: a) I will replace my cotton blankets with polyester ones b) My son will not be able to smoke when I am around

A) I will replace my cotton blankets with polyester ones

The shift change while the nursing staff was waiting for the adult children of a deceased client to arrive. The oncoming nurse has never met the family. Which of the following initial greetings is most appropriate: a) I'm very sorry for your loss b) I'll take you in to view the body

A) I'm very sorry for your loss

The patient has been admitted with complaints of shortness of breath for 2 week duration and has received the nursing diagnosis impaired gas exchange. Which admission laboratory result would support the choice of this diagnosis: a) Increased hematocrit b) Decreased BUN

A) Increased Hematocrit

The nursing process is a dynamic process. This means that it: a) Is ever changing to the client's needs b) Conveys the force or power of the health team

A) Is ever changing in response to the client's needs

The nurse anticipates that osteoposis may result from prolonged immobilization because of: a) Lack of weight bearing, which decreases osteoblastic activity b) Decreased dietary calcium intake

A) Lack of weight bearing, which decreases osteoblastic activity

A patient has the following arterial blood gas (ABG) results: ph 7.32, PAO2 88 mmHg, PaCO@ and HCO3 16 mEqL. The nurse interprets these results as: a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

A) Metabolic Acidosis

At SAM, a nurse checks the amount of solution left in a potential nutrition infusion bag for an assigned client. It is a 3000 mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at: a) Noon b) 2 pm

A) Noon

A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBC)s and a shift to the left. The nurse anticipates that the next action will be to: a) Obtain wound cultures b) start antibiotic c) Reddress the wound with wet-to-dry dressing d) Continue to monitor the wound for purulent drainage

A) Obtain wound cultures

An 85 year old client has impaired hearing. When creating the care plan which intervention should have the highest priority: a) Obtaining an amplified telephone b) Teaching the importance of changing his position

A) Obtaining an amplified telephone

Which of these patients in the clinic will the nurse plan to teach about risks associated with obesity: a) Patient who has a BMI of 18 kg/m2 b) Patient with a waist circumference 34 inches (86 cm) d) patient whose waist measures 30 in. (75 cm) and hips measure 34 in. *85 cm)

A) Patient who has a BMI of 18 kg/m2

A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care: a) Place a bedside commode near the patient's bed b) Demonstrate the use of the Crede maneuver to the patient

A) Place a bedside commode near the patient's bed

The edges of a patient's appendectomy incision are approximated, and no drainage is noted. The nurse documents on the client's wound record that the incision appears to be healing by: a) Primary intention b) Secondary intention

A) Primary Intention

Which of these nursing actions included in the plan of care for a patient who is receiving intermittent tube feedings through a percutaneous endoscopic gastrostomy )PEG) tube may be delegated to an LPN/LVN: a) Providing skin care to the area around the tube site b) Assessing the patient's nutritional status at least weekly

A) Providing skin care to the area around the tube site

While changing a patient's dressing the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wounds drainage: a) Purulent b) Serous

A) Purulent

After completing a scheduled every 2-hour turn by turning the patient to the left side, the nurse notices a reddened are over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area: a) Reactive hyperemia c) Stage II pressure ulcer d) Stage III pressure ulcer

A) Reactive Hyperemia

The nurse is caring for an 80 year old female nursing home resident who has been admitted to the hospital with pneumonia and is becoming progressively more confused. Her vital signs are: Temp 101' F, Pulse 112, Resp. 28 and BP 100/70. ABG results include pH 7.50, PaCO@ 25 mmHg, and bicarbonate level 18 mEq/L. The nurse interprets these findings to indicate: a) Respiratory acidosis secondary to hypoexmia b) Respiratory acidosis secondary to anxiety

A) Respiratory acidosis secondary to hypoeximia

The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is: a) Risk for deficient fluid volume related to excessive fluid loss from ostomy b) Disturbed body image related to presence of ostomy

A) Risk for Deficient Fluid Volume related to Excessive Fluid loss from Ostomy

A patient who has just been started on continuous tube feedings of a full strength commercial formula at 100 mL/hr using a closed system method has six diarrhea stools the first day. What action should the nurse plan to take: a) Slow the infusion rate of the tube feeding b) Check the gastric residual volumes more frequently c) Change the internal feeding system and formula every 8 hrs d) Discontinue administration of water through the feeding tube

A) Slow the infusion rate of the tube feeding

When asked to sign the permission form for surgical removal of a large but noncancerous lesion on her face, the client begins to cry. Which of the following is the most appropriate response: a) Tell me what it means to you to have surgery b) you must be very glad to be having this lesion removed

A) Tell me what it means to you to have surgery

The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern: a) The BP is 90/40 mm/Hg c) Oral fluid intake is 100 mL for the last 8 hours d) There is prolonged skin tenting over the sternum

A) The BP is 90/40 mm/Hg

A nurse is practicing the concept of holism to the client. Which of the following is the best example of this: a) The nurse considers how the loss of a client's job will affect the regulation of the client's diabetes b) The nurse makes sure to do a complete teaching regarding pharmacological interventions c) The nurse is careful to follow physician treatments on schedule d) The nurse is able to prioritize the needs of the client assigned according to Maslow's hierarchy

A) The nurse consider's how the loss of a client's job will affect the regulation of the client's diabetes

Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD: a) The patient demonstrates the correct way to pursed lip breathe b) The client lists three signs/symptoms to report to the Health Care provider

A) The patient demonstrates the correct way to pursed lip breathe

The nurse case manager is concerned about A particular client being discharged from the hospital. Which of the following factors, if present for this client, would alert the nurse to possible problems with treatment adhearance: a) The prescribed therapy is costly and of unknown duration b) The therapy will require no lifestyle changes of the client c) The client has not had difficulty understanding the regimen d) The client's culture is supportive of Western medicine

A) The prescribed therapy is costly and of unknown duration

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has the following diagnoses: anxiety related to unfamiliarity of disease process, manifested by restlessness tachycardia. The etiology of this diagnoses is which of the following: a) Unfamiliarity of disease process b) Anxiety c) Restlessness d) Tachycardia

A) Unfamiliarity of disease process

A client has a serum sodium concentration of 160 mEq/L and exhibits generalized weakness and confusion. The nurse should plan to initiate: a) Fluid restrictions c) Monitoring of urine specific gravity d) Seizure precautions

A) fluid restrictions

Because of significant concerns about financial problems a middle-aged client complains of difficulty sleeping. Which outcome would be the most appropriate for the nursing care plan? By day 5, the client will: b) Report falling asleep within 20 to 30 minutes c) Have a plan to pay all bills

B) Report falling asleep within 20 to 30 minutes

When coaching a client to improve their health, which strategy is the most effective for the nurse to use to help clients take an active role in their health care?

Ask clients for their views of their health and health care. One of the best strategies to help empower clients to manage their health is to ask them their view of situations and to respond to what they say. This technique acknowledges that clients' opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation, but alone it does not acknowledge their views.

As a young adult single mother of a second-grade child has to make a decision regarding the teacher for her child will have in third grade and asks the nurse for advice: All other variables being equal which choice is best: a) A woman with 35 year old of teaching experience b) A man who is 40 years old

B) A man who is 40 years old

During a routine physical, an 11 year old tells the nurse that many students in school are "doing it". How should the nurse respond to this statement: a) Tell the client to talk with parents about sexual matters b) ASk what "doing it" means to the client

B) ASk what "doing it" means to the client

Which of the following nursing diagnosis pertains to a client's learning needs: b) Altered health maintenance related to knowledge deficit: catheter care d) Anxiety related to wife's illness

B) Altered health maintenance related to knowledge deficit: catheter care

A client is hospitialized with numerous acute health problems. According to Maslow's Basic needs model, which nursing diagnosis would take the highest priority: a) Risk for injury related to unsteady gait b) Altered nutrition, less than body requirements related to inability to absorb nutrients c) Self-care deficit related to weakness and debilitation d) Powerlessness related to chronic disease state

B) Altered nutrition, less than body requirements related to inability to absorb nutrients

The most appropriate manner in which to state an intervention directed towards assisting a client with ambulation is: a) Assist patient with ambulation b) Ambulate with client, using gait belt, two times daily for 15 minutes

B) Ambulate with client, using gait belt, two times daily for 15 minutes

Which statement best reflects the nurse's assessment of the fifth vital sign: a) Do you have any complaints b) Are you experiencing any discomfort right now

B) Are you experiencing any discomfort right now

The nurse primarily uses the nursing process in the care of patient's: a) To explain nursing interventions to other health care professionals b) As a problem solving tool to identify and treat patient's health care problems c) As a scientific based process of diagnosing the patient's health care problems d) To establish nursing theory that incorporates the biopsychosocial nature of humans

B) As a problem solving tool to identify and treat patient's health care needs

A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do? a) Assign UAP the task of giving the client's bath b) ASk the client the usual way bathing occurs at home c) Skipping the patient's bath and documenting "refused" is not following at client-centered approach d) Tell the client that a bath is needed and ignore the client's comment

B) Ask the client the usual way bathing occurs at home

The daughter of an 80 year old man is aphastoc after suffering a cerebrovascular accident (stroke) express concern that their father is "always" exposing and playing with himself and his catheter. While they are in the room. Upon assessment the nurse finds the patient pulling on and rubbing his penis. What is the nurse's priority action: b) Assess the client's penis for irritations from the catheter c) ASk the client to keep his linens at waist level when he has visions

B) Assess the client's penis for irritations from the catheter

One of the client's assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not not listed in the drug reference manual. The best action of the nurse is to: a) Follow the physician's order as written and give the medication b) Call the pharmacy and do further investigating before administering the medication c) Ask the client about this medication d) Call the physician and ask what the medication is and what it is used for

B) Call the pharmacy and do further investigating before administering the medication

After the nurse implements diet instructions for a patient with heart disease the patient can explain the information but fails to make recommended dietary changes. The nurse's evaluations that: a) Learning did not occur because the patient's behavior did not change b) Choosing not to follow the diet is the behaviors that resulted from learning c) The nursing responsibility for helping the patient make dietary changes has been fulfilled d) The teaching methods were ineffective in helping the patient learn the dietary information

B) Choosing not to follow the diet is the behaviors that resulted from learning

When the nurse is evaluating the fluid balance for a patient admitted for hypervolemia associated with multiple draining wounds, the most accurate assessment to include is: a) Skin turgor b) Daily weight c) Presence of edema

B) Daily Weight

Which are the following are normal physiological changes that occur during non- REM sleep: b) Decrease in pulse d) drop in basal metabolic rate

B) Decrease in pulse

A 43 year old is diagnosed with type 2 diabetes mellitus after being admitted to the hospital with an infected foot wound. When applying principles of adult learning, which teaching strategy by the nurse is most likely to be effective: a) Discuss the importance of blood glucose control in maintenance of long term health b) Demonstrate the correct method for cleaning and redressing the wound to the patient c) Assure the patient that the nurse is an expert on management of diabetes complications

B) Demonstrate the correct method for cleaning and redressing the wound to the patient

When preparing to teach an 82 year old Hispanic patient who lives with an adult daughter ways to improve nutrition, which action should the nurse take first: a) Ask the daughter about the patient's food preference b) Determine who shops for groceries and prepare meals

B) Determine who shops for groceries and prepare meals

Upon entering the room, the client is found crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following: B) Determining the nurse's needs for assistance c) Supervision delegated care d) Reassuring the client

B) Determining the nurse's needs for assistance

Two days after surgery for an Ileal conduit, the patient will not look at the stoma or participate in care. The patient insists that no one but the ostomy nurse specialists care for the stoma. The nurse identifies a nursing diagnosis of: a) Anxiety related to effects of procedure on lifestyle b) Disturbed body image related to change in body function

B) Disturbed body image related to change in body function

Nurses must use critical thinking in their day-to-day-practice, especially in circumstances surrounding client care and wise use of resources. In which of the following situations would critical thinking be most beneficial: a) Administering IV push medications to critically ill patients b) Educating a home health patient about treatment options c) teaching a new parent car seat safety d) Assisting an orthopedic client with the proper use of crutches

B) Educating a home health patient about treatment options

Which nursing intervention would be the most beneficial in preparing the patient psychologically for ileostomy surgery: a) Include the patient's family in preoperative teaching sessions b) Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy

B) Encourage the patient to express his or her concerns and to ask questions regarding the management of the ileostomy

An older patient receiving intravenous fluids at 175 mL/HR is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy: b) Fluid volume excess c) Pulmonary embolism

B) Fluid volume excess

Which statement indicates the client needs a sensory aid in the home: a) I tripped over that throw rug again b) I can't hear the doorbell

B) I can't hear the doorbell

The nurse is caring for a client who uses cathartics frequently. Which statement made by the client indicates an understanding of the discharge teaching: a) In the future I will eat a banana every time I take the medication b) I don't have to have a bowel movement every day

B) I don't have to have a bowel movement every day

A patient who is suspected of experiencing respiratory distress from a left-sided pneumothorax should be positioned: a) On the right side b) In semi-fowler's position

B) In the Semi-Fowler's Position

The nurse teaching a 32 year old man with renal failure about the path physiologic mechanism of acid-base balance recognize that the instructions have been understood when the client says: a) I lose too much acid through my kidneys b) My breathing increases to correct imbalances

B) My breathing increases to correct imbalances

What is wrong with the following outcome? Client will be able to climb one flight of stairs without shortness of breath: a) Nothing is wrong b) No target time is given

B) No target time is given

A patient returns to the clinic with recurrent dysuria after being treated with trimethoprium and sulfamethoxazole (Bactrim) for 3 days. Which action will the nurse plan to take: a) remind the patient about the need to drink 1000 mL of fluids daily b) Obtain a midstream urine specimen for culture and sensitivity testing

B) Obtain a midstream urine specimen for culture and sensitivity testing

How should the nurse position a client who is complaining of dyspnea: a) A high fowler's position with two pillows behind the head b) Orthopneic position across the over bed table

B) Orthopneic position across the over bed table

When the client has arrived at the nursing unit from surgery, the nurse is most likely to give priority to which of the following assessments? a) pain tolerance b) Pain intensity

B) Pain Intensity

A client has been having pain without any clear pathology for cause. The most appropriately written nursing diagnoses for this client would be which of the following: a) Pain due to unknown factors b) Pain related to unknown etiology c) Pain caused by psychosomatic condition d) Pain manifested by client's report

B) Pain related to unknown etiology

A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior- specific conditions: a) Interpersonal influences b) Perceived benefits of action c) Situational influences

B) Perceived benefits of action

What is primary function of a family? a) Provide everything each member wants b) Provide an environment that supports growth of individuals

B) Provide an environment that supports growth of individuals

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in the client's plan of care: a) Weight-bearing activities to stimulate joint relaxation b) Range of motion exercises to prevent worsening of contractures c) Exercises to strengthen flexor muscles

B) Range of motion exercises to prevent worsening of contractures

Which action can the nurse delegate to nursing assistive personnel (NAP) who help with treatment of a patient admitted with tuberculosis and placed on airborne precautions: a) Teach the patient about how to use tissues to dispose of respiratory secretions b) Stock the patients room with all necessary personal protective equipment c) Interview the patient to obtain the names of family members and close contacts d) tell the patient's family members the reason for the use of airborne precautions

B) Stock the patient's room with all the necessary personal protective equipment

The nurse is organizing a wellness project to educate teenagers about keeping their bodies healthy. Which information about diet and exercise should be included: a) Diet is the most important predictor of health b) The most important factors for maintaining health are diet and activity

B) The most important factors for maintaining health are diet and activity

A patient with poor circulation to the feet requires teaching about foot care. Which learning goal should the nurse include in the teaching plan? a) The nurse will demonstrate the proper technique for trimming toenails b) The patient will list three ways to protect the feet from injury by discharge d) The patient will understand the rationale for proper foot care after instructions

B) The patient will list three ways to protect the feet from injury by discharge

The nurse is preparing written handouts to be used as part of the standardized teaching plan for patient's who have been recently diagnosed with diabetes. Which of the following statements would be appropriate to include in the handouts: a) Polyphagia, polydipsia, and polyuria are common symptoms of Diabetes mellitus b) The use of the right foods can help in keeping blood glucose at a near-normal level c) Some diabetes control blood glucose with oral medications or nutritional interventions d) Diabetes mellitus is characterized by chronic hyperglycemia and the associated symptoms

B) The use of the right foods can help in keeping blood glucose at a near-normal level

Which factor reduces the risk of electrical hazards: a) two-pronged electrical plugs b) Three-prolonged electrical plugs

B) Three-prolonged electrical plugs

The nurse notes that the tube fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What is the nurses priority action: a) Place the client in high fowler's position b) Turn off tube feeding d) Assess the patient's bowel sounds

B) Turn off the tube feeding

The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perception disturbance would best fit a client who: a) Cut a foot by stepping on broken glass b) Uses a wheelchair due to paraplegia

B) Uses a wheelchair due to paraplegia

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease (COPD) to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed: a) Face tent b) Venture Mask

B) Venture Mask

When reviewing both the client's problem list against the various identified nursing diagnoses, both of which include client and family input, the nurse is utilizing of the following processes to minimize diagnostic error: a) Understanding what is normal vs. what is not normal b) Verifying c) Consulting resources d) Basing diagnoses on patterns

B) Verifying

A patient with frequent urinary tract infections ask the nurse how she can prevent the reoccurence. The nurse should teach the client to: a) Douche after intercourse b) Void every three hours

B) Void every three hours

The nurse is caring for the patient with clostridum difficile. Which intervention should the nurse implement to prevent nosocomial spread to other clients: a) Wash hands with betadine for 2 min after giving care b) Wear nonsterile gloves when handling GI excretions

B) Wear nonsterile gloves when handling GI excretions

To assess a patient's readiness to learn before planning, teaching activities, which question should the nurse ask: a) What kind of work and leisure activities do you do b) What information do you think you need right now c) Do you have any religious beliefs that are inconsistent with the treatment

B) What information do you think you need right now

During an initial interview the client makes this statement, I'm really not that sick or in pain right now. The nurses best response is: a) It's ok to be worried surgery is a big step b) What kind of questions do you have about your surgery c) I think these are things you should be asking your doctor d) have you had surgery before

B) What kind of questions do you have about your surgery

A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results would the nurse expect to find in this patient: a) pH 7.30, PaCO2 50, HCO3 27 b) pH 7.47, PaCO2 43, HCO3 28 c) pH 7.43, PaCO2 50, HCO3 28

B) pH 7.47, PaCO2 43, HCO3 28

The nurse uses the PLISSIT format in helping client's who have sexual dysfunction. Which action by the nurse best reflects the "P" section of this format: a) ASk the physician for permission to discuss sexual topics with the client c) Acknowledge the clients spoken and unspoken sexual concerns when providing care

C) Acknowledge the clients spoken and unspoken sexual concerns when providing care

The client being admitted from the ED is diagnosed with a fecal impaction. Which nursing intervention should be implemented: c) Administer an oil retention enema d) Prepare for an UGI X-ray

C) Administer an oil retention enema

The nurse is caring for a patient diagnosed with pneumonia who is having shortness of breath and difficulty breathing. Which intervention should the nurse implement first: a) Take the client's vital signs b) Check the client's pulse oximetry c) Administer oxygen via nasal cannula

C) Administer oxygen via nasal cannula

A patient is receiving tube feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care: a) Keep the patient positioned on the left side b) Obtain a daily x-ray to verify tube placement c) Check the gastric residual volume every 4 to 6 hours

C) Check the gastric residual volume every 4 to 6 hours

An 80 year old client is transferred to a long term care facility. On the second night, he becomes confused and agitated. What is the most appropriate nursing diagnosis? c) Disturbed Sensory Perception d) Disturbed Thought Process

C) Disturbed Sensory Perception

The client is admitted to a comprehensive rehabilitation center for continuing care,following a motor vehicle crash. While the admitting nurse will develop the initial care who will be involved with the ongoing planning of this client's care: a) The admitting nurse continues to assume that responsibility b) All nurses who work with the client c) Everybody involved in the client's care d) The client and the client's support system

C) Everybody involved in the client's care

The nurse is caring for an 80 year old patient with the medical diagnosis of heart failure. The patient has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client: c) Excess fluid volume related to retension of fluids as evidence by edema and orthopnea d) Excess fluid volume related to cognitive heart failure as evidence by edema and confusion

C) Excess fluid volume related to retension of fluids as evidence by edema and orthopnea

A 76 year old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep granulation tissue. The nurse documents the wound as a: a) Red wound b) Yellow wound c) Full thickness wound

C) Full thickness wound

Which question should the nurse ask when assessing a patient who has a history of benign prostatic hyperplasia (BPH): c) Has there been a decrease in the force of your urinary stream d) Have you been experiencing any difficulty in achieving an erection

C) Has there been a decrease in the force of your urinary stream

While assisting the client with a bath, the nurse encourages full range of motion in all the client's joints. Which activity would best support range of motion in the hand and arm: b) Move the wash basin farther toward the foot of the bed so the client must reach c) Have the client brush their hair and teeth d) Move each of the patient's hand and arm joints through passive range of motion

C) Have the client brush their hair and teeth

The nurse obtains this information when assessing a 74 year old patient in the outpatient clinic. Which finding os of the highest priority when the nurse is planning care for the patient: c) History of recent loss of balance and fall d) Complaint of left hip aching when jogging

C) History of recent loss of balance and fall

Wanting to know more about the client's pain experience, the nurse continues to explore different questioning techniques. Which of the following is the best example of an open-ended question for this situation: a) Is your pain worse at night b) What brought you to the clinic c) How has the pain impacted your life d) You're feeling down about having pain, aren't you

C) How has the pain impacted your life

Which statement made by a post menopausal client, would the nurse evaluate as indicating the need for further assessment: a) For some reason, I have more sexual desire than ever c) I am so glad that I don't need to worry about sex anymore d) Sex certainly takes longer that it used to, but im getting used to that

C) I am so glad that I don't need to worry about sex anymore

When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes the part of the purpose of the nursing process is to: a) Deliver care to a client in an organized way b) Implement a plan that is close to the medical model c) Identify client needs and deliver care to meet those needs d) Make sure that standardized care is available to clients

C) Identify client needs and deliver care to meet those needs

The 45 year old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How does the nurse interpret this assessment data: c) If both partners share the same lack of desire there is often not a problem d) This situation is so unnatural that some dysfunction is present

C) If both partners share the same lack of desire there is often not a problem

The client has a documented Stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client: c) Impaired tissue integrity d) Risk for Injury

C) Impaired Tissue Integrity

A patient with a stroke is paralyzed on the left side of the body and has developed a pressure ulcer on the left hip. The best nursing diagnoses for this patient is: a) Impaired physical mobility related to left-sided paralysis b) Risk for impaired tissue integrity related to left-sided weakness c) Impaired skin integrity related to altered circulation and pressure d) Ineffective tissue perfusion related to inability to move independently

C) Impaired skin integrity related to altered circulation and pressure

A nurse is providing a back rub to a client just after administering a pain medication, with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing: a) Assessment b) Diagnosis c) Implementation d) Evaluation

C) Implementation

Upon assessment the nurse notes that the client is dyspneic; has bibasilar crackles, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details: b) Anxiety c) Ineffective airway clearance d) Impaired gas exchange

C) Ineffective Airway Clearance

A client just had a baby following a long labor and difficult delivery. Which of the following nursing diagnoses is formulated correctly: a) Constipation, due to tissue trauma, manifested by no bowel movements for two days b) Risk for infection, because of new incision, related to episiotomy c) Ineffective breast feeding, related to lack of motivation, secondary to exhaustion d) Altered urinary elimination, secondary to childbirth

C) Ineffective breast feeding, related to lack of motivation, secondary to exhaustion

An example of correctly written nursing diagnoses statement is: a) Altered tissue perfussion related to heart failure b) Risk for impaired tissue integrity related to sacrel redness c) Ineffective coping related to response to biopsy test results d) Altered urinary elimination related to urinary tract infection

C) Ineffective coping related to response to biopsy test results

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse: b) Palpate for bladder fullness c) Inspect the sacrel area for edema d) Use the PRN order to medicate the client with an antacid

C) Inspect the sacrel area for edema

Which nursing intervention should be applied to a client with a nursing diagnosis of Risk for Skin Integrity impairment related to immobility: a) Encourage client to eat at least 40% of meals b) Restrict fluid intake c) Keep lines dry and wrinkle free

C) Keep linens dry and wrinkle free

A client is exhibiting signs and symptoms of acute confusion/delirium. Which strategy should the nurse implement to promote a therapeutic environment: c) keep the room organized and clean d) Use restraints for client safety

C) Keep the room organized and clean

Which information noted by the nurse when caring for a patient with a bladder infection is most important to report to the health care provider: c) Left-sided flank pain d) Temp 100.1" F

C) Left-Sided Flank Pain

A client who describes his pain as 6 on a scale of 1 to 10 is classified as having which of the following: c) Moderate to severe pain d) Very severe pain

C) Moderate to severe pain

Formulating nursing diagnoses and client strengths is a joint function of: c) Nurse and client d) Physician and client

C) Nurse and client

The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse's states, "This is not normal behavior". The nurse documents this is which of the following: a) inference b) Subjective data c) Objective data d) Secondary subjective

C) Objective data

When assessing the musculoskeletal system the nurse's initial action will usually be to: b) Have the patient move the extremities against resistance c) Observe the patient's body build and muscle configuration

C) Observe the patient's body build and muscle configuration

All of the following nursing actions are included in the plan of care for the patient who is malnourished. Which action is appropriate for the nurse to delegate to nursing assistive personnel (NAP): c) Offer the patient the prescribed nutritional supplement between meals d) Assess the patient's strength while ambulating the patient in the room

C) Offer the patient the prescribed nutritional supplement between meals

Which behavior is characteristic of someone who is coping well with stress: c) Sets aside 30 min a day to exercise d) has no hobbies

C) Sets aside 30 min a day to exercise

How should the nurse use the JCAHO 2006 National Patient Safety Goals to improve communication among caregivers: a) Review a list of look-a-like sound-a-like drugs used in the organization c) Studying a list of abbreviations that are not to be used throughout the organization d) Use the client's room number as an identifier

C) Studying a list of abbreviations that are not to be used throughout the organization

The aspect of an older adult's history indicating a risk, for developing hyperatremia is that the client: c) Takes an over the counter antacid d) Has had frequent urinary tract infections

C) Takes an over the counter antacid

In planning preoperative teaching for a patient undergoing a Roux-en y gastric bypass as treatment for morbid obesity the nurse places the highest priority on: b) Discussing the necessary postoperative modifications in lifestyle c) Teaching the patient proper coughing and deep breathing techniques

C) Teaching the patient proper coughing and deep breathing techniques

The nurse assesses an open area over a patient's greater trochanted that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional findings would indicate to the nurse that this is a Stage IV pressure ulcer: b) The crater extends into the subcutaneous tissue c) The joint capsule of the hip is visable

C) The joint capsule of the hip is visable

Which information obtained during the nurse assessment of the patient's nutritional- metabolic pattern may indicate the risk for musculoskeletal problems: c) The patient is 5 ft. 2 inches and weighs 180 lbs. d) The patient prefers whole milk to nonfat milk

C) The patient is 5 ft. 2 inches and weighs 180 lbs.

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin: b) Coat the patient's back and buttocks with baby powder after bathing c) Use a turn sheet lifted by two staff member to move the client in bed

C) Use a turn sheet lifted by two staff member to move the client in the bed

The client has been close to death for some time and the family asks how the nurse will know when the client has actually died,. Which of the following would be the most accurate response from the nurse: c) When there is no apical pulse d) When the extremities are cool and dark in color

C) When there is no apical pulse

Prior to finalizing a family orientated nursing care plan and implementing interventions, it is essential for the nurse to perform which of the following: a) Meet with all family members simultaneously c) establish a trusting relationship with the family as a group

C) establish a trusting relationship with the family as a group

Which client is at greatest risk for experiencing sensory overload: c) A 16 year old listening to loud music d) An 80 year old client admitted for emergency surgery

D) An 80 year old client admitted for emergency surgery

A 52 year old man is scheduled for an annual physical exam. The nurse will plan to teach the patient about: c) Normal decreases in testosterone level d) Annual prostate specific antigen testing (PSA)

D) Annual prostate specific antigen testing (PSA)

During an admission nursing assessment, a client with diabetes describes his leg pain as a "dull, burning sensation." The nurse recognizes this description to be characteristic of which type of pain: c) Visceral d) Neuropathic

D) Neuropathic

Serous:

Clear

Serous Sanguineous:

Clear and blood tinged

A client has just expelled a hydatidiform mole. She's visibly upset over the loss and wants to know when she can try to become pregnant again. How should the nurse respond?

Clients who develop a hydatidiform mole must be instructed to wait at least 1 year before attempting another pregnancy, despite testing that shows they have returned to normal. A hydatidiform mole is a precursor to cancer, so the client must be monitored carefully for 1 year by an experienced health care provider. Discussing this situation at a later time or checking with the physician to give the client something to relax does nothing to address the client's immediate concerns. Advising the client to wait until all tests are normal is a vague response and provides the client with little information.

A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping the client cope with these cramps?

Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a well-balanced diet, calcium supplements and additional servings of high-calcium foods may be unnecessary.

Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patient's coping-stress tolerance pattern is: b) What do you think caused this abdominal pain c) How do you feel about yourself and your hospitalization d) Are there other major problems that are a concern right now

D) Are there other major problems that are a concern right now

The nurse assess a surgical patient in the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate: a) Obtain wound cultures b) document the assessment d) Assess the wound every 2 hours

D) Assess the wound every 2 hours

A 78 year old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care: c) Insert an indwelling catheter until the symptoms have resolved d) Assist the patient to the bathroom every 2 hours during the day

D) Assist the patient to the bathroom every 2 hours during the day

In discussing diet modifications the nurse encourages a client with cellulitus and severe inflammation to include: c) Pretzels d) Citrus fruit

D) Citrus Fruit

During the assessing component of the nursing process, the primary reason for interviewing the client is to: c) Provide emotional therapy d) Collect data

D) Collect Data

The patient's teaching plan includes this goal, "The patient will select 2 gram sodium diet from the hospital menu for the next three days". Which evaluation method will be best for the nurse to use. When determining whether teaching was effective: a) Check the sodium content of the patient's menu choices over the next three days c) Have the patient list favorite foods that are high in sodium and foods that could be substituted for these favorites d) Compare the patient's sodium intake over the next three days with the sodium intake before the teaching was implemented

D) Compare the patient's sodium intake over the next three days with the sodium intake before the teaching was implemented

A client reports to the nurse that she has been taking barbiturate sleeping pills every night for several months and now wishes to stop taking them. Which statement is the most appropriate advice for the nurse to provide the client? c) Discontinue taking the pills d) Continue taking pills and discuss tapering the dose with the primary care provider

D) Continue taking the pills and discuss tapering the dose with the primary care provider

A 72 year old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper tract infection (UTI): c) Foul smelling urine d) Costovertebral tenderness

D) Costovertebral Tenderness

The nurse observes nursing assistive personnel (NAP) taking the following actions when caring for a patient with a retention catheter. Which action requires that the nurse intervene: c) Using an alcohol based hand cleaner before performing catheter care d) Disconnecting the catheter from the drainage tube to obtain a specimen

D) Disconnecting the catheter from the drainage tube to obtain a specimen

A client has a history of sleep apnea. Which is the most appropriate question for the nurse to ask? c) Have you had chest pain with or without activity d) Do you have difficulty with daytime sleepiness

D) Do you have difficulty with daytime sleeping

When assessing a 64 year old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit 2 years ago. The nurse will plan to teach the patient about: c) Magnetic reasonable imaging (MRI) d) Dual energy x-ray absorption (OEXA)

D) Dual Energy X-ray Absorption (OXEA)

When providing care using evidence-based practice, the nurses uses: a) Clinical judgement based on experience c) Evidence-based guidelines in addition to clinical expertise d) Evaluation of data showing that the patient outcomes are met

D) Evaluation of data showing that the patient outcomes are met

A patient who has been admitted to the hospital for surgery tells the nurse, 'I do not feel right about leaving my children with my neighbor", which action should the nurse take next: a) Reassure the patient that these feelings are common for parents b) Have the patient call the children to ensure that they are doing well c) Call the neighbor to determine whether adequate childcare is being provided d) Gather more data about the patient's feeling about the child-care arrangements

D) Gather more data about the patient's feeling about the child-care arrangements

A patient is taking a potassium-wasting diurectic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as: a) personality change b) Frequent loose stools c) Facial muscle spasms d) Generalized weakness

D) Generalized weakness

A patient who has a wound infection after major surgery has only been taking in about 50% to 75% of the ordered meals and states, "Nothing on the menu really appeals to me." Which action by the nurse will be most effective in improving the patient's oral intake: a) Make a referral to the dietician d) Have family members bring in favorite foods from home

D) Have family members bring in favorite foods from home

A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nurse's professor responds: "The nursing diagnosis statement: a) Describes client problems that nurses are licensed to treat c) Includes the disease the client has during the treatment of care d) Helps standardize care for all clients

D) Helps standardized care for all clients

The nurse has admitted a patient with a new diagnoses of pneumonia and explained to the patient that together they will plan the patient's care and set goals for discharge. The patient says, "How is that different from what the doctor does?" Which response by the nurse is most appropriate: c) Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors d) In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health

D) In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health

When the nurse is planning for the physical examination of an alert 86 year old patient. Adaptions to the examination technique should include: a) Speaking slowly when directing the patient b) Avoiding the use of touch as much as possible c) Using slightly more pressure for palpation of the liver d) Organizing the sequence to minimize position changes

D) Organizing the sequence to minimize position changes

When assessing the patient who has a lower urinary infections (UTI), the nurse will initially ask about: c) Poor urine output d) Pain with urination

D) Pain with urination

The patient has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client: c) Encourage the client to use a cathartic laxative on a daily basis d) Place the client on a high fiber diet

D) Place the client on a high fiber diet

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client: a) Institute an exercise plan that includes weight-bearing activities b) Protect the client's bones with strict bed rest d) Provide the client with assisted range of motion exercising twice daily

D) Provide the client with assisted range of motion exercising twice daily

A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaCO@ 32 mmttg, and HCO 25 mEq/L. The nurse interprets these results as: a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

D) Respiratory Alkalosis

A patient who is having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to: a) Obtain subjective data about the patient's family membrane b) Omit subjective data collection and obtain the physical examination c) Use the health care provider's medical history to obtain subjective data d) Schedule several short sessions with the patient to gather subjective data

D) Schedule several short sessions with the patient to gather subjective data

The nurse is doing bowel and bladder retraining for the client with oaraplegia. Which of the following is NOT a factor for the nurse to consider: c) Fluid intake d) Sexual Function

D) Sexual Function

A nurse in instructing a hospitalized client with a diagnosis of emphysemia about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following position will the nurse instruct the client to assume: c) Sitting in a recliner chair d) Sitting on the side of the bed and leaning on an over bed table

D) Sitting on the side of the bed and leaning on an over bed table

A patient returns to the surgical nursing unit following a vertical banded gastroplasty with a nasogastric tube to low, intermittent suction and a patient controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care: b) Offer sips of sweetened liquids at frequent intervals c) remind the patient that PCA use may slow the return of bowel functions d) Support the surgical incision during patient coughing and turning in bed

D) Suport the surgical incision during patient coughing and turning in bed

A patient with protein calorie malnutrition who has had abdominal surgery is receiving potential nutrition (PN). Which assessment information obtained by the nurse is the best indicator that the patient is receiving adequate nutrition: a) Blood glucose is 110 m/dL b) Serum albumin level is 3.5 mg/dL d) Surgical incision is healing normally

D) Surgical incision is healing normally

When admitting a patient who has just Arrived on the medical unit with severe abdominal pain, what should the nurse do first: A) Complete only basic demographics data before addressing the patient's abdominal pain b) Medicate the patient for the abdominal pain before attending to the health history and examination c) Inform the patient that the abdominal pain will be treated as soon as the health history is completed d) Take the initial vital signs and then deal with the abdominal pain before completing the health history

D) Take the initial vital signs and then deal with the abdominal pain before completing the health history

While the nurse is assessing a 62 year old man, the patient says he does not respond to sexual stimulation the way he did when he was younger. The nurse's best response to the patient's comment is: c) Erectile dysfunction is a common problem with older man d) Tell me more about how your sexual response has changed

D) Tell me more about how your sexual response has changed

Which would be an expected outcome for a client with the following nursing diagnoses self-care deficit related to congnitive impairment: a) The client will be able to name the staff that works on the day shift b) The client will eliminate safety hazards in her environment c) The nurse will stress the importance of adequate fluid intake d) The client with supervision will brush her teeth

D) The client with supervision will brush her teeth

The nurse has formulated a diagnosis of Activity Intolerance related to Decreased Airway Capacity for chronic asthma. In looking at the client's coping skills, the nurse realizes that the patient has a vast knowledge about the disease and what exacerbates symptoms in particular situations. The nurse will utilize this information because: a) Strengths can be an aid to mobilizing health and the healing process c) It will be easier for the nurse to educate the client about other interventions d) The nurse wont have to spend time going over the pathology of the client's disease

D) The nurse wont have to spend time going over the pathology of the client's disease

The nurse has just received change-of-shift report about the following four patients which patient will the nurse assess first: a) The patient who has multiple black wounds on the feet and ankles b) The newly admitted patient with a stage IV pressure ulcer on the coccyx c) The patient who needs to be medicated with multiple analgesics before a scheduled dressing change d) The patient who has been receiving immunosuppressants medications and has a temp of 102' F

D) The patient who has been receiving immunosuppressants medications and has a temp of 102' F

The nurse is performing an admission assessment on a 20 year old college student who is being admitted for electrolyte disorders of unknown etiology. Which assessment is most important to report to the health care provider: c) The patient has history of weight fluctuations d) The patient's serum potassium level is 2.9 mEq/L

D) The patient's serum potassium level is 2.9 mEq/L

Nurses often utilize systems theory to assess family units. Which example illustrates a family unit that does NOT meet the criteria of a well-functioning system? c) Each member's personal boundaries are well defined d) The primary activities of each member focus on personal purposes

D) The primary activities of each member focus pn personal purposes

While admitting a patient to the medical unit, the nurse learns that the patient does not read well. This information will guide the nurse in determining: a) The degree of patient motivation and readiness to learn b) What information the patient will be able to understand c) That the family must be included in the teaching process d) Which instructional strategies should be used in teaching

D) Which instructional strategies should be used in teaching

The nurse is developing a weight loss plan for a 21 year old patient who is morbidly obese. Which statement by the nurse is most likely to help the patient in loosing weight on the planned 1000 calorie diet: c) Most of the weight that you lose during the first weeks of dieting is water weight rather than fat d) You are likely to start to notice changes in how you feel with just a few weeks of diet and exercise

D) You are likely to start to notice changes in how you feel with just a few weeks of diet and exercise

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant?

Daily weights are an appropriate intervention for an infant with failure to thrive. It would be inappropriate for the nurse to encourage the mother to continue to try to feed the infant when crying because the infant may develop further aversion to eating. It is also inappropriate to assume that abuse has taken place; there is no information in the stem to suggest this. The parents would benefit from a community support group; however, the nurse cannot require the parents to attend a community support group prior to discharge.

Black:

Debride

A nurse is monitoring a client receiving tranylcypromine sulfate. Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor? You Selected:

Hypertensive crisis. The most serious adverse reaction associated with high doses of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high doses. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.

A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first?

Initiate fetal and contraction monitoring. The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other prescriptions. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. The nurse should then start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if prescribed.

A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is most important at this time?

Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect passage of the stone. Hematuria is to be expected from the irritation of the stone. Analgesics should be administered when the client needs them, not routinely. Moist heat to the flank area is helpful when renal colic occurs, but it is less necessary as pain is lessened.

A client with peptic ulcer disease is taking ranitidine. What is the expected outcome of this drug?

Limit gastric acid secretion. Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretion. Antisecretories, or proton-pump inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8 weeks. Cytoprotective drugs, such as sucralfate, protect the ulcer surface against acid, bile, and pepsin. Antacids reduce acid concentration and help reduce symptoms.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which of the following instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet. A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake is not necessary because chronic pancreatitis is not associated with hyponatremia or fluid loss.

Role Ambiguity: Don't know if I'm ready to be a mom:

Negative self-esteem

The client is to have a gastrectomy. The surgeon will use a transverse incision. Prior to surgery, the nurse is checking to be sure the correct site has been marked. Identify the site that should have marked.

Note: use the marking drawn in the picture!

Mild anxiety:

Perception and learning is enhanced

The nurse is caring for a comatose, older adult with stage III pressure ulcers over two bony prominences. Which intervention should be added to the plan of care?

Place the client on a pressure redistribution bed.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Pregnancy should be avoided for 4 weeks after the immunization.

Purulent:

Pus

The nurse cares for the client diagnosed with asthma. The physician orders neostigminenIM. Which of the following actions by the nurse is MOST appropriate? 1. Administer the medication. 2. Check the blood pressure and pulse. 3. Ask the pharmacy if the medication can be given orally. 4. Notify the physician.

Question: Can neostigmine be administered to a client with asthma? Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. Needed Info: Neostigmine (Prostigmin) is a cholinergic (parasympathomimetic) used to treat myasthenia gravis and is an antidote for nondepolarizing neuromuscular blocking agents; side effects include nausea, vomiting, abdominal cramps, respiratory depression, bronchoconstriction, hypotension, and bradycardia. Nursing considerations include monitoring vital signs frequently, having atropine injection available, taking with milk, potentiates the action of morphine. (1) causes bronchoconstriction; notify physician (2) assessment; neostigmine causes hypotension and bradycardia; important to monitor vital signs, but priority is to notify the physician (3) medication used cautiously in clients with asthma. (4) CORRECT - cholinergics can cause bronchoconstriction in asthmatic clients; may precipitate an acute asthmatic attack

The nurse cares for the client receiving phenytoin intravenously. The nurse recognizes that the medication is administered in which of the following fluids? 1. 5% dextrose in water (D5W). 2. Lactated Ringer's solution. 3. 10% dextrose in water (D10W). 4. Normal saline.

Question: Dilantin should be mixed with which type of fluid? Strategy: Determine the outcome of each answer. Needed Info: Phenytoin (Dilantin) is an anticonvulsant; side effects include drowsiness, ataxia, nystagmus, blurred vision, gingival hypertrophy; give medication with meals to minimize GI irritation, inform client that red-brown or pink discoloration may occur; instruct about proper oral hygiene; never mix with other drugs. (1) may precipitate in any fluid containing dextrose (2) body can convert to glucose, which will precipitate med (3) may precipitate in any fluid containing dextrose (4) CORRECT - phenytoin may precipitate in any fluid containing dextrose; clear IV tubing with normal saline prior to administering to remove all traces of dextrose

The nurse cares for the multipara who comes to the hospital at 29 weeks gestation with reports of backache and pelvic pressure "on and off all day." Which of the following assessments, if made by the nurse, is MOST important in determining if the patient is in premature labor? 1. The patient's history of her subjective symptoms. 2. The cervix is 50% effaced, 1 centimeter dilated. 3. The presenting part is at -1 station. 4. Regular contractions are noted on a monitor tracing.

Question: How can you tell if the patient is in true labor? Strategy: Establish priorities. When a question includes words such as "MOST important" or "FIRST," this indicates that more than one answer choice may be correct but one choice is more important than the others. Narrow the answer choices to those that are correct and then put them in order of priority. The highest priority will be the correct answer. Needed Info: Effacement: shortening and thinning of the cervix. Dilation: enlargement of opening of cervix from a few mm to an opening large enough to allow for passage of infant. Station: indicates progress of labor; relationship of presenting fetal part to imaginary line between ischial spines of pelvis in the mother. S/S premature labor: abdominal pain resembling menstrual cramps, dull backache, pelvic pressure. (1) not most important information; must differentiate regular contractions of labor from Braxton-Hicks contractions (do not occur on a regular basis, do not cause cervical dilation) (2) common occurrence especially in multiparas (women who have carried 2 or more pregnancies to viability) (3) presenting part is 1 cm above ischial spines of the pelvis; does not indicate true labor (4) CORRECT - most important; if contractions are regular (occur at least every 10 min for 1 hour), would indicate premature labor

The nurse on the medical unit is performing a physical assessment on a newly admitted patient. To locate the point of maximum impulse (PMI) of the patient's heart, the nurse's hand (fingertips) should be placed over which of the following locations? 1. The fifth intercostal space directly over the sternum. 2. The second intercostal space to the right of the sternum. 3. The second intercostal space to the left of the sternum. 4. The fifth intercostal space at the midclavicular line.

Question: How do you locate the PMI? Strategy: Picture the anatomy of the heart and its position in the body. Needed Info: PMI: forward thrust of L ventricle during systole produces normal pulsation on chest wall; indicates size and position of heart; should be felt in 1 intercostal space; if larger, indicates ventricular enlargement. (1) position of R ventricle (2) best for aortic valve sounds (3) best for pulmonic valve sounds (4) CORRECT

The nurse cares for the 4-year-old diagnosed with a fractured pelvis due to an auto accident. The nurse prepares the child for the application of a hip spica cast. The nurse recognizes that it is MOST important to include which of the following in the child's plan of care? 1. Obtain a doll with a hip spica cast in place. 2. Tell the child that the cast will feel cold when it is put on the skin. 3. Reassure the child that the cast application is painless. 4. Introduce the child to another child who has a hip spica cast.

Question: How do you prepare a 4-year-old for the procedure? Strategy: "MOST important" indicates that discrimination is required to answer the question. Needed Info: Preschool children (age 36 months - 6 years) fear injury, mutilation, and punishment; allow child to play with models of equipment; encourage expression of feelings; spica cast immobilizes the hip and knee. (1) CORRECT - preschoolers need to see and play with dolls and equipment; explain procedure in simple terms and explain how it will affect the child (2) may feel a warm or burning sensation under cast while it dries, due to chemical reaction between the plaster and the water (3) will be placed on special cast table that holds the child's body; turning to apply the cast may be painful (4) more important to allow child to play with doll with a hip spica cast; viewing the cast may be frightening.

The nurse plans care for the adult with pneumonia. The patient is to be suctioned PRN. Which of the following techniques, if used by the nurse, MOST accurately describes proper suctioning? 1. Apply suction with rotation, for no more than 20 seconds, as the catheter is inserted. 2. Apply suction, for no more than 10 seconds, as the catheter is both inserted and withdrawn. 3. Apply suction, for no more than 10 seconds, as the catheter is withdrawn. 4. Apply suction each time the patient inhales.

Question: How do you suction an adult? Strategy: Think about the outcome of each answer choice. Needed Info: Pneumonia: infection of the lungs due to viruses/bacteria, aspiration of food/fluids or inhalation of toxic chemicals. S/S: fever, chills, hemoptysis, dyspnea, fatigue. Treatment: antibiotics. Nursing responsibilities: turn, cough, deep breath, Fowler's position; suction to remove secretions and provide open airway; use 12 - 14 French catheter; use suction pressure less than 120 mm Hg and gently rotate the catheter 360 degrees. Complications: infection, trauma, hypoxemia, dysrhythmias. (1) not done for that length of time or during insertion, which would cause trauma to the mucous membrane (2) no suction when inserted (3) CORRECT - short time of suctioning, when pulling out catheter; too long can cause hypoxia, dysrhythmias; hyperoxygenate before, during, and after (4) suctioning process not correlated with breathing pattern.

The nurse cares for the client who is to receive warfarin sodium. The nurse recalls that which of the following is the mechanism of action of this medication? 1. It inhibits prothrombin synthesis. 2. It prevents conversion of fibrinogen to fibrin. 3. It inactivates thrombin. 4. It inhibits platelet aggregation.

Question: How does Coumadin work? Strategy: Think about each answer choice. Needed Info: warfarin sodium (Coumadin): long acting anticoagulant that inhibits Vitamin K-dependent clotting factors. Side effects: excessive dosage may cause hemorrhage, rash, fever. Prothrombin time (PT) used to control dosage. Therapeutic range is 1.5 - 2 times normal level. Antidote vitamin K (phytonadione: Mephyton). May eat consistent amounts of green leafy vegetables containing vitamin K. (1) CORRECT (2) action of heparin (3) action of heparin (4) action of aspirin and dipyridamole (Persantine).

The nurse cares for the client receiving lansoprazole. The nurse recognizes that lansoprazole has which of the following effects on the gastrointestinal system? 1. It increases bowel motility. 2. It reduces bowel motility. 3. It neutralizes gastric acid secretion. 4. It decreases gastric acid secretion.

Question: How does lansoprazole work? Strategy: Think about the actions of lansoprazole. Needed Info: Lansoprazole (Prevacid) is a protein pump inhibitor used to treat and prevent stomach and intestinal ulcers. It reduces gastric acid production. Prevacid 24HR should be taken only once every 24 hours for 2 weeks. May take 4 days to work. (1) no effect on bowel motility; laxatives (bisacodyl: Dulcolax) increase motility, these are contraindicated for pt with abdominal pain (2) no effect on bowel motility (3) effect of antacids such as aluminum hydroxide with magnesium hydroxide (Maalox) or aluminum hydroxide with magnesium hydroxide and simethicone (Mylanta) (4) CORRECT

The nurse cares for the patient with Parkinson's disease who is receiving levodopa. The nurse recalls that levodopa works by which of the following actions? 1. It blocks central cholinergic receptors. 2. It restores dopamine levels in extrapyramidal centers. 3. It releases dopamine and other catecholamines from neuronal storage sites. 4. It activates dopaminergic receptors in the basal ganglia.

Question: How does levodopa work? Strategy: Think about each answer choice and how it relates to Parkinson's disease. Needed Info: Parkinson's disease: caused by impairment of dopamine-producing cells in the brain. Levodopa is converted to dopamine in the body to supply the extrapyramidal centers in the brain. Side effects: hemolytic anemia, aggressive behavior, dystonic movements, depression, hallucinations, dizziness, orthostatic hypotension. (1) action of benztropine mesylate (Cogentin) used with levodopa; side effects: urinary retention, dry mouth, constipation; takes 2 - 3 days before effects are seen (2) CORRECT - don't take with vit B6 or fortified cereals: will block effects (3) action of amantadine (Symmetrel) used with levodopa; side effects: irritability, insomnia, dizziness; take after meals (4) action of bromocriptine (Parlodel) used with levodopa; side effects: dizziness, HA, orthostatic hypotension, abdominal cramps, pleural effusion; take with meals.

The nurse cares for the patient on the telemetry unit. The patient's orders include nifedipine 10 mg PO TID. The patient asks the nurse how the medication works. Which is the BEST response by the nurse? 1. "It constricts the coronary arteries." 2. "It increases myocardial contractility." 3. "It decreases myocardial oxygen demand." 4. "It promotes coronary artery spasms."

Question: How does nifedipine work? Strategy: Determine the outcome of each answer choice. Is it desirable? Needed Info: nifedipine (Procardia): antianginal medication that is a calcium channel blocker (inhibits calcium ion flow across cardiac and smooth muscle). Side effects: light-headedness, HA, hypotension, hypokalemia. Nursing responsibilities: monitor BP and potassium levels. (1) dilates coronary arteries (2) decreases myocardial muscle contractility; digoxin increases myocardial contractility (3) CORRECT - antianginal (4) inaccurate.

The client is admitted to the hospital for surgery on a ruptured anterior cruciate ligament in the right knee. Following surgery, the physician prescribes morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. Which explanation by the nurse BEST describes this method of pain medication administration? 1. "You will contact your nurse when you feel pain, and the nurse will bring pain medication to add to your intravenous pump." 2. "You will receive a large dose of pain medication continually from an intravenous pump." 3. "You will be able to self-administer a preset dose of pain medication as needed by pressing a button connected to the intravenous pump." 4. "You will be able to self-administer an unlimited amount of pain medication as needed by pressing a button connected to the intravenous pump.

Question: How is a PCA pump used? Strategy: "BEST" indicates that there may be more than one correct response. Each part of the answer choice must be correct. Needed Info: PCA amount allows patients to control administration of IV analgesics; preloaded pump system administers preset amount of medication when button is pushed by patient; predetermined lock-out time interval; amount of medication is displayed on front of machine; reduces pulmonary complications, and patient is more alert. (1) contact with a nurse is not required (2) client does not get a large amount of medication continuously, which might lead to an unintentional drug overdose (3) CORRECT - client is able to pace the rate of medication being dispensed by taking responsibility for when it is administered; provider continues to take responsibility for the amount administered at any one time (4) client gets only a pre-set amount of medication at any one time.

The client is admitted for evaluation of a convulsive disorder. An electroencephalogram (EEG) is scheduled. The client asks the nurse how an EEG is performed. Which of the following explanations by the nurse is MOST accurate? 1. "Several small electrical shocks are given that feel like pinpricks." 2. "Electrodes are attached to the head and the electrical activity of the brain is evaluated." 3. "A radiopaque substance is injected into an artery and x-rays are taken." 4. "A radioactive material is injected intravenously followed by a brain scan."

Question: How is an EEG performed? Strategy: Picture the test being performed. Needed Info: EEG: measurement of the electrical activity of the brain to evaluate seizure disorders. Nursing responsibilities: keep awake night before test; shampoo client's hair; stimulants (coffee, tea, cigarettes, cola), antidepressants, tranquilizers, anticonvulsants held for 24 - 48 hours before test to avoid alteration (particularly lowering) of the seizure threshold. (1) not accurate; no shocks given; painless procedure (2) CORRECT -readings taken awake, asleep, while hyperventilating, viewing flickering lights (3) cerebral angiography; nursing responsibilities: check for allergies to contrast medium and iodine; prep: NPO 6 - 8 hours, will feel heat sensation when dye injected; post-test: bed rest 6 - 24 hours, pressure dressing over insertion site 6 - 12 hours, force fluids for 24 hours to excrete contrast medium (4) brain positron emission tomography (PET) scan: preparation: empty bladder; isotope injected, takes 2 hours to be absorbed in brain; post-test: force fluids, urine does not need special care.

The nurse cares for the client receiving pain medication via a patient controlled analgesia pump (PCA). The syringe contains hydromorphone 6 mg in 30 mL. The client is prescribed hydromorphone 0.2 mg/hour IV per the PCA pump. How many milliliters per hour does the client receive?

Question: How much hydromorphone is needed an hour on this PCA pump? Strategy: Utilize the correct equation to figure out the answer in mL per hour. Needed Info: Set the answer up as a ratio proportion. The answer is being calculated from the concentration of hydromorphone (Dilaudid) available in order to figure out the hourly rate to be set on the pump. CORRECT ANSWER: 1 mL / hour. (0.2 mg / 6 mg) x 30 mL = 1 mL/hour

The nurse teaches the group of men about testicular cancer and testicular self-examination. The nurse instructs the men to perform testicular self-examination at which frequency? 1. Weekly. 2. Monthly. 3. Yearly. 4. Biannually.

Question: How often should men do a testicular exam? Strategy: Think about each answer choice. Needed Info: Testicular cancer most common in men 15 - 34 years old; best to do after a shower when the body is warm and relaxed; hold scrotum in the palm of hand; roll each testicle between thumb and fingers. Symptoms of cancer: painless enlargement or heaviness in testicle. (1) too often (2) CORRECT (3) too infrequent (4) too infrequent.

The father of the day-old infant tells the nurse that he will be driving his wife and infant home from the hospital. It is MOST important for the nurse to make which of the following recommendations for how the infant should be transported? 1. In a front-facing infant car seat in the back seat. 2. In a rear-facing infant car seat in the back seat. 3. In an infant seat on the wife's lap in the passenger seat. 4. In the wife's arms in the back seat.

Question: How should a newborn be transported in a car? Strategy: Think about the outcome of each answer choice. Needed Info: The American Academy of Pediatrics recommends that children under 2 years of age use a rear-facing infant car seat. Children should ride in the rear of a vehicle until they are 13 years old. (1) bone structure inadequate to handle motor vehicle accidents (2) CORRECT - until a minimum age of 2 years, can be longer if the child is small for age (3) unsafe (4) unsafe.

The nurse evaluates the progress of the patient hospitalized with depression. The nurse considers which of the following statements by the patient as an indication of improvement? 1. "I slept well last night." 2. "I can't seem to stop eating." 3. "I feel tired." 4. "I am feeling sad."

Question: What indicates an improvement in a patient who has been depressed? Strategy: Think about each answer choice. How does it relate to depression? Needed Info: S/S: unkempt appearance, lack of energy, change in sleep pattern, weight loss, decreased concentration, slowed motor activity. (1) CORRECT - depression indicated by excessive sleeping or difficulty falling asleep, staying asleep, or awakening too early (2) sign of depression (3) sign of depression (4) sign of depression.

The nurse cares for the postoperative patient who is to receive psyllium. When administering psyllium, the nurse uses which of the following techniques? 1. Mix with 6 ounces of orange juice; let stand for 1 minute, then administer it. 2. Mix with 8 ounces of water; administer it immediately followed by another 8 ounces of water. 3. Sprinkle on the patient's food; add 4 ounces of water and mix until well blended. 4. Pour into 8 ounces of milk; let it stand for 1 minute, then administer it.

Question: How should you mix psyllium? Strategy: Think about the outcome of each answer choice. Needed Info: psyllium (Metamucil): bulk-forming laxative used to treat constipation; on contact with water it forms a bland, gelatinous bulk that promotes peristalsis; can be mixed with water, milk, or fruit juice. (1) do not let stand; use 8 oz fluid (2) CORRECT (3) should not be chewed (4) do not let stand.

The patient with peripheral vascular disease is returned to the room following a right below-the-knee amputation (BKA). During the first 24 hours postoperatively, how does the nurse position the patient's residual limb? 1. Elevates the stump by raising the foot of the bed on blocks. 2. Dangles the stump over the side of the bed. 3. Abducts the stump by placing pillows between the legs. 4. Places the stump in correct anatomical alignment.

Question: How should you position a patient after a BKA? Strategy: Determine the outcome of each answer choice. Needed Info: Common complication after amputation is hip flexion contracture, resulting from elevation of stump on pillows. (1) CORRECT - increases venous return, prevents edema, promotes comfort (2) increases edema (3) legs should be adducted, not abducted (4) after 24 hours.

The pregnant woman is given an epidural anesthetic in preparation for cesarean section. Following administration of the epidural, the patient's blood pressure falls from 120/84 to 94/50. The nurse recognizes that it is ESSENTIAL to assist the patient into which of the following positions? 1. Supine. 2. Sitting. 3. Side-lying. 4. Trendelenburg.

Question: How should you position the patient? Strategy: "Essential" indicates that this is a priority question. Think about the outcome of each answer choice. Needed Info: Spinal anesthetic: local anesthetic injected into the lumbar intervertebral space beyond the dura mater into the subarachnoid space, which blocks pain sensations and movement. Epidural: local anesthetic injected into the lumbar intervertebral space outside the dura mater, which blocks pain sensations only, not movement. Complication of regional anesthetics: sympathetic nerve fibers blocked, hypotension due to loss of vasoconstrictor ability. Prehydrate before regional anesthetic to ensure adequate blood volume. (1) position impedes blood return to maternal heart due to pressure of fetus on vena cava; worsens hypotension (2) causes greater pooling of blood in legs, contributing to hypotension (3) CORRECT - optimizes blood return from lower extremities; displaces heavy uterus from inferior vena cava (4) weight of uterus against diaphragm impedes respirations.

The nurse in the well child clinic receives a call from a parent stating the parent's child attended a birthday party the day before with a child who had a facial rash and was diagnosed with erythema infectiosum (fifth disease). The parent is concerned that the parent's child may develop the disease. Which of the following responses by the nurse is BEST? 1. "Your child will not develop the disease." 2. "Look for a rash in 4 to 14 days." 3. "Bring your child into the clinic this afternoon." 4. "Does your child have a facial rash now?

Question: Is a child with a rash due to fifth disease contagious? Strategy: Think about the outcome of each answer. Needed Info: Erythema infectiosum (fifth disease) is a virus caused by human parvovirus B19; symptoms include erythema on face, lacy red rash on trunk and limbs. May have cold-like symptoms prior to onset of rash; treatment includes antipyretics, analgesics, and anti-inflammatory drugs. (1) CORRECT - fifth disease is a virus that is found in respiratory secretions; not contagious after the rash develops (2) incubation period is 4 to 14 days but may be as long as 20 days; an infected person is contagious prior to development of rash, whereas the child at the party already had a rash; (3) no reason for child to come to clinic (4) no reasons to assess for a rash.

The nurse performs discharge teaching for the patient with chronic renal failure. The nurse recognizes that teaching has been successful if the patient makes which statement? 1. "I will weigh myself every morning, before I eat breakfast." 2. "I will restrict my sodium and protein intake." 3. "I will take my antivomiting pills right after I eat." 4. "I will avoid between-meal snacks."

Question: What are appropriate self-care activities for a patient with chronic renal failure? Strategy: Recall the pathophysiology of chronic renal failure. Needed Info: Chronic renal failure is the slow progressive loss of renal function; gain of 2 pounds or more in 24 hours indicates fluid retention; antiemetics can be taken 30 to 60 minutes before meals; to increase nutritional balance, sodium and protein are not restricted, and between-meal snacks are encouraged. (1) CORRECT - most accurate measurement (2) not useful approach (3) need to be taken before the meal (4) less likely to prompt nausea.

The nurse cares for children in the pediatric clinic. After assessing a 3-year-old, the nurse instructs the child's parent about safety precautions. The nurse determines teaching is effective if the parent states which of the following? Select all that apply. 1. "My child wears a helmet while riding in the bike seat on the back of my bike." 2. "Our cleaning products at home are in a closed cabinet below the kitchen sink." 3. "Our medications are kept in childproof containers in a locked cabinet." 4. "My child sits in a forward-facing seat with a harness while riding in the car." 5. "Since we call vitamins 'candy,' our child eagerly takes them each day." 6. "The number to poison control is posted on our refrigerator."

Question: What are correct child safety precautions? Strategy: Consider each answer as a child safety precaution. More than one answer will be correct. Needed Info: Unintentional injury is the leading cause of death among children aged 1 - 4 years, accounting for about one-third of their deaths. (1) CORRECT - bike helmets prevent concussions if the child falls off the bike (2) need for locked cabinet, not just closed door (3) CORRECT - the locked cabinet is key to preventing accidental poisoning; childproof containers are not sufficient by themselves (4) CORRECT - the American Academy of Pediatrics in June 2011 recommended using a backward-facing seat for children under 2 years of age; use a forward-facing seat with a harness for children over 2 years (5) does not give child idea of possible danger of taking more. (6) CORRECT - posting an emergency contact in a visible spot allows faster response when time is critical.

The nurse prepares to change the central line dressing on the child. Arrange the following steps of the procedure in the correct order from first to last. All options must be used. 1. Open sterile towel to create a field. 2. Apply nonsterile gloves. 3. Apply an occlusive dressing. 4. Remove old dressing and wash hands. 5. Cleanse the area with acetone and alcohol swabs in a circular motion. 6. Cleanse the area with 1% povidone-iodine swabs. 1. 1, 2, 4, 5, 6, 3 2. 1, 4, 2, 6, 5, 3 3. 2, 4, 1, 5, 6, 3 4. 2, 4, 1, 6, 5, 3

Question: What are the steps of a central line dressing change for a child? Strategy: Be careful! Arrange the steps of the dressing change in the correct order in which to perform the task. Needed Info: The central line dressing needs to be changed regularly, at least every 48 hours using sterile technique. The site must be cleansed properly, and signs of infection need to be assessed. CORRECT ANSWER: 2, 4, 1, 5, 6, 3 (2) The first step is to apply nonsterile gloves. (4) The second step is to remove old dressing and wash hands. (1) The third step is to open sterile towel to create a field. (6) The fourth step is to cleanse the area with 1% povidone-iodine swabs. (5) The fifth step is to cleanse the area with acetone and alcohol swabs in a circular motion. (3) The sixth step is to apply an occlusive dressing.

The nurse cares for the patient who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings does the nurse recognize as consistent with this diagnosis? 1. Increased urine output; decreased serum sodium. 2. Decreased urine output; increased serum sodium. 3. Increased urine output; increased serum sodium. 4. Decreased urine output; decreased serum sodium.

Question: What are the symptoms of SIADH? Strategy: Think about how the disease affects the body. Needed Info: SIADH: seen with head injury, encephalitis, lung cancer, myxedema. Excessive amounts of antidiuretic hormone (ADH) from posterior pituitary results in water imbalance; water intoxication occurs due to fluid retention; opposite of diabetes insipidus. S/S: decreased LOC (cerebral edema, increased intracranial pressure), seizures, coma, sodium less than 120 mEq/L. Treatment: fluid restriction (500 - 600 mL/24 hr), sodium replacement, diuretics. Nursing responsibilities: daily weight, neuro checks, I + O, check electrolytes, position flat in bed. (1) decreased urine output (2) in SIADH, the serum sodium is washed out, resulting in a decreased level (3) diabetes insipidus due to lack of ADH; S/S: polyuria, polydipsia; treatment: vasopressin (Pitressin) (4) CORRECT - alderosterone is suppressed, causing hyponatremia with normal or increased plasma volume

The nurse administers morphine sulfate as ordered to the patient reporting severe pain. The nurse recognizes that which of the following signs indicates morphine toxicity? 1. The patient has blurred vision. 2. The patient's pupils are pinpoint. 3. The patient's pupils are unequal. 4. The patient's pupils are dilated.

Question: What are the symptoms of morphine toxicity? Strategy: Think about what causes each symptom. Does it relate to morphine? Needed Info: Morphine: narcotic analgesic used for severe pain. Side effects: sedation, hypotension, N + V, urinary retention, and physical dependence. Nursing responsibilities: check pupils and respirations. (1) inaccurate (2) CORRECT - indicators of morphine toxicity include pinpoint pupils and/or respirations less than 13 per min (3) not seen (4) not seen.

The nurse observes the behavior of the patient seen in the emergency room. Which of the following indicates to the nurse that the patient is experiencing a panic level of anxiety? 1. Reduced sensory input, distorted perception, behavioral disorganization. 2. Behavioral disorganization, inability to negotiate simple life demands, increased ability to concentrate. 3. Heightened sensory awareness, impaired cognitive function, distorted perception. 4. Increased pulse, increased muscle tension, rate of speech and volume are adequate for communication.

Question: What behaviors indicate a panic level of anxiety? Strategy: All symptoms must be correct in order for the answer to be correct. Needed Info: Anxiety is feeling of dread or fear in the absence of external threat, or disproportionate to the nature of the threat. In panic level anxiety, the patient is unable to see, hear, or function. Assess level of anxiety, decrease environmental stimuli, use unhurried approach, and stay with the patient. (1) CORRECT - reduced sensory input, distorted perception, behavioral disorganization are indicators of panic (2) will have decreased ability to concentrate with panic (3) sensory input is decreased with panic (4) pulse, muscle tension, rate of speech and volume all increase with panic.

The nurse performs screening on a group of older adult males. The nurse recognizes that which of the following is the MOST frequent cause of their urinary problems? 1. Degeneration of the renal arteries. 2. Degeneration of prostatic tissue. 3. Hyperplasia of the renal arteries. 4. Hyperplasia of the prostate gland.

Question: What causes urinary problems in elderly males? Strategy: Think about the answers. Needed Info: Symptoms of benign prostatic hypertrophy (BPH) include dysuria, frequency, urgency, decreased urinary stream, hesitancy, and nocturia; later symptoms may include cystitis, hydronephrosis, or urinary calculi. (1) renal blood vessels become thickened and more rigid, rather than degenerated (2) prostate enlarges, rather than degenerates, due to aging (3) blood vessels become thickened and more rigid, but they do not cause the manifestations of BPH (4) CORRECT - prostate enlargement (hyperplasia) causes urethral obstruction

The nurse cares for the emaciated patient admitted with Crohn's disease (regional enteritis). The nurse expects the patient to be placed on which of the following diets? 1. High-calorie, high-protein, high-residue. 2. Low-calorie, low-protein, low-residue. 3. High-calorie, high-protein, low-residue. 4. Low-calorie, low-protein, high-residue.

Question: What diet is used for Crohn's disease? Strategy: Think about Crohn's disease. Needed Info: Crohn's disease (regional enteritis): inflammatory bowel disease involving segments of the terminal ileum and proximal colon. The entire wall of the colon is affected. Restricts absorption of nutrients. S/S: right lower quadrant abdominal pain, diarrhea, weight loss, low-grade fever. Remissions and exacerbations seen. Treatment: meds: antidiarrheals (loperamide), antispasmodics, anticholinergics, sulfonamides (sulfasalazine), steroids. (1) high residue; may cause diarrhea (2) nutritional deficiencies (3) CORRECT - nonirritating, high in nutrients and minerals (4) nutritional deficiencies and high residue; may cause diarrhea.

The nurse conducts a physical assessment of the newly admitted client on the medical unit. When auscultating breath sounds over the trachea, the nurse normally expects to hear sounds that can be BEST characterized as which of the following? 1. Soft and low pitched. 2. Coarse and rumbling. 3. Fine and crackling. 4. Loud and high pitched.

Question: What do breath sounds sound like over the trachea? Strategy: "Best categorized" indicates that there may be more than one correct response. Think about what causes each breath sound. Needed Info: Use diaphragm of stethoscope, have patient take slow, deep breaths through the mouth. If crackles or wheezes are heard, ask patient to cough to see if sound changes. (1) inaccurate; vesicular: peripheral parts of lungs (2) inaccurate; rhonchi/wheezes: air over mucus; abnormal (3) inaccurate; rales: air over fluid; abnormal (4) CORRECT - hollow, harsh sounding; air passing through a tube

The woman is brought to the emergency room complaining of severe left lower quadrant pain. She tells the nurse that she performed a home pregnancy test and believes she is 8 weeks pregnant. On admission the patient's vital signs are pulse 90, blood pressure 110/70, respirations 20. A half-hour later her vital signs are pulse 120, blood pressure 86/50, respirations 26. The nurse recognizes that the change in the patient's vital signs indicates which of the following? 1. The patient's pain may have increased. 2. The patient may be bleeding internally. 3. The patient may be frightened. 4. The patient may have an infection.

Question: What do the changes in vital signs mean? Strategy: Think about the significance of each assessment. Needed Info: Ectopic pregnancy: fetus implanted outside of uterus, usually the fallopian tube. (1) usually BP increases with pain increase (2) CORRECT - increased P, decreased BP = decreased intravascular volume; shock (3) usually BP + P increases with fear (4) usually won't change BP unless in septic shock.

The nurse cares for the newly admitted patient who reports abdominal cramping and generalized weakness. When the nurse sends a stool sample to the lab for a guaiac test, what positive finding could be expected? 1. White blood cells. 2. Red blood cells. 3. Ova and parasites. 4. Mucus.

Question: What does a guaiac test indicate? Strategy: Think about each answer choice. Needed Info: Guaiac fecal occult blood test (G-FOBT): occult means hidden, often done as a screening test for colon cancer. Positive indicates need for further studies. (1) not accurate (2) CORRECT - none usually found (3) not accurate (4) not accurate.

The patient visits the physician for HIV testing. The physician notifies the patient that the results are positive. The patient asks the nurse what this means. The nurse's response should be based on recognition of which of the following? 1. The patient has AIDS. 2. The patient will develop AIDS within the year. 3. The patient has been exposed to the HIV virus. 4. The patient has been infected with the HIV virus.

Question: What does it mean if a person is HIV positive? Strategy: Think about each answer choice: Is it true about AIDS? Needed Info: AIDS (acquired immunodeficiency syndrome): caused by human immunodeficiency virus (HIV). Alters the functioning of immune system. Transmission: contact with blood and body fluids (semen). Test that detects presence of antibodies: enzyme-linked immunosorbent assay (ELISA). Test that confirms presence of virus: Western blot. (1) not true; AIDS: defined as presence of complications (such as opportunistic infections--Pneumocystis pneumonia) from HIV virus (2) not completely certain; AIDS Related Complex (ARC) has symptoms (fever, drenching night sweats, weight loss, fatigue, lymphadenopathy) without opportunistic infections (3) no test determines exposure; only detects infection. (4) CORRECT - HIV virus is considered infected and infectious

The nurse cares for the woman who has just delivered her first child, a boy weighing 6 lb 2 oz. The Apgar scores at one and five minutes are 8 and 9. The nurse recognizes that these scores indicate which of the following? 1. An isolette should be ready in the nursery for close observation of this infant. 2. The newborn is making an optimal transition to extrauterine life. 3. The parents will need emotional support to deal with a less than perfect infant. 4. Apgar scores correlate well with future emotional and intellectual development.

Question: What does this Apgar mean? Strategy: Think about each answer choice. Is it true about Apgar score? Needed Info: Apgar scores, checked at 1 and 5 min, are used to assess a newborn's initial adaptation to extrauterine life. There are five categories, each of which gets a score of 0 - 2: heart rate, resp effort, muscle tone, reflex irritability, color. (1) not needed; radiant warmer (2) CORRECT - good Apgar (3) Apgar score is fine (4) no relationship.

The parent of the adolescent being admitted to the psychiatric unit reports that the adolescent has become increasingly withdrawn at home. During the admission interview with the nurse, the patient says, "When I look in the mirror, I cannot see myself." The nurse recognizes that the patient is experiencing which of the following? 1. Displacement. 2. Dissociation. 3. Denial. 4. Depersonalization.

Question: What does this describe? Strategy: Think about each answer choice. Needed Info: Adolescence provides a time for development of a healthy self-concept and discovering one's role in life. If the road to these discoveries is blocked, the person experiences depersonalization. (1) unconscious placing of emotions onto others (boss yelling at employee, person yelling at spouse) (2) splitting off anxiety producing experiences (multiple personalities) (3) refusal to acknowledge reality (will not accept bad news). (4) CORRECT - feelings of unreality concerning self or environment

The nurse teaches the client how to increase dietary potassium. The client knows bananas are high in potassium but she does not like their taste. What foods should the nurse recommend the client include in the diet? 1. Potatoes, spinach, raisins. 2. Rhubarb, tofu, celery. 3. Carrots, broccoli, yogurt. 4. Onions, corn, oatmeal.

Question: What foods are high in potassium? Strategy: Think about each food. Needed Info: Potassium functions in water balance in cells, protein synthesis, and heart contractility; primary sources include grains, meats, vegetables, and fruits. (1) CORRECT - potassium content: potatoes 610 mg, spinach 838 mg, raisins 1,089 mg, for a total of 2,537 mg (2) potassium content: rhubarb 548 mg, tofu 9 mg, celery 114 mg, for a total of 671 mg (3) potassium content: carrots 221 mg, broccoli 254 mg, yogurt 251 mg, for a total of 726 mg (4) potassium content: onions 318 mg, corn 192 mg, oatmeal 132 mg, for a total of 642 mg.

The 72-year-old parent is brought to the clinic as a patient by the adult child who reports that the patient is not eating well but is otherwise healthy. The patient is not taking any medications. The nurse determines that which of the following meals is the BEST choice for this patient's nutritional needs? 1. Grilled cheese sandwich, cookie, tea. 2. Broiled chicken, broccoli, skim milk. 3. Raisin toast, tapioca pudding, apple juice. 4. Liver and onions, decaffeinated coffee, jell-o.

Question: What foods are in a nutritionally well balanced diet? Strategy: Think about the type of diet that is needed for an elderly person. Needed Info: Patients with anorexia (poor appetite) need nutrient-dense, high-calorie diet. Nutritionally well-balanced diet contains foods from 6 basic food groups: bread, cereal, rice, and pastas (6 - 11 servings); vegetable group (3 - 5 servings); fruit (2 - 4 servings); milk, yogurt, cheese group (2 - 3 servings); meat, poultry, fish, dry beans, eggs, nuts group (2 - 3 servings); fats, oils, and sweets (use sparingly). (1) some protein, some carbohydrate, some fluid (2) CORRECT - source of protein, vegetable, milk (3) some carbohydrate, some fruit (4) source of iron and fluids.

The nurse cares for the client experiencing an episode of acute pain. Which of the following physiologic changes does the nurse expect to see in this client during this episode? 1. Decreased blood pressure. 2. Decreased heart rate. 3. Decreased skin temperature. 4. Decreased respirations.

Question: What happens to the vital signs when a client is in pain? Strategy: Think about the cause of each vital sign change. Is it consistent with pain? Needed Info: Pain causes increased blood pressure and heart rate, which leads to increased blood flow to the brain and muscles; rapid irregular respirations lead to increased oxygen supply to brain and muscles; increased perspiration removes excessive body heat; increased pupillary diameter leads to increased eye accommodation to light. (1) blood pressure increases to enhance alertness to threats (2) heart rate increases (3) CORRECT - skin cools due to diaphoresis (4) respirations increase.

The nurse cares for the patient 1 hour after a percutaneous liver biopsy. The nurse is MOST concerned if which of the following is observed? 1. The patient frequently coughs after deep breathing. 2. The patient lies on the right side with a pillow under the costal margin. 3. The LPN/LVN obtains the blood pressure and pulse every 15 minutes. 4. The patient reports mild pain radiating to the right shoulder.

Question: What indicates a complication of a liver biopsy? Strategy: "Nurse is MOST concerned" indicates a complication. Needed Info: Sampling of tissue by needle aspiration; preparation for procedure includes administer IM vitamin K, NPO morning of exam, instruct patient to hold breath; post-procedure nursing care includes position on right side for 1 - 2 hours, maintain bed rest for 24 hours, obtain frequent vital signs to monitor for hemorrhage. (1) CORRECT - avoid coughing or straining to prevent hemorrhage (2) prevents hemorrhage or escape of bile (3) vital signs monitored every 10 - 15 minutes during first hour and every 30 minutes for next 1 - 2 hours; assess for hemorrhage (4) referred pain often happens, associated with current liver problems.

The nurse in the same-day surgery department cares for the client after a sigmoidoscopy. Which of the following symptoms, if exhibited by the client an hour after the procedure, MOST concern the nurse? 1. The client reports fullness and pressure in abdomen. 2. The client reports grogginess and thirst. 3. The client reports lightheadedness and dizziness. 4. The client reports mild pain and cramping in abdomen.

Question: What indicates a complication of a sigmoidoscopy? Strategy: Think about what causes each symptom. Needed Info: Direct visualization of the sigmoid colon, rectum, and anal canal; laxative night before exam and enema or suppository morning of procedure; NPO at midnight. Post-procedure: allow client to rest; observe for hemorrhage, perforation; encourage fluids. (1) expected after this procedure (2) expected after this procedure; has been NPO since midnight before the procedure; midazolam (Versed) is used to aid in relaxation during procedure; atropine is used during procedure to decrease peristaltic activity (3) CORRECT - could signify hypovolemic shock due to bowel perforation (4) expected after this procedure.

The nurse cares for the patient after a traditional cholecystectomy. The patient has a nasogastric tube connected to suction, an IV of D5W infusing into the right arm, and a T-tube and Penrose drain in place. The nurse is MOST concerned by which of the following findings? 1. The systolic blood pressure is 10 mm Hg lower than it was preoperatively. 2. There is 250 cc of bloody drainage from the T-tube during the first 24 hours. 3. There is 30 cc of serosanguineous drainage in the Penrose drain during the first 24 hours. 4. The patient experiences a 2 degree temperature decrease in the evening after surgery.

Question: What indicates a complication? Strategy: Think about each answer. Needed Info: T-tube ensures drainage of bile from common bile duct until edema in area decreases; protect skin around incision from bile drainage irritation; observe for jaundice. (1) decrease could be due to position change or fluids lost during surgery (2) CORRECT - would expect drainage of 400 mL/day with gradual decrease in amount; will be bloody initially and change to greenish-brown; T-tube getting dislodged is most frequent cause of ineffective drainage (3) drainage is expected, prevents accumulation of fluid in the incision (4) expected outcome of taking temperature by a different method, as patient is now a mouth-breather.

The nurse educator presents an in-service for staff on family dynamics. The nurse educator identifies which behavior as being associated with a functional family process related to communication? 1. Acknowledgment of personal needs and role responsibilities. 2. Congruence between verbal and nonverbal messages. 3. Ability to meet emotional needs of family members. 4. Appropriate responsibility for other family members' needs.

Question: What indicates a functional family process? Strategy: Think about each answer. Needed Info: Family function is how individual members relate to each other; functional communication is characterized by clear direct messages and by requesting and receiving feedback; dysfunctional communication is characterized by double-bind communication, contradictions, inconsistencies, obscure speech, and misunderstandings. (1) indicates a functional family, but this is not necessarily related to communication (2) CORRECT - indicates a functional family; double-bind communication, by contrast, is an example of conflicting messages (3) one function of a family system is assisting members to meet their physical, emotional, and safety needs; dysfunctional families are unable to meet these needs, but this is not necessarily related to communication (4) indicates a functional family, but this is not necessarily related to communication.

The nurse plans care for the patient admitted reporting fever, vomiting, and diarrhea. The nurse writes the following nursing diagnosis on the patient's care plan: "Fluid volume deficit." The nurse recognizes that which of the following changes in laboratory values BEST demonstrates improvement in the patient's condition? 1. Decreased specific gravity of urine, decreased hematocrit. 2. Increased specific gravity of urine, increased hematocrit. 3. Decreased specific gravity of urine, increased hematocrit. 4. Increased specific gravity of urine, decreased hematocrit.

Question: What indicates an improvement in fluid volume deficit? Strategy: Think about physiology. Needed Info: Urine specific gravity depends on hydration; normal: 1.010 - 1.030; will increase if patient is dehydrated. Hematocrit measures % volume of RBCs in whole blood; normal: men 42 - 50%, women 40 - 48%; increases in severe dehydration (volume). (1) CORRECT - specific gravity and hematocrit increase with dehydration (2) ongoing fluid volume deficit (3) does not best indicate improvement; specific gravity is decreased but hematocrit still increased (4) does not best indicate improvement; hematocrit is decreased but specific gravity still increased.

The nurse cares for the woman at 37 weeks gestation. The nurse is MOST concerned by which finding? 1. The patient reports right quadrant pain. 2. The patient's BP is 150/95. 3. The patient has 1+ proteinuria. 4. The patient has 3+ pitting edema of the ankles.

Question: What indicates impending eclampsia? Strategy: "MOST concerned" indicates a complication. Question unstated. Read answer choices for clues. Needed Info: Eclampsia is seizures in a pregnant woman not related to a pre-existing brain condition. Providers intervene before that advanced stage, when symptoms of impending eclampsia occur. Preeclampsia causes hypertension, proteinuria, and edema; symptoms of severe preeclampsia include BP of 150 - 160/100 - 110 mm Hg; 4+ proteinuria; headache, epigastric pain; treatment for severe preeclampsia includes bed rest, vital signs and fetal heart tones, monitor I + O, seizure precautions, and administer magnesium sulfate. (1) CORRECT - indicates impaired liver function, sign of impending eclampsia (2) elevated BP less than 160/110 considered moderate preeclampsia (3) indicates mild preeclampsia (4) dependent edema, indicative of mild preeclampsia.

The patient is admitted to the hospital for a myelogram using a water-soluble dye. What information is MOST important for the nurse to obtain about the patient's medication history? 1. Is the patient currently taking any antihypertensives? 2. Is the patient currently taking any nonsteroidal anti-inflammatory medications? 3. Is the patient currently taking any antibiotics? 4. Is the patient currently taking any antidepressants or antipsychotics?

Question: What information do you need from the patient's medication history? Strategy: Think about each medication given. How does it relate to a myelogram? Needed Info: Meds that lower the seizure threshold such as phenothiazines (chlorpromazine), MAO inhibitors (isocarboxazid, phenelzine), tricyclic antidepressants (imipramine, amitriptyline), CNS stimulants, psychoactive drugs (methylphenidate) should be held for 48 hours before and 24 hours after test. The reason to stop such meds is that their presence could increase the risk of seizures. (1) will not affect test (2) will not affect test (3) will not affect test. (4) CORRECT - need to hold any meds that lower seizure threshold

The 80-year-old patient is admitted to the hospital with a diagnosis of carcinoma of the colon. A hemicolectomy is scheduled. On admission, the patient appears disheveled and is restless and confused. It is MOST important that the nurse obtain the answer to which of the following questions? 1. Which prescription and/or over-the-counter medications is the patient taking? 2. What is the medical history of the patient's family? 3. What was the patient's previous occupation? 4. Has the patient smoked cigarettes in the past?

Question: What information is MOST important to get about the patient since he is confused? What is a frequent cause of confusion in the elderly? Strategy: Picture the patient as described. Needed Info: Polypharmacy, the taking of multiple medications, is common in elderly adults, accounting for the dispensing of one-third of prescribed medications. Decreases in kidney and liver functioning can allow a buildup of toxic chemicals. (1) CORRECT - confusion can be caused by drug toxicity (2) not most important (3) not most important (4) not most important.

The nurse cares for the patient during the acute phase of a cerebrovascular accident (stroke). The nurse gives the HIGHEST priority to which of the following? 1. Maintaining musculoskeletal function. 2. Maintaining nutritional status. 3. Maintaining respiratory function. 4. Maintaining skin integrity.

Question: What is MOST important for a patient right after a CVA? Strategy: Remember your ABCs: airway, breathing, circulation. Needed Info: Manifestations of stroke vary with the involved cerebral vessel and the area of the brain affected; women more likely to report nontraditional manifestations; manifestations always sudden in onset, focal, and usually one-sided. (1) ROM, positioning (2) soft diet due to possible dysphagia, or tube feedings (3) CORRECT - ABCs first (4) bed rest 48 - 72 hours during acute phase.

The patient is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. The nurse recognizes it is MOST important to include which goal on the patient's preoperative care plan? 1. Fluid replacement. 2. Pain relief. 3. Emotional support. 4. Respiratory therapy.

Question: What is MOST important for a patient with a ruptured ectopic pregnancy? Strategy: Remember Maslow's hierarchy of needs. Meet physical needs before addressing psychosocial needs. Needed Info: Dehydration can become a serious danger in a preoperative patient, especially if bleeding occurs. Fluid replacement prevents that complication. Pain relief can be well handled in the postoperative period. Emotional support, while important, is a lower priority than ensuring that the patient's life is not in danger. (1) CORRECT - physical need; IV fluids, blood transfusion (2) not most important (3) not most important (4) not a problem.

The nurse prioritizes the needs of the patient who has been raped. Which of the following is MOST important initially? 1. Emotional needs. 2. Physical needs. 3. Hygiene needs. 4. Legal responsibilities.

Question: What is MOST important for a person who has been raped? Strategy: Establish priorities. Remember Maslow's hierarchy of needs. Meet the physical needs before you address safety, love, belonging, esteem, and self-actualization needs. Needed Info: Major effort in working with the person raped concentrates on first collecting physical evidence, such as proof of injuries and possible specimens for DNA testing. Emotionally charged crime. (1) not most important initially (2) CORRECT - Maslow's hierarchy: physical is first (3) not most important initially (4) not most important initially.

Arterial blood gases (ABGs) are ordered for the patient following a myocardial infarction. After obtaining the ABGs, which of the following measures is MOST important for the nurse to implement? 1. Obtain ice for the specimen. 2. Apply a sterile dressing to the site. 3. Apply direct pressure to the site. 4. Observe the site for hematoma formation.

Question: What is MOST important for you to do after obtaining an ABG? Strategy: Picture yourself doing the procedure. Set priorities. Care for the patient first and the equipment or samples second. Needed Info: ABGs: measurement of partial pressure of oxygen, carbon dioxide, and pH of blood; assessment of acid-base status of body; use a heparinized syringe; needle inserted 45 - 60 degrees to skin surface and advanced into radial artery; apply pressure after needle removed; put specimen on ice. (1) should be done, but not most important; care for the patient first (2) bandage applied (3) CORRECT - prevents bleeding, hematoma; maintain for at least 5 min, 15 min if on anticoagulant (4) not highest priority; check for discoloration, numbness, tingling, temperature.

The nurse cares for the client after a ureterolithotomy. The nurse notes that the client has a left ureteral catheter in place. The nurse includes which of the following in the client's plan of care? 1. Clamp the catheter for short periods of time. 2. Irrigate the catheter every 2 hours. 3. Gently advance the catheter if no drainage is observed. 4. Instruct the client that urine from the catheter should be clear.

Question: What is a correct action for a client with a ureteral catheter? Strategy: Determine the outcome of each answer. Needed Info: Ureterolithotomy is surgical removal of calculus from the ureter; do not irrigate ureteral catheter, check incisional drain, check surgical dressing; encourage oral fluids. (1) due to small size of catheter, do not clamp (2) do not irrigate, since that would change the direction of the fluid flow; measure intake and output (3) do not advance catheter, may cause trauma (4) CORRECT - immediately after surgery, a small amount of blood-tinged urine is normal but then it becomes clear; increase fluid to promote flow of urine

The nurse reviews patient assignments made by the student nurse. The nurse determines that assignments are appropriate if a nursing assistant is assigned to which patient? 1. The patient scheduled for an MRI. 2. The unconscious patient who requires mouth care. 3. The patient admitted for uncontrolled seizures. 4. The patient with diabetes who requires foot care.

Question: What is a correct patient assignment for a nursing assistant? Strategy: Think about each answer. Needed Info: Delegate standard, unchanging procedures to a nursing assistant. (1) requires assessment and teaching (2) CORRECT - mouth care for an unconscious patient can be delegated to the nurse assistant; the nurse must first assess for a gag reflex (3) nurse must care for patient; assess for patent airway, adequate respirations, and circulatory status (4) nursing assistant can perform foot care for a nondiabetic patient.

The nurse performs teaching for the client being discharged with a new ileostomy. The nurse includes which of the following statements in the discharge teaching? 1. "Change the appliance every day." 2. "The ileostomy does not require irrigation." 3. "Decrease your fluid intake." 4. "Apply cream around the stoma."

Question: What is a correct statement about caring for an ileostomy? Strategy: Determine the outcome of each answer. Needed Info: Ileostomy is an opening into the ileum from the abdominal wall for evacuation of feces; drainage bag with pectin-based skin barrier must be worn at all times. (1) appliance should only be changed if there is a leak (2) CORRECT - no need to irrigate; stool remains loose and cannot be controlled with irrigation (3) maintain high fluid intake due to loss of fluids through the ileostomy (4) prevents the appliance from adhering to skin; increases the incidence of leaking.

The nurse has completed discharge instructions for the primigravida at 29 weeks gestation who is hospitalized for treatment of deep vein thrombosis (DVT). Which of the following statements, if made by the patient to the nurse, indicates that teaching has been successful? 1. "I will give myself heparin every day." 2. "I should check my leg once a week." 3. "I will massage my leg nightly." 4. "I can take Pepto-Bismol for diarrhea."

Question: What is a correct statement about deep vein thrombosis and pregnancy? Strategy: "Teaching has been successful" indicates a correct response. Needed Info: Pregnancy, immobility, obesity, and surgery are risk factors for deep vein thrombosis. Heparin is anticoagulant that blocks conversion of prothrombin to thrombin; side effects include hematuria and bleeding gums; monitor partial thromboplastin time (PTT). (1) CORRECT - heparin does not cross the placenta; considered safe during pregnancy (2) not an aspect of self-care (3) contraindicated with DVT; clot can be released (4) bismuth subsalicylate (Pepto-Bismol) increases the anticoagulant effectof heparin;, do not use together.

The patient is admitted to the unit for treatment of acute glomerulonephritis. The nurse teaches the patient about the disease and the treatment required. The nurse determines that teaching is successful if the patient makes which of the following statements? 1. "Who would have thought that a sore throat two weeks ago would cause this!" 2. "I am in the hospital because my grandmother receives dialysis three times per week." 3. "I'm glad that I don't have to restrict my activities." 4. "My roommate is going to bring me a double cheeseburger with bacon."

Question: What is a correct statement about glomerulonephritis? Strategy: Think about what the words mean. Needed Info: Acute glomerulonephritis is usually caused by beta hemolytic streptococcal infection; symptoms include fever, chills, hematuria, weakness, pallor, weight gain, lung rales, and fluid overload. (1) CORRECT - inflammatory reaction of the kidney to infection that occurs on skin or in the throat (2) no relationship; damage to glomerulus caused by an immunological reaction (3) bed rest ordered during acute phase to guard against hematuria and proteinuria; promotes diuresis (4) usually anorexic; protein and sodium limited until BUN, creatinine and BP normal.

The nurse assesses the child diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse expects to observe which of the following? 1. Feeding difficulties. 2. Head banging. 3. Easy distractibility. 4. Rigid arms and legs.

Question: What is an indication of ADHD? Strategy: Think about each answer. Needed Info: Characteristics of ADHD include distractibility, immaturity relative to chronologic age, impulsivity, and learning disabilities; nursing considerations include reducing frustration, providing safety and security, and administering medication. (1) exhibited by children diagnosed with failure to thrive (2) observed in children diagnosed with pervasive developmental disorders and mental retardation (3) CORRECT - major clinical manifestation is distractibility; child has difficulty attending to unwanted tasks such as chores or homework (4) side effect of antipsychotic medication.

The nurse performs discharge teaching for the client receiving trifluoperazine. The nurse determines that teaching is successful if the client verbalizes which of the following? 1. "I should take two pills at night if I have difficulty sleeping." 2. "I cannot breastfeed my baby while I am taking this medication." 3. "I may experience frequent tearing in my eyes." 4. "I will have to increase my calorie intake daily."

Question: What is a correct statement about trifluoperazine? Strategy: Think about each statement. Needed Info: Trifluoperazine (Stelazine) is an antipsychotic phenothiazine; side effects include pseudoparkinsonism, dystonia, akathisia, tardive dyskinesia; instruct client to avoid alcohol, report urine retention or constipation, use sunblock, and chew sugarless gum or suck on hard candy to relieve dry mouth. (1) cannot increase or decrease dosage without physician approval (2) CORRECT - breastfeeding is contraindicated because trifluoperazine is excreted in breast milk (3) side effect is dry eyes--use artificial tears (4) may have weight gain; should decrease calorie intake and exercise frequently.

The nurse teaches the patient who is lactose intolerant about alternative ways to obtain adequate amounts of calcium in the diet. Which of the following items, if selected by the patient, indicates understanding of which foods to eat? 1. Eggs and green leafy vegetables. 2. Instant breakfast mixes and skim milk. 3. Cottage cheese and yogurt. 4. Custard and mashed potatoes.

Question: What is a good source of calcium for a lactose intolerant patient? Strategy: Eliminate foods that contain milk. Needed Info: Lactose intolerance: inability of intestine to absorb milk due to deficiency in enzyme that breaks down milk sugar (lactase). Calcium: milk, seafood, orange juice, cereals, and dark green leafy vegetables such as spinach, kale, and mustard greens. Yogurt and hard cheeses may be tolerated because of how they are processed. (1) CORRECT - good sources of Ca (2) contain lactose (3) contain lactose; yogurt may be tolerated; cottage cheese is a soft cheese and would not be tolerated ( 4) made with milk, contains lactose.

The nurse counsels the client in the outpatient psychiatric clinic for treatment of a fear of water. The nurse recognizes that a phobia can BEST be described as which of the following? 1. A form of sublimation that is adaptive to the client. 2. A persistent fear that is excessive and unrealistic. 3. A persistent uncontrolled thought precipitated by anxiety. 4. A manipulative behavior used to achieve secondary gain.

Question: What is a phobia? Strategy: Think about each answer. Needed Info: Client feels apprehension, anxiety, helplessness when confronted with the feared object; nursing considerations include: avoid confrontation and humiliation, do not focus on trying to stop the client from being afraid, use systematic desensitization, try relaxation techniques. (1) sublimation is a defense mechanism; diversion of unacceptable, instinctual drives into socially acceptable outlets (2) CORRECT - phobia is a lasting and unreasonable fear caused by a specific object or situation that poses little or no danger (3) this is description of an obsession (4) this is when one person attempts to influence another person in order to meet one's own needs or desires.

The nurse conducts the admission interview of the client scheduled for surgical repair of an inguinal hernia. Which of the following client statements MOST concerns the nurse? 1. "I am allergic to bananas." 2. "I am allergic to shellfish." 3. "I am allergic to peanuts." 4. "I am allergic to milk."

Question: What is a potential complication to the surgery? Strategy: "MOST concerned" indicates something is wrong. Needed Info: Indication of latex allergy includes urticaria, rash, wheezing, rhinitis, conjunctivitis, bronchospasm, and anaphylactic shock; instruct client to avoid latex products. (1) CORRECT - latex products are used extensively during surgery; certain food allergies may indicate an allergy to latex; foods include apricots, cherries, grapes, kiwis, passion fruit, mangoes, bananas, avocados, chestnuts, tomatoes, and peaches (2) a concern if client going to be given a dye (3) can cause anaphylactic reaction; latex allergy is concern prior to surgery (4) can cause diarrhea; latex allergy is concern prior to surgery.

The nurse on the surgical unit is assigned to care for two patients in traction. The nurse recognizes that when caring for the patient in traction it is MOST important to take which of the following actions? 1. Allow the weight to hang freely at all times. 2. Encourage the patient to limit body movements. 3. Immediately remove the weights if the patient complains of discomfort. 4. Give pain medication regularly.

Question: What is a priority when caring for a client in traction? Strategy: Determine the outcome of each answer. Needed Info: Traction reduces fractures, alleviates pain and muscle spasms, prevents or correct deformities, and promotes healing; maintain straight alignment of ropes and pulleys, ensure that weights hang freely, frequently inspect skin for areas of breakdown, maintain position for countertraction. (1) CORRECT - necessary for proper pull of traction (2) twisting and turning may be prohibited, but movement of unaffected extremities is encouraged (3) weights should not be removed, changes pull of traction (4) pain should be investigated rather than routinely treated; pain may indicate circulatory impairment.

The nurse cares for clients being treated for narcotic abuse. The nurse recognizes that which of the following data obtained during a client history presents the HIGHEST risk for the client developing a disease process? 1. The use of multiple drugs. 2. Intravenous administration of narcotics. 3. Unsuccessful efforts to decrease drug use. 4. Legal difficulties encountered as a result of drug use.

Question: What is a risk factor for IV drug users? Strategy: Think about each answer. Needed Info: Symptoms of narcotic abuse include marked respiratory depression, hyperpyrexia, seizures, ventricular dysrhythmias, pinpoint pupils, stupor leading to coma. (1) associated with some increased risk of complications, but not as severe as IV use (2) CORRECT - IV drug use is associated with increased risk of developing HIV, septicemia, hepatitis, and respiratory failure (3) not directly linked to the development of disease processes (4) not linked to disease processes.

The nurse plans care for the patient diagnosed with Graves' disease. The nurse includes which of the following in the patient's plan of care? 1. Provide frequent rest periods. 2. Provide 2 meals per day. 3. Provide extra clothing for warmth. 4. Provide caffeinated beverages.

Question: What is the appropriate action? Strategy: Determine the outcome of each answer. Needed Info: Graves' disease is hyperthyroidism; assessment includes hyperactivity, sensitivity to heat, rest and sleep disturbance, increased perception of stimuli, weight loss, and tachycardia. (1) CORRECT - due to increased metabolic rate, provide for frequent rest periods and provide an environment that is free of stress (2) requires 6 meals per day that are high in calories due to high metabolic rate (3) suffers from heat intolerance; requires cool environment (4) has increased metabolic rate and caffeine would further increase it.

The nurse does discharge teaching with the parent of the child diagnosed with epilepsy. The child is going to be discharged on phenytoin. Which of the following statements, if made by the parent, indicates understanding of the potential side effects of phenytoin? 1. "My child's teeth may become discolored." 2. "My child may develop strange food cravings." 3. "My child may be more sensitive to x-rays." 4. "My child's urine may turn pink, red, or brown."

Question: What is a side effect of phenytoin? Strategy: Eliminate what you know to be wrong. Needed Info: 1) Epilepsy: uncontrolled abnormal discharge of electrical activity in the brain. 2) Sequence of seizures: prodromal stage: vague change in emotions, aura: brief sensation, epileptic cry, convulsion, postictal: change in consciousness. 3) Phenytoin (Dilantin): anticonvulsant and antiarrhythmic. Side effects: thrombocytopenia, leukopenia, ventricular fibrillation, nystagmus, diplopia, gingival hyperplasia, toxic hepatitis. (1) inaccurate (2) inaccurate (3) inaccurate, is more sensitive to ultraviolet rayS (4) CORRECT: harmless side effect

The nurse cares for the client after a below-the-knee amputation. The nurse assesses for infection and is MOST concerned if which of the following is observed? 1. The client appears restless. 2. The client reports a throbbing headache. 3. The client reports persistent pain at the operative site. 4. The skin feels cool proximal to the operative site.

Question: What is a symptom of infection at the operative site? Strategy: Determine what causes each symptom. Does it indicate infection? Needed Info: Major complications after amputation are hemorrhage, infection, and skin breakdown; monitor for bleeding; keep tourniquet placed in site at bedside; skin hygiene important to prevent skin breakdown; wash and dry residual limb twice per day. (1) restlessness indicates hypoxia (2) does not indicate infection (3) CORRECT - infection is frequent complication of amputation; assess for change in color, odor, and consistency of drainage, increased pain, elevated temperature; contact physician immediately (4) does not indicate infection.

The nurse cares for clients in the psychiatric unit. When administering antipsychotic medication, the nurse observes for tardive dyskinesia. The nurse recognizes that which of the following is characteristic of tardive dyskinesia? 1. Masklike face and shuffling gait. 2. Involuntary grimacing and protrusion of the tongue. 3. Motor restlessness and pacing. 4. Severe muscle contractions of the face.

Question: What is a symptom of tardive dyskinesia? Strategy: Think about each answer. Needed Info: Antipsychotics are major tranquilizers used to treat psychotic symptoms; examples are chlorpromazine (Thorazine), thioridazine (Mellaril), fluphenazine (Prolixin), haloperidol (Haldol), clozapine (Clozaril), and risperidone (Risperdal). (1) side effect that describes parkinsonism; notify physician; administer trihexyphenidyl (Artane) or benztropine (Cogentin) as prescribed (2) CORRECT - describes tardive dyskinesia; important to prevent this side effect by maintaining client on lowest possible dose of medication (3) describes akathisia; notify physician; requires reduction of the dose of antipsychotic or may receive benztropine or trihexyphenidyl (4) describes dystonic reaction; can compromise airway; administer diphenhydramine (Benadryl) or benztropine; provide quiet, nonstimulating environment; reassure client that symptoms will resolve.

The patient arrives at the health clinic with reports of dark urine, fever, and flank pain. The initial nursing assessment of the patient reveals which of the following EARLY symptoms of glomerulonephritis? 1. Polyuria. 2. Oliguria. 3. Polydipsia. 4. Enuresis.

Question: What is an EARLY symptom of glomerulonephritis? Strategy: Be careful! The question asks about early symptoms. Needed Info: Acute glomerulonephritis: group of kidney diseases resulting in inflammatory changes from immunological responses. S/S: edema, abdominal pain, hypertension, fever. Nursing responsibilities: restrict sodium and water, daily weight, I + O, bed rest, high-calorie, low-protein diet. (1) excessive output seen with diabetes mellitus, acute renal failure; normal output 1,200 - 1,500 mL/day (2) CORRECT - reduced urinary output (100 - 400/day); also hematuria (blood in urine), proteinuria (protein in urine) (3) excessive thirst seen with diabetes mellitus due to osmotic diuresis; normal intake 1,500 - 2,000 mL/day (4) bedwetting after age 5; not seen with glomerulonephritis.

The nurse assesses the 8 lb 4 oz newborn infant. Which of the following observations, if made by the nurse, requires an intervention? 1. The infant's respirations are 36, shallow and irregular in rate, rhythm, and depth. 2. Rapid pulsations are visible in the fifth intercostal space, left midclavicular line. 3. The infant's axillary temperature is 96.2°F (35.6°C). 4. There is asynchronous spontaneous movement of the infant's extremities.

Question: What is an abnormal finding for a newborn? Strategy: Think about cause of each answer. "Requires an intervention" indicates a complication. Needed Info: Important to assist newborn with heat regulation: wrap newborn to protect from cold, dry infant after birth, place fabric insulated cap on head. Cold stress: infant unable to increase activity and lacks a shivering response to cold; causes metabolic acidosis, hypoxia, and hypoglycemia. (1) normal due to immaturity of respiratory system (2) normal, site of apical pulse, normal rate 120 - 140 bpm (3) CORRECT - subnormal indicates prematurity, infection, low environment temperature, inadequate clothing, dehydration (4) normal, legs move in bicycle fashion, should have equal extension of all extremities.

The patient receives morphine sulfate postoperatively for complaints of pain. Since the patient is receiving morphine, which of the following medications is MOST important for the nurse to have available? 1. Naloxone. 2. Disulfiram. 3. Methadone. 4. Epinephrine.

Question: What is an antidote to morphine? Strategy: Think about each answer choice and how it relates to morphine. Needed Info: Remember that an overdose of morphine causes respiratory depression; need availability of the antidote in case of overdose. (1) CORRECT - narcotic antagonist; rapid onset, duration 3 - 5 hours; reverses respiratory depression (2) treatment for alcohol abuse; reacts with alcohol to cause flushing, HA, vomiting, palpitations, hypotension (3) treatment for drug abuse; narcotic analgesic used to detoxify addicts (4) nervous system stimulant; used in asthmatic attacks, anaphylactic reactions, cardiac arrest.

The nurse cares for the depressed client who frequently verbalizes a negative self-image. The nurse recognizes that which of the following nursing interventions is MOST appropriate for this patient? 1. Help the client identify areas of weakness. 2. Help the client identify unrealistic expectations. 3. Ask the client to identify goals for the next 2 years. 4. Tell the client to stop having negative thoughts.

Question: What is an appropriate nursing action for a client who is depressed? Strategy: Determine the outcome of each answer. Needed Info: Depression may be a response to a real or imagined loss; it may result from anger and aggression toward self that results from feeling of guilt about negative or ambivalent feelings; nursing considerations include being alert for signs of self-destructive behavior, promote eating and rest, support self-esteem. (1) action too negative; reinforces what client already feels (2) CORRECT - unrealistic expectations that client fails to meet reinforces feelings of low self-esteem; the first step is to help client identify what is unreasonable (3) time frame is too long (4) not most appropriate; altering negative thoughts can be helpful in improving self-esteem, but it is not simply a matter of telling a client to stop them; that has a punitive tone and is not realistic.

The nurse observes the student nurse caring for a patient with a tracheostomy tube. The nurse intervenes if which of the following is observed? 1. The student nurse uses clean gloves to remove the tracheostomy dressing. 2. The student nurse cleans the inner cannula by soaking it in hydrogen peroxide. 3. The student nurse removes the soiled trach ties and then reattaches clean ties. 4. The student nurse replaces the dressing with a folded gauze 4 x 4.

Question: What is an incorrect action when caring for a patient with a tracheostomy tube? Strategy: "Need for an intervention" indicates an incorrect action. Needed Info: Perform tracheostomy care every 8 hours and as needed; hyperoxygenate patient prior to suctioning trach tube; sterile procedure. (1) appropriate procedure; dispose of soiled dressing and gloves appropriately (2) appropriate procedure; clean with small brush or pipe cleaner; rinse well in normal saline (3) CORRECT - apply new ties prior to removing old ties to prevent dislodgment of the trach (4) use folded 4 x 4 or commercially prepared 4 x 4; in order to prevent aspiration, do not cut dressing.

The home care nurse assesses the client diagnosed with gout. The nurse is MOST concerned if the client makes which of the following statements? 1. "I drink at least 2 quarts of liquid each day." 2. "I am losing 3 pounds per week." 3. "I limit my protein intake to 3 to 4 ounces per meal." 4. "I have quit drinking beer."

Question: What is an incorrect statement about gout? Strategy: "MOST concerned" indicates an incorrect statement. Needed Info: Gout is overproduction or underexcretion of uric acid; causes joint pain, swelling, limitation of movement, nodules over bony prominences; treatment includes colchicine, analgesics, and anti-inflammatory drugs. (1) increase fluid intake to 2 - 3 quarts per day to promote uric acid excretion and dilute the urine (2) CORRECT - excessive weight loss may precipitate an attack of gout; if overweight, lose 0.5 - 1 pounds per week (3) limit foods high in purines--anchovies, dried peas and beans, and organ meats; cheese, eggs, milk, and vegetables are lower in purines (4) excessive alcohol reduces uric acid excretion.

The nurse instructs the client receiving levothyroxine 100 mcg daily. The nurse identifies that further teaching is necessary if the client states which of the following? 1. "If I have chest pain, I will call my doctor." 2. "If my hands shake, I will call my doctor." 3. "I will take my medication before I go to sleep." 4. "I will inform my other health care providers about this medication."

Question: What is an incorrect statement about levothyroxine? Strategy: Think about the action of the medication. Needed Info: Levothyroxine (Synthroid) increases metabolic rate of body and is used as a thyroid replacement; side effects include nervousness, tremors, insomnia, tachycardia, palpitations, dysrhythmias, and angina; instruct client to report chest pain, palpitations, sweating, nervousness, or shortness of breath. (1) appropriate action: indicates a potentially serious side effect; instruct client to report unusual cardiovascular symptoms (2) appropriate action: may indicate overdose (3) CORRECT - take thyroid replacement at the same time each day; morning is preferred to prevent insomnia (4) appropriate action.

The community health nurse conducts a prevention program at the high school and discusses high-risk groups for suicide. The nurse recognizes that further teaching is necessary if a student states which of the following? 1. "Adolescents are at high risk." 2. "Depressed people are at high risk." 3. "History of previous suicide attempts put people at high risk." 4. "Those who are grieving in response to a loss for 9 months are at high risk."

Question: What is an incorrect statement about suicide? Strategy: Think about each answer. Needed Info: Be alert for signs of self-destructive behavior; behavioral clues of impending suicide include any sudden change in behavior; client becomes energetic after period of severe depression, finalizes business or personal affairs, withdraws from social activities and plans, presence of weapon, razors, or pills, has a death plan. (1) suicide is the third leading cause of death among people 15 to 24 years old (2) symptoms of depression include social withdrawal, feelings of hopelessness, irritability, and difficulty sleeping (3) previous suicide attempts and easy access to lethal methods are risk factors; of those who commit suicide, 80% made previous attempts. (4) CORRECT - grieving is a normal human response that occurs in response to a loss and the entire process may take more than 1 year.

The nurse counsels the young parent about how the parent will know when the child is ready for toilet training. The nurse recognizes that further teaching is necessary if the parent makes which of the following statements? 1. "I can consider toilet training when my child's diaper is dry after naps." 2. "I can begin toilet training when my child begins to walk." 3. "My child must be able to sit for five to ten minutes before I can start toilet training." 4. "It is important that I have the time to spend in toilet training."

Question: What is an incorrect statement about toilet training? Strategy: "Further teaching is necessary" indicates an incorrect statement. Needed Info: Child must be able to control anal and urethral sphincters, recognize the urge to void and defecate, and be able to communicate the need to the parents; readiness occurs around 18 - 24 months; practice sessions should be limited to 5 - 10 minutes, and a parent should stay with the child. (1) staying dry for 2 hours or waking up dry after a nap indicates toilet training readiness (2) CORRECT - voluntary control of anal and urethral sphincters is required; usually occurs at 18 - 24 months; toddlers usually walk at 12 - 13 months (3) must be able to sit without getting up or fussing (4) parent must also recognize child's readiness; if major changes occurring in the family (divorce, moving, vacation) do not begin toilet training.

The nurse manager observes the staff nurse assist the physician with a lumbar puncture. The manager determines that the care is appropriate if the staff nurse does which of the following? 1. The staff nurse instructs the patient to hyperventilate. 2. The staff nurse instructs the patient to maintain a full bladder. 3. The staff nurse explains to the patient that the procedure is always painless. 4. The staff nurse assists the patient into a fetal position.

Question: What is appropriate position for lumbar puncture? Strategy: Determine outcome of each answer. Needed Info: Lumbar puncture is the insertion of needle into subarachnoid space to obtain specimen, relieve pressure, inject dye or medication. Preparation for procedure: explain procedure, confirm that consent has been signed, position in lateral recumbent fetal position. Post-test nursing care: position flat for 4 - 12 hours; encourage PO fluids to 3,000 mL, neurological assessment every 15 - 30 min until stable. Oral analgesics for headache. (1) patient should breathe normally; hyperventilation may lower an elevated pressure (2) patient should empty bladder for comfort (3) patient will feel a needle prick or may feel pain in the leg. (4) CORRECT - the patient uses own arms to hold knees in place, head bent forward; increases space between vertebrae

The nurse cares for clients in the outpatient clinic. The client diagnosed with glaucoma experiences severe restrictions of peripheral vision and asks the nurse if the vision will improve. Which of the following statements by the nurse is BEST? 1. "If you continue to take your medication, the pressure in your eyes will decrease. Your vision will improve." 2. "The physician will perform surgery to remove the lens in your eyes. This will increase your vision." 3. "The current damage to your vision is permanent. Continued use of the eye drops will prevent further damage." 4. "After the eye pressure is stabilized, the physician will reevaluate your vision. Your vision can be corrected with glasses."

Question: What is correct information about glaucoma? Strategy: Think about each answer. Needed Info: Glaucoma is abnormal increase in intraocular pressure leading to visual disability and blindness; signs and symptoms include cloudy, blurry vision, or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; pain, headache, nausea, and vomiting; treatment is miotics. (1) vision will not improve (2) lens is removed during cataract surgery (3) CORRECT - true statement about glaucoma (4) damage is permanent.

The nurse cares for the client who was admitted to the cardiac unit reporting retrosternal chest pain and severe anxiety. The client was diagnosed with arteriosclerotic heart disease (ASHD) and angina. The client is ready for discharge and nitroglycerin is prescribed. Which of the following statements does the nurse include in the discharge teaching? 1. "Store the nitroglycerin tablets in a special clear plastic pillbox with a bright lid." 2. "Take a nitroglycerin tablet before engaging in any activity that may produce chest pain." 3. "Swallow the nitroglycerin tablets, but do not take with water or any other liquids." 4. "You will not have to renew your prescription for nitroglycerin for the next 12 months."

Question: What is correct information about nitroglycerin? Strategy: Determine the outcome of each answer. Needed Info: Nitroglycerin is an antianginal that relaxes vascular smooth muscle; side effects include flushing, hypotension, headache, tachycardia, dizziness, and blurred vision. (1) nitroglycerin is very unstable and should be kept in a dark glass bottle which is securely capped; do not store in metal or plastic (2) CORRECT - prophylactic dose of nitroglycerin increases client's tolerance for stress and exercise (3) nitroglycerin is not swallowed; place under tongue, wet tablet with saliva; do not swallow saliva until tablet dissolves (4) nitroglycerin is unstable, volatile, and inactivated by moisture, air, light, heat, and time; renew supply every 3 months.

The nurse cares for the client who will be taking phenelzine sulfate following discharge. Which of the following is important information for the nurse to include in the teaching plan regarding this medication? 1. The client will see the effects of the medication immediately. 2. The client does not need to use sunblock during outside activities. 3. Drinking coffee or carbonated beverages will decrease the effectiveness of the medication. 4. Combining the medication with certain foods significantly increases blood pressure.

Question: What is correct information about phenelzine? Strategy: Think about the action of the drug. Needed Info: phenelzine sulfate (Nardil) is an MAO inhibitor; interacts with foods containing tyramine or drugs containing sympathomimetic substances to cause a hypertensive crisis. (1) takes 3 - 4 weeks for drug to begin working (2) sunblock is required (3) may precipitate hypertensive crisis (4) CORRECT - instruct client to avoid pickled herring, liver, dry sausage, sauerkraut, aged cheese, yogurt, yeast, and meat extracts, and other pickled, fermented, or smoked foods to prevent a hypertensive crisis

The nurse cares for the client in the outpatient clinic who has received a prescription for verapamil 80 mg TID. The nurse includes which of the following instructions when teaching the client about this medication? 1. "Drink lots of fluids during the day to prevent liver and kidney damage." 2. "When you awaken in the morning, sit on the side of the bed for a few minutes before standing." 3. "If you are feeling stress and develop symptoms, take an extra dose of verapamil." 4. "Take the medication before meals on an empty stomach."

Question: What is correct information about verapamil? Strategy: Determine the outcome of each answer. Needed Info: Verapamil (Calan): calcium-channel blocker; side effects include transient hypotension, dizziness, headache, constipation, elevated liver enzymes; instruct client to take medication with food, monitor vital signs, and instruct not to chew or divide sustained-release medication. (1) encourage client to increase fluid and fiber intake to counteract constipation side effect (2) CORRECT - medication causes transient hypotension; monitor blood pressure when first taking the medication and when dosage is adjusted (3) take medication as prescribed; given as an antihypertensive and antianginal (4) take with food; increase intake of fiber and fluids.

The parents of the 6-month-old bring the infant to the pediatrician's office for a routine immunization. The nurse is to administer the immunization by intramuscular (IM) injection. The nurse recognizes that which of the following is the preferred site for an IM injection in an infant? 1. Deltoid. 2. Vastus lateralis. 3. Dorsogluteal. 4. Ventrogluteal.

Question: Where should you give an IM injection to a 6-month-old child? Strategy: Think about each site. What is the size of the muscle? Are there nerves and blood vessels in the area? Needed Info: To determine where to give injection, consider: amount and type of med, size and condition of muscle, and the ability to access site. Inject up to 0.5 mL in infant and 1 mL in child. (1) small muscle mass; radial nerve near (2) CORRECT - no blood vessels or nerves; easily accessible (3) not used until walking (about 1 year) (4) not used until walking (about 1 year).

The nurse plans postoperative care for the patient scheduled for a stapedectomy. When the patient is returned to the room after surgery, the nurse expects to observe which of the following? 1. Patient's hearing is completely restored. 2. Patient is still drowsy from the general anesthesia. 3. Patient experiences vertigo, nausea, and vomiting. 4. Patient has drains in both ears.

Question: What is expected after a stapedectomy? Strategy: Think about each answer. Needed Info: Excision of stapes with or without prosthesis to correct hearing loss; during first 24 hours post-op position patient flat in bed with minimal head movement; instruct patient to not blow nose or sneeze; assess for facial nerve damage or muscle weakness or changes in taste. (1) hearing initially worse; improves after 6 weeks (2) local anesthetic used (3) CORRECT - close to inner ear; meclizine (Antivert) (anti-vertigo) and prochlorperazine (Compazine) (antiemetic) used; assist with ambulation, side rails up, change positions slowly (4) drains not used; gel foam (absorbent sponge) packing used to decrease bleeding

The patient with a history of heart failure (HF) is admitted to the hospital with flulike symptoms. When taking the history, the nurse learns that the patient has been taking digoxin 0.125 mg PO daily for 3 years. Last month the physician changed the prescription for digoxin to 0.25 mg PO daily and ordered furosemide 40 mg daily. The nurse expects the physician to order which of the following laboratory tests? 1. Serum electrolytes and digoxin level. 2. White blood cell count and hemoglobin and hematocrit. 3. Cardiac enzymes and an arterial blood gas. 4. Blood cultures and urinalysis.

Question: What is going on with the patient, and which tests will help identify the problem? Strategy: Think about what each test measures. Needed Info: Digoxin (Lanoxin): cardiac glycoside works by strengthening myocardial contraction and slowing conduction through the AV node. Furosemide (Lasix): acts at loop of Henle to inhibit reabsorption of sodium, chloride; side effects: agranulocytosis (decreased WBC), hypokalemia. Heart failure (HF): failure of heart to adequately pump blood. S/S: dyspnea; weight gain, edema, crackles. Treatment: cardiac glycosides (digoxin), diuretics, restricted sodium diet. Nursing responsibilities: promote rest, give oxygen, teach about meds. (1) CORRECT - check potassium; hypokalemia may precipitate dig toxicity: N + V, bradycardia, AV block, visual disturbances, PVCs (2) WBC indicates infection, inflammation; hemoglobin and hematocrit measure functioning of red blood cells, low values indicate anemia (3) CPK + LDH isoenzymes indicate cardiac damage; ABG indicates acid/base balance (4) blood cultures indicate infection; UA indicates urinary problems.

The nurse cares for the recently retired salesman who is brought to the psychiatric hospital by his spouse. The spouse states that since retirement, the patient has been listless and roams around the house complaining of nothing to do. The patient states, "Without a job I have no purpose in life." The spouse adds that the patient recently lost 10 pounds and sleeps for only 2 to 3 hours each night. In order to prioritize the patient's nursing care, the nurse assesses which of the following areas FIRST? 1. Suicidal ideation. 2. Level of insight into his problem. 3. Nutritional deficiencies. 4. Motivation to solve own personal problems.

Question: What is most important for a patient with depression? Strategy: Set priorities according to Maslow's hierarchy of needs. Needed Info: Symptoms of depression: regressive behavior, obsessive thoughts, unkempt appearance, insomnia, withdrawn behavior. Nursing responsibilities: check for possible suicide, report behavioral changes, meet physical needs, structure simple routines, use touch judiciously, encourage expression of feelings. Treatment: antidepressants; group, individual, and family therapy. (1) CORRECT - safety needs highest (2) safety needs higher priority (3) safety needs more important (4) later issue.

The nurse teaches the group of parents of toddlers how to prevent accidental poisoning. Which of the following suggestions does the nurse give regarding medications? 1. Lock all medications in a cabinet. 2. Childproof all the caps to medication bottles. 3. Store medications on the highest shelf in a cupboard. 4. Place medications in different containers.

Question: What is the BEST way to prevent accidental poisoning in children, especially toddlers? Strategy: Picture toddlers at play. Needed Info: Remember that no bottle's cap can be made totally childproof; only a locked cabinet can provide protection. Even the highest shelf is no barrier for some climbing toddlers. Changing the containers will only make life difficult for the parents; it will not prevent accidental poisoning. (1) CORRECT - improper storage most common cause of poisoning; highest incidence in 2-year- olds (2) children can open (3) toddlers climb (4) keep in original containers.

The nurse cares for the patient who is being treated for heart failure (HF) and atrial fibrillation. The physician orders digoxin 0.25 mg PO daily. Prior to administering the medication, the nurse assesses that the patient's heart rate is 98 and irregular. Which of the following actions should the nurse take FIRST? 1. Administer the digoxin and chart the rhythm. 2. Hold the digoxin until the patient's pulse slows down. 3. Hold the digoxin until the patient's pulse increases. 4. Call the physician for clarification of the medication order.

Question: What is the FIRST thing you should do? Strategy: Determine the outcome of each answer choice. Needed Info: Atrial fibrillation: rapid, irregular depolarization of atria. Results in irregular and rapid pulse. Treatment: digoxin (Lanoxin; strengthens the myocardial contraction and slows the rate of conduction), calcium channel blockers nifedipine (Procardia), quinidine, procainamide (Pronestyl), anticoagulants (heparin), cardioversion. (1) CORRECT - drug of choice for atrial fib and flutter; report to physician any increase, decrease, irregularity and/or change in regularity of pulse rate (2) needs digoxin to do (3) already is rapid; would increase myocardial demands (4) not necessary

The nurse cares for the patient receiving neomycin sulfate. The nurse recalls that this medication is given for which of the following reasons? 1. To increase digestive functioning by supporting intestinal bacteria. 2. To decrease postoperative wound infection by suppressing intestinal bacteria. 3. To serve as an adjunct to systemic antibiotic therapy. 4. To prevent the occurrence of ulcerative colitis.

Question: What is the action of neomycin? Strategy: Think about the action of the medication. Needed Info: Neomycin sulfate (Neo-fradin) is an aminoglycoside used to treat infections caused by Pseudomonas and E. coli, used to suppress intestinal bacteria, and as adjunct treatment for hepatic coma; side effects include ototoxicity and nephrotoxicity; nursing considerations include check hearing and renal function, encourage fluids, and offer small frequent meals. (1) no improved digestion (2) CORRECT - neomycin sulfate is an aminoglycoside used to suppress intestinal bacteria; acts as a bowel sterilizer; used to prevent wound and abdominal infections (3) used as adjunctive treatment of hepatic coma (4) sulfasalazine (Azulfidine), not neomycin, is helpful in preventing the recurrence of ulcerative colitis.

The nurse cares for the infant being evaluated for pyloric stenosis. The nurse recognizes that it is MOST important to offer which of the following feedings? 1. Clear fluids. 2. Continuous nasogastric feedings. 3. Intermittent nasogastric feedings. 4. Small, frequent feedings.

Question: What is the appropriate feeding for an infant with pyloric stenosis? Strategy: Determine the outcome of each answer. Needed Info: Pyloric stenosis is obstruction caused by hypertrophy and hyperplasia of pylorus, the muscular sphincter at the gastroduodenal juncture; projectile vomiting occurs 2 - 4 weeks after birth; postoperative care includes provide parenteral fluids as ordered, check incision site, monitor warmth, offer clear liquids with glucose or electrolyte solution first; if tolerated, infant begins formula or breast feeding. (1) clear fluids offered only in special situations, such as initial feeding after surgery or in preparation for surgery or diagnostic tests of the bowel (2) IV fluids will be given rather than NG tube feedings; exception--NG tube may be inserted prior to surgery for gastric decompression and may be continued immediately after surgery (3) if unable to tolerate oral feedings, infant is NPO and given IV fluids, not NG tube feedings, containing glucose and electrolytes (4) CORRECT - normal amounts of feeding may not be tolerated; may cause aspiration; position upright on right side after feedings

The nurse cares for clients in the outpatient clinic. Which of the following is the MOST important immediate nursing goal for the client just diagnosed with glaucoma? 1. Prepare for required surgery. 2. Prevent further deterioration of the vision. 3. Assist the client to deal with the inevitable effects of blindness. 4. Decrease the ocular pressure and improve vision.

Question: What is the appropriate goal for a client diagnosed with glaucoma? Strategy: Think about each answer. Needed Info: Glaucoma is an abnormal increase in intraocular pressure, leading to visual disability and blindness; signs and symptoms include cloudy, blurry vision or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; pain, headache, nausea, and vomiting; treatment is miotics. (1) surgery is not always indicated (2) CORRECT - damage to vision cannot be corrected; further damage can be prevented with medication; client can complete a trial of medication before contemplating surgery or assuming blindness as an outcome (3) most important immediate goal is to prevent further loss of vision, possible with medication, so that client will not develop blindness, which is NOT inevitable (4) ocular pressure can be decreased, but vision cannot be improved.

The nurse cares for the patient admitted to the recovery room following a total left hip replacement. The nurse positions the patient in which of the following positions? 1. On the right side with the head of the bed slightly elevated and the left hip adducted. 2. On the left side with the head of the bed slightly elevated and the hips flexed 120 degrees. 3. Supine with the knee gatch elevated to 30 degrees and the left hip extended. 4. Supine with the head of the bed slightly elevated and a pillow between the legs.

Question: What is the appropriate position to place a client in after a total left hip replacement? Strategy: Determine the outcome of each answer. Needed Info: Nursing care includes abduction of affected extremity using splints, wedge pillow, or 2 - 3 pillows between legs, turn patient as ordered, ice to operative site, do not sleep on operative side, do not flex hip more than 45 - 60 degrees. (1) adduction should be avoided to prevent dislocation (2) do not flex more than 45 - 60 degrees to prevent dislocation (3) head of bed should be slightly elevated, knee gatch is never used (4) CORRECT - keeps legs abducted and prevents hip flexion; maintains alignment of the prosthesis and prevents dislocation

The nurse is performing a home care visit on the 3-year-old with a cast on the left arm due to a fracture of the radius. The nurse is MOST concerned when which of the following is observed? 1. The mother wraps the cast with plastic wrap prior to bathing the child. 2. The child elevates the arm on a pillow while watching television. 3. The child sits at the table playing with small toy figurines. 4. The mother encourages the child to wiggle the fingers on the left hand.

Question: What is the child doing wrong? Strategy: "MOST concerned" indicates an actual or potential complication. Needed Info: Immediate cast care includes avoid covering cast until dry, handle with palms, not fingertips, watch for danger signs such as blueness or paleness, pain, numbness or tingling sensations on affected area; intermediate cast care includes mobilize client, encourage isometric exercises, do not put anything inside cast, keep small items that might be placed inside the cast away from small children. (1) waterproofs cast against splashes; cast should be kept out of water (2) prevents swelling; can support with a sling or on pillow (3) CORRECT - possibility of child sticking small items down cast (4) indicates good circulation; also check for swelling, discoloration, or decreased sensation.

A neighbor calls the nurse stating that a piece of glass is embedded in the neighbor's child's eye. Which of the following instructions by the nurse is MOST important? 1. Irrigate the injured eye with warm normal saline and apply a dressing. 2. Place a pressure dressing on the injured eye and take the child to the emergency room. 3. Remove the piece of glass from the child's eye. 4. Put an eye patch over both eyes and immediately take the child to the emergency room.

Question: What is the correct action for an eye injury? Strategy: Determine the outcome of each answer. Needed Info: If nonpenetrating abrasion, patch eye for 24 hours; if nonpenetrating contusion, apply cold compresses and take analgesics; if penetrating injury, cover with patch and refer to surgeon. (1) appropriate for nonpenetrating foreign body that is causing an irritation (2) would lead to further eye injury (3) would lead to further eye injury; removal should be done only by a surgeon (4) CORRECT - minimize eye movement in order to prevent further injury

The nurse manager reviews infection prevention practices with the staff caring for clients with central venous catheters (CVCs). Which of the following statements by a staff member indicates the BEST understanding of the precaution required to prevent infections for these clients? 1. "If the dressing is wet or soiled, I will change it immediately." 2. "I will apply the antibiotic ointment as ordered by the physician." 3. "I will assess for swelling in the shoulder, neck, chest, and arm at least twice per shift." 4. "I will flush the catheter at regular intervals."

Question: What is the correct care to prevent infection? Strategy: Determine the outcome of each answer. Needed Info: Central venous catheter used to deliver parenteral nutrition; complications of insertion of central venous catheter include pneumothorax and infection. (1) CORRECT - prevents growth of microorganisms; use aseptic technique when changing dressing (2) relates to treatment, not prevention; if infection occurs, physician may order local antibiotic ointment and /or systemic antibiotic or antifungal (3) swelling indicates possible pneumothorax, which is not an infection (4) important to maintain patency of central venous catheter, but not expected to play a role in infection prevention.

The nurse evaluates care for the client with a diagnosis of vaginal cancer being treated with an internal radium implant. The nurse determines that the nursing care of the client is appropriate if which of the following is observed? 1. The nurse wears a dosimeter film badge when in the client's room. 2. The client uses the bedside commode. 3. The client's 10-year-old grandchild visits for 20 minutes. 4. The nurse stands at the foot of the bed to talk with the client.

Question: What is the correct procedure when caring for clients with an internal radium implant? Strategy: Determine the outcome of each answer. Needed Info: Internal radiation is a sealed source placed in a body cavity or tumor. Place client in private room; save all dressing, bed linens until source is removed; then discard dressing and linens as usual; rotate staff caring for client. (1) CORRECT - measures the amount of radiation that nurse is exposed to; each nurse should have individual badge (2) is on bed rest to prevent dislodgment of the implant (3) children under age of 16 and pregnant women not allowed to visit; limit time in room (4) do not stand in the direct line of the radiation source; limit time in room.

The nurse cares for the postoperative client receiving cephalexin monohydrate 500 mg PO QID. The nurse schedules the administration of this medication at which of the following times? 1. Prior to meals. 2. 9AM, 3PM, 9PM, 3AM. 3. 9AM, 1PM, 5PM, 9PM. 4. After administration of an antacid.

Question: What is the correct schedule to administer cephalexin monohydrate? Strategy: Determine the outcome of each answer. Needed Info: Cephalexin (Keflex) is a first-generation cephalosporin antibiotic; side effects include diarrhea, nausea, dizziness, abdominal pain, superinfection, allergic reactions; take with food, avoid alcohol while taking medication; assess for penicillin allergy (up to 20% have cross-allergy). (1) take with food or milk to avoid GI upset (2) CORRECT - blood level must be achieved and maintained for an antibiotic to be effective; medication should be given around-the-clock, every 6 hours (3) schedule medication around-the-clock, every 6 hours (4) antacids will reduce the effectiveness of the medication.

The nurse cares for clients in the orthopedic clinic. The nurse is MOST concerned if which of the following is observed? 1. The teenager who is 6'4" tall places the crutches about 6" to the side of the feet when ambulating with them. 2. The school-aged child who is 4'8" tall flexes the elbows about 20 degrees when ambulating with crutches. 3. The middle-aged adult who is 5'10" tall advances the crutches first when walking down the stairs. 4. The older adult who is 5'6" tall uses a 4-point gait when ambulating with crutches.

Question: What is the correct technique for crutch-walking? Strategy: "MOST concerned" indicates an incorrect action. Needed Info: To determine crutch height, measure 2 fingers below axilla; support weight on hand pieces, not on axilla; crutches should be kept 8 - 10 inches out to side. (1) CORRECT - taller person requires a broader base of support, at least 8 inches (2) elbows flexed 20 - 30 degrees enables correct hand placement on grips (3) appropriate technique, follow crutches with weak leg, then strong leg (4) provides maximum support, partial weight bearing, both feet required.

The nurse instructs the client about how to perform breast self-examination. The nurse should include which of the following instructions about examining the breasts in a mirror? 1. "Stand with your arms at your sides. Bend from the waist to the left side. Bend from the waist to the right side." 2. "Stand with both arms above your head. Lower the right arm and keep the left arm raised. Lower the left arm and raise the right arm." 3. "Stand with your hands on your hips. Clasp your hands behind your back." 4. "Stand with your arms at your sides. Clasp your hands behind your head and press your hands forward. Place your hands on your hips and bow slightly toward the mirror."

Question: What is the correct way to perform self-breast examination using a mirror? Strategy: Determine the outcome of each answer. Needed Info: Perform breast self-examination monthly beginning at age 20; after inspecting breasts in the mirror, client should palpate the breasts when standing and lying down. (1) should bend forward with hands on hips (2) raise arm to palpate breast to detect unusual growths (3) clasp hands behind head first and then place hands on hips. (4) CORRECT - stand before mirror to inspect breast for discharge from nipples, puckering, dimpling, or scaling of skin; placing hands behind head and on hips will show changes in shape and contour of the breast

The client in the clinic asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which of the following responses by the nurse is BEST? 1. "Rheumatoid arthritis is quickly progressive, and osteoarthritis has periods of remission." 2. "Rheumatoid arthritis is a systemic disease, and osteoarthritis is deterioration of the synovial joints." 3. "Rheumatoid arthritis is often treated surgically, and osteoarthritis is treated by medication." 4. "There is very little clinical difference between rheumatoid arthritis and osteoarthritis."

Question: What is the difference between rheumatoid arthritis and osteoarthritis? Strategy: Think about each answer. Needed Info: Rheumatoid arthritis is a chronic systemic disease that causes inflammatory changes in joints; osteoarthritis is nonsystemic and degenerative; symptoms include joint pain, swelling, and limitation of movement; nursing care includes pain management, rest, activity, and exercise. (1) rheumatoid arthritis is progressive and has periods of remission and exacerbations; osteoarthritis is degenerative and there are no remissions (2) CORRECT - rheumatoid arthritis is a chronic systemic disease that causes inflammatory changes in joints; osteoarthritis is nonsystemic and degenerative affecting the synovial joints (3) both diseases can be treated with medication; both diseases may require joint replacement (4) untrue statement.

The nurse cares for the client who experiences severe panic attacks when planning to go grocery shopping. The nurse expects to administer which of the following oral medications? 1. Chlorpromazine. 2. Carbamazepine. 3. Flurazepam. 4. Imipramine.

Question: What is the drug of choice for clients experiencing panic-level anxiety? Strategy: Think about the action of each medication. Needed Info: Anxiety is feeling of dread or fear in the absence of external threat or disproportionate to the nature of the threat; in panic level anxiety, the client is unable to see, hear or function; assess level of anxiety, decrease environmental stimuli, use unhurried approach and stay with the client. (1) chlorpromazine (Thorazine): antipsychotic medication; not used to treat panic attacks (2) carbamazepine (Tegretol): anticonvulsant used to treat seizures and nightmares (3) flurazepam (Dalmane) : sedative-hypnotic, used to produce sleep. (4) CORRECT - imipramine (Tofranil): tricyclic antidepressant used to treat panic attacks

The patient with a history of alcoholism is brought to the emergency room in an agitated state. The patient is vomiting and diaphoretic. The patient had the last drink 5 hours ago. The nurse expects to administer which of the following medications? 1. Disulfiram. 2. Methadone hydrochloride. 3. Naloxone hydrochloride. 4. Chlordiazepoxide hydrochloride.

Question: What is the drug used to treat acute alcohol withdrawal? Strategy: Think about the action of each drug. Needed Info: Symptoms of acute alcohol withdrawal include tremors, being easily startled, insomnia, anxiety, anorexia, and alcoholic hallucinations. Nursing care includes administering sedation as needed, monitoring pulse, blood pressure, and temperature, seizure precautions, orienting frequently, and not leaving hallucinating, confused client alone. (1) disulfiram (Antabuse): used as a deterrent to impulsive drinking; contraindicated if patient drank alcohol in previous 12 hours (2) methadone hydrochloride (Dolophine): opioid analgesic, used to treat narcotic withdrawal syndrome; S/E seizures, respiratory depression (3) naloxone hydrochloride (Narcan): narcotic antagonist used to reverse narcotic-induced respiratory depression; S/E ventricular fibrillation, seizures, pulmonary edema. (4) CORRECT - chlordiazepoxide hydrochloride (Librium): antianxiety; used to treat symptoms of acute alcohol withdrawal; S/E lethargy, hangover, agranulocytosis

The nurse manager notes that one of the staff members is frequently absent, and this has adversely affected the quality of care given to patients on the unit. When INITIALLY counseling the staff member, which of the following approaches by the nurse manager is BEST? 1. Inform the staff member that the next missed day will be grounds for termination. 2. Talk with the staff member and remind the staff member of the standards of the agency. 3. Give the staff member a written reminder of the standards of the agency. 4. Document the staff member's absenteeism.

Question: What is the first action the nurse manager should take? Strategy: Determine the outcome of each answer. Needed Info: If the staff member does not clearly understand what is expected, the staff member may feel role strain, which might cause withdrawal from the work situation. (1) important to clarify the staff member's role; give oral and written reminders before terminating employee (2) CORRECT - first action is to give employee an oral reminder of the agency's standards; do not threaten discipline; purpose is to clarify role expectation (3) if absenteeism continues to be a problem after the verbal reminder, the staff member is given the same reminder in writing (4) should be documented, but the nurse's first action should be to give the staff member a verbal reminder.

At midnight, 2 days following a hemicolectomy, the patient awakens frightened and agitated. The patient climbs out of bed, removes the indwelling urinary drainage catheter, and runs down the hall screaming. Which of the following actions is most appropriate for the nurse to take INITIALLY? 1. Call the physician and request a sedative for the patient. 2. Return the patient to bed and restrain the patient immediately. 3. Replace the patient's indwelling urinary drainage catheter. 4. Return the patient to bed and assess the patient's condition.

Question: What is the first thing you should do in this situation? Strategy: Establish priorities. Remember the steps of the nursing process. Needed Info: Hemicolectomy: removal of half or less of the colon in order to remove tumors. (1) assessment needed first (2) last resort; needs assessment and reorientation (3) not first priority. (4) CORRECT - assessment first step

The woman in her second trimester of pregnancy tells the clinic nurse that her 5-year-old child has been asking questions "about sex." The client asks the nurse what she should tell her child. Which of the following statements, if made by the nurse, is BEST? 1. "Buy a book about sex designed for young children and read it with your son." 2. "Have your child touch your abdomen and tell him about your pregnancy." 3. "Tell your child that this subject is complicated, and you will discuss it as the child gets older." 4. "Answer your child's questions in a matter-of-fact manner, in words that the child will understand."

Question: What is the most appropriate response? Strategy: "BEST" indicates discrimination is required. Needed Info: Important to determine what the child knows and thinks and to offer honest explanations. (1) not best action, may provide more information than child is seeking (2) does not answer particular questions child has; assumes that questions are about pregnancy (3) questions should be answered as they are asked, not postponed or ignored. (4) CORRECT - helps child understand his concerns, allows for answering exact question that is being asked

The nurse cares for the patient with a diagnosis of chronic obstructive pulmonary disease (COPD) and bronchitis. The patient constantly rings the call bell and rattles the bed rails. Which of the following actions by the nurse is MOST appropriate? 1. Check the patient's pulse oximetry. 2. Send a nursing assistant to sit with the patient. 3. Sit the client in a chair next to the nurses' station. 4. Request that the patient's family order the TV for the patient.

Question: What is the most important action for this patient? Strategy: Remember to assess before implementing. Needed Info: COPD is a group of conditions associated with obstruction of air flow entering or leaving the lungs; indications include change in skin color, weakness and weight loss, dyspnea, use of accessory muscles to breathe, cough, abnormal ABGs. (1) CORRECT - decreased oxygenation will cause confusion; assess before implementing (2) assess before implementing (3) obtain pulse oximetry reading before determining appropriate intervention (4) assess before implementing.

The client is brought to the community mental health center by the spouse. One year ago the client's youngest child was killed in a car accident. The graduation of the child's high school class triggered feelings of sadness and guilt. As a result, the client has been having severe headaches, insomnia, and poor appetite. In planning care for this client, the nurse recognizes that the symptoms are MOST likely an example of which of the following? 1. Turning aggression inward. 2. Receiving inadequate support from her family. 3. Displacement of anger. 4. Delayed grief reaction.

Question: What is the most likely cause of these symptoms in this patient? Strategy: Think about each action. Needed Info: At the one-year time point, a client would often be moving toward the stage of grief called acceptance. However, the stages are not sequential and do not have a guaranteed timeframe. The client has faced a major anniversary, reminding client of the loss. (1) partial possible explanation (2) assumption (3) not accurate; no evidence of displacement (4) CORRECT - anniversaries of loss can trigger symptoms of grief

The patient diagnosed with multiple myeloma is admitted to the unit after developing pneumonia. When the nurse enters the patient's room wearing a mask, the patient says in an irritated tone of voice, "Why are you wearing that mask?" Which of the following responses by the nurse is BEST? 1. "The chest x-ray taken this morning indicates you have pneumonia." 2. "What have you been told about the x-rays that were taken this morning?" 3. "You have been placed on contact precautions due to your infection." 4. "I am trying to protect you from the germs in the hospital."

Question: What is the most therapeutic response? Strategy: Remember to assess before implementing. Needed Info: Multiple myeloma is a neoplastic disease that infiltrates bone and bone marrow, causes anemia, renal lesions, and high globulin levels in blood. Pneumonia is inflammatory process resulting in edema of lung tissue and extravasation of fluid into alveoli, causing hypoxia. (1) does not assess what client knows; physician responsible for telling patient the medical diagnosis (2) CORRECT - assessment; determines what client knows before responding; allows client to verbalize (3) pneumonia requires droplet precautions (4) pneumonia requires droplet precautions.

The nurse has just given a client a subcutaneous injection. What immediate follow-up action does the nurse take? 1. The nurse removes and discards gloves in the designated receptacle. 2. The nurse performs hand hygiene, to protect both the nurse and the client. 3. The nurse discards the uncapped needle with the syringe in the designated receptacle. 4. The nurse caps the needle before discarding the syringe in the designated receptacle.

Question: What is the next step after giving an injection? Strategy: Think about each answer choice. Needed Info: Capping a needle can lead to a needlestick injury. Gloves kept on until syringe disposal, as a safety precaution. Hand hygiene after all other steps. (2) hand hygiene after syringe and gloves disposal (3) CORRECT - the Centers for Disease Control and Prevention (CDC) recommends not capping the needle before disposal (1) discard gloves after syringe disposal (4) violates CDC recommendation

The school nurse observes the group of school-aged children playing on the playground. A child begins to cry and reports being stung by a bee. Which of the following actions should the nurse take FIRST? 1. Inject IM epinephrine. 2. Remove the stinger. 3. Apply a warm compress. 4. Wash with soap and water.

Question: What is the nurse's priority for a bee sting? Strategy: All answers are implementation; determine the outcome of each answer. Needed Info: Hymenopteran stings (bees, wasps, hornets, yellow jackets, fire ants) inject venom through a stinging apparatus; local reaction includes small red area, wheal, itching, and heat. Assess for systemic reaction and instruct client about how to avoid contact. (1) appropriate for hypersensitive individuals or if the client demonstrates a severe life-threatening response (2) CORRECT - remove stinger by scraping skin until stinger is removed; remove the stinger as quickly as possible to avoid injection of venom (3) apply cool compress after removing stinger and clean the bee sting (4) cleanse wound after removing stinger; apply paste made with baking soda or meat tenderizer.

The nurse cares for the 19-year-old client admitted to the emergency department after an auto accident. Even though the client denies drinking alcohol, the nurse notes that the client's breath smells of alcohol, speech is slurred, reflexes are diminished, and the client has difficulty recalling the events of the evening. The physician orders an MRI. Which of the following actions should the nurse take FIRST? 1. Inform the client that since he is of the age of consent, he can sign the consent form for the MRI. 2. Instruct the client to remove his watch. 3. Contact the client's parents to give consent for the MRI. 4. Restrict food and fluids for 4 hours.

Question: What is the nurse's priority in this situation? Strategy: Determine the outcome of each answer. Needed Info: In most states, young adults (18 years and older) can legally give consent; a client cannot give informed consent if s/he has been drinking or is premedicated. (1) cannot give consent since client has apparently been drinking and has altered mental status (2) appropriate action; however, health care provider must obtain consent prior to an MRI (3) CORRECT - MRI provides detailed pictures of body structures; procedure requires consent, and client unable to give informed consent due to probable drinking and altered mental status (4) no food or fluid restrictions for adults.

The nurse auscultates the abdomen of the pregnant woman at 38 weeks gestation to determine fetal heart rate. If the fetal heartbeat is located in the right lower quadrant, which of the following is MOST likely the presenting part? 1. Shoulder. 2. Head. 3. Feet. 4. Buttocks.

Question: What is the position of the fetus? Strategy: Map out the abdomen and picture the position of the fetus. Needed Info: Lower quadrant heartbeat indicates vertex or head/cephalic presentation; fetal heartbeat is best heard over the fetus's back. (1) only 1% of births; uncommon (2) CORRECT - right lower quadrant heartbeat indicates occiput of fetal head is on the right side of the mother's body and facing the front (anterior) of the mother's body; (ROA) (3) breech; would hear FHT in upper quadrant (4) breech; would hear FHT in upper quadrant.

The home care nurse cares for the child diagnosed with hemophilia A recovering from the acute phase of spontaneous bleeding into the joints. It is MOST important for the nurse to give the parents which of the following instructions? 1. Administer ibuprofen for pain. 2. Apply ice to the joint. 3. Decrease the risk of injury. 4. Encourage active range-of-motion exercises.

Question: What is the priority nursing action after the acute phase of spontaneous bleeding? Strategy: "MOST important" indicates a priority. Determine the outcome of each answer. Needed Info: Hemophilia is a bleeding disorder caused by deficiency of factor VIII (most common) or factor IX; symptoms include easy bruising, joint pain with bleeding, prolonged internal or external bleeding. (1) use ibuprofen (Advil) with caution because it inhibits platelet aggregation; offer acetaminophen (Tylenol) at home to control pain (2) appropriate action during bleeding episode; rest, ice, compression, and elevation to prevent excessive blood loss; administer factor VIII concentrate (3) important to prevent bleeding episodes; encourage age-appropriate exercises that strengthen muscles and joints (4) CORRECT - active range-of-motion encouraged after bleeding episode to prevent crippling effects of bleeding; active range-of-motion allows the child to control the amount of exercise according to the pain level; do not perform passive range-of-motion

The nurse cares for the client after an above-the-knee amputation. The client has a closed rigid cast dressing in place. Several days after surgery, the nurse enters the client's room and finds that the cast has come off. Which of the following actions does the nurse take FIRST? 1. Wrap the residual limb with an elastic compression bandage. 2. Observe the residual limb for swelling. 3. Contact the physician. 4. Ask the client how the cast came off.

Question: What is the priority nursing action if the rigid cast dressing comes off an above-the-knee amputation? Strategy: Determine the outcome of each answer. Needed Info: Observe for signs of oozing; elevate residual limb for 24 hours; turn client prone to prevent contractures; client ambulates early with rigid cast dressing because it functions as a socket for fitting of a prosthetic immediately post-op. (1) CORRECT - will prevent edema from developing; edema will delay the rehabilitation process (2) important to prevent edema; if residual limb not wrapped immediately, significant swelling will occur (3) notify surgeon so that a new cast dressing can be applied; wrap residual limb before notifying the physician (4) more important to prevent edema from developing.

The nurse cares for clients in the labor and delivery unit. The nurse notes that a client's membranes have ruptured and the amniotic fluid is meconium-stained. The nurse determines that there is no prolapsed cord. Which of the following actions does the nurse take NEXT? 1. Contact the health care provider. 2. Assess fetal heart tones. 3. Start an intravenous line. 4. Obtain the client's pulse and blood pressure.

Question: What is the priority nursing action when a client passes meconium-stained amniotic fluid? Strategy: Determine whether it is appropriate to assess or implement. Needed Info: Amniotic fluid is straw-colored and pale; meconium-stained fluid (greenish-brown) indicates fetus has probably experienced recent hypoxic episode; meconium-stained fluid may be normal finding in breech presentation. (1) assess for nonreassuring fetal heart tone patterns before contacting health care provider (2) CORRECT - meconium-stained amniotic fluid may be an ominous sign; assess for the nonreassuring fetal heart tone patterns of fetal bradycardia, fetal tachycardia, irregular FHR, late, severe, variable, and prolonged deceleration patterns; if fetal distress, turn client to left side, give supplemental oxygen, start IV (3) assess fetus first (4) no reason to assess mother; meconium-stained fluid might indicate fetal distress.

The nurse cares for the 6-year-old child placed in Russell's traction due to a fracture of the left tibia. After repositioning the child, it is MOST important for the nurse to take which of the following actions? 1. Administer pain medication. 2. Offer the child a book. 3. Check the position of the left hip. 4. Assess the pin site for infection.

Question: What is the priority nursing action when caring for a child in Russell's traction? Strategy: "MOST important" indicates priority. Answers are a mix of assessment and implementation. Needed Info: Skin traction is used on the lower leg and a padded sling is placed under the knee; "pulls" contracted muscles; elevate foot of bed with shock blocks to provide countertraction; check popliteal pulse; do not turn from waist down; lift patient, not leg, to provide assistance. (1) analgesics and muscle relaxants are administered due to discomfort caused by traction pull; offer at regular intervals (2) important to offer children an opportunity for play; explain to child what is happening (3) CORRECT - hip is flexed at a prescribed angle to prevent fracture malalignment; after moving child, assess that the prescribed amount of hip flexion is maintained (4) Russell's traction is a form of skin traction; no pins are used.

The staff nurse observes the newly licensed LPN/LVN prepare to administer iron dextran IM to a patient with iron deficiency anemia. It is MOST important for the staff nurse to give which of the following instructions to the LPN/LVN? 1. "Massage the injection site for one minute after the injection of the medicine." 2. "Tap out the air bubble prior to administering the medication." 3. "Release the skin prior to withdrawing the needle." 4. "Change the needle after drawing up the medication."

Question: What is the priority when administering iron dextran? Strategy: Determine the outcome of each answer. Needed Info: Iron dextran (DexFerrum) is a hematinic used to treat iron deficiency anemia; administer using Z-track method; select large, deep muscle; pull skin and subcutaneous tissue 1.5 inches to the side; release skin after withdrawing needle. (1) causes medication to leak into subcutaneous tissue, staining skin (2) draw up 0.2 mL of air to create an airlock (3) release skin after withdrawing the needle. (4) CORRECT - ensures that no solution remains on outside of needle

The home care nurse visits the client diagnosed with non-Hodgkin's lymphoma who is receiving chemotherapy. After the second round of chemotherapy, the client reports a sore mouth and loss of taste. Which of the following actions does the nurse take FIRST? 1. Examine the client's mouth. 2. Instruct the client to use a saline rinse. 3. Obtain a diet history from the client. 4. Instruct the client to avoid spicy foods.

Question: What is the priority when client is complaining of a sore mouth? Strategy: Assess before implementing. Needed Info: Chemotherapy causes stomatitis; assess frequently; good oral hygiene; use soft-bristled toothbrush; avoid dental floss, water pressure gum cleaners, and mouthwashes containing alcohol or glycerin. (1) CORRECT - assess every 4 hours; instruct client about good oral hygiene (2) implementation; important to rinse mouth with water or saline rinse every 12 hours (3) assessment; encourage client to avoid spicy foods or hard foods (4) implementation; correct action, but assess first.

The home care nurse visits the client who has been receiving lithium carbonate for 3 weeks. The client reports to the nurse experiences of blurred vision and intense dizziness. Which of the following actions does the nurse take FIRST? 1. Encourage the client to increase fluid intake. 2. Notify the physician. 3. Instruct the client to breathe into a paper bag. 4. Teach the client about relaxation techniques.

Question: What is the priority when the client is complaining of adverse effects of lithium? Strategy: Determine the outcome of each answer. Needed Info: Lithium used to treat bipolar disorder; has a narrow therapeutic range (1 - 1.5 mEq/L); side effects include dizziness, headache, impaired vision, fine hand tremors, and reversible leukocytosis; nursing considerations include monitor blood levels frequently, encourage 2,500 - 3,000 mL fluids daily. (1) intake should be 2,500 - 3,000 mL daily; more important to contact physician (2) CORRECT - important to confirm lithium level; levels over 2.0 mEq/L may cause lithium intoxication, agitation, ataxia, blurred vision, confusion, tinnitus, vertigo, hyperreflexia, and myoclonic twitching (3) appropriate action if client hyperventilating (4) not priority; symptoms indicate adverse side effects; need physician management.

The home care nurse is visiting the 82-year-old client living with the client's adult child. The client appears malnourished and has multiple bruises on the body. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Place a home health aide with the patient to document incidents of abuse. 2. Discuss the nurse's observation with the client's children. 3. Report the situation to the nursing supervisor. 4. Request that another nurse visit the patient to assess the situation.

Question: What is the priority when the nurse suspects elder abuse? Strategy: Determine the outcome of each answer. Needed Info: Indications of elder abuse include battering, fractures, bruises, overmedicated or undermedicated, poor nutritional status, dehydration; nursing care includes providing for the client's safety, providing for physical needs, and reporting to appropriate agency. (1) must report suspected cases (2) report to the nursing supervisor (3) CORRECT - required by state law (4) no reason to involve another nurse.

The male patient is admitted to the hospital for evaluation of hematuria. An intravenous pyelogram (IVP) is ordered. The patient asks the nurse to explain what will happen to him during the IVP. Which of the following explanations, if made by the nurse, is MOST accurate? 1. "An intravenous line will be inserted, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder." 2. "A scope will be inserted into your penis so that the inside of your bladder can be visualized." 3. "A catheter will be inserted into your penis, dye injected into it, and then x-rays will be taken of your bladder and ureters." 4. "A small incision is made in the kidney, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder."

Question: What is the procedure for an IVP? Strategy: Form a mental image of the procedure. Needed Info: Hematuria: blood in the urine. IVP: radiographic exam of the kidney, ureter, bladder. Prep: check for sensitivity to contrast medium, iodine, shellfish; prep bowel (laxatives, enemas); may be NPO or allowed fluids. Post-test: force fluids. (1) CORRECT - describes procedure (2) cystoscopy; prep: NPO, bowel prep (laxatives, enemas), general or local anesthesia used; post-test: check for bleeding and infection (3) cystourethrogram; prep: none; post-test: check for infection (4) inaccurate.

The nurse cares for the 1-year-old patient who is admitted to the hospital with a fractured femur and is placed in Bryant's traction. The nurse recognizes that the child should be maintained in which of the following positions? 1. Buttocks slightly elevated off the bed. 2. Buttocks flat on the bed. 3. Knees slightly flexed. 4. Hips extended.

Question: What is the proper position for a child in Bryant's traction? Strategy: Picture the traction apparatus. Remember the concepts for effective traction. Needed Info: Bryant's traction: type of running traction used to reduce a fractured femur in a child; adhesive strips are applied to both legs and secured with elastic bandages wrapped from foot to groin; both legs are suspended by weights and pulleys. (1) CORRECT - child's weight provides countertraction (2) no countertraction (3) not possible; must be extended (4) must be flexed at 90 degree angle.

The nurse conducts the admission physical examination for the new clinic patient. Which of the following sequences represents the order in which the nurse performs the assessment of the patient's abdomen? 1. Observe, auscultate, percuss, palpate. 2. Auscultate, observe, percuss, palpate. 3. Palpate, percuss, auscultate, observe. 4. Percuss, palpate, auscultate, observe.

Question: What is the proper sequence of steps to take to assess a patient's abdomen? Strategy: Remember to look and listen before you feel. Needed Info: Percussion and palpation alter the mobility of the bowel and heighten bowel sounds. Use the diaphragm of a stethoscope because sounds are high pitched. Percuss, checking for tympany (hollow sound) and dullness (high-pitched sound). To palpate, depress abdominal wall 1 cm using the pads of your fingers. (1) CORRECT (2) inaccurate; look first (3) inaccurate; look first (4) inaccurate; look first.

The nurse cares for the postoperative client who had an abdominal resection for colon cancer, including the insertion of a Jackson-Pratt drain. The nurse recognizes that which of the following is the PRIMARY purpose of the drain? 1. To irrigate the incision with a saline solution. 2. To prevent bacterial infection of the incision. 3. To prevent accumulation of drainage in the wound. 4. To measure the amount of fluid lost after surgery.

Question: What is the purpose of a Jackson-Pratt drain? Strategy: Think about each answer. Is it the primary purpose of a drain? Needed Info: Jackson-Pratt drain: tissue drain used postoperatively to prevent accumulation of fluid in wound. (1) not accurate (2) not best answer; prophylactic antibiotics and sterile technique used (3) CORRECT - portable wound suction; speeds wound healing; document color, odor, amount, consistency of drainage (4) not primary purpose.

The nurse cares for the patient who returns to the nursing unit in stable condition after having a myelogram using a water-soluble dye. An intravenous infusion is in progress. The nurse recognizes that which of the following is the PRIMARY purpose of the intravenous fluid? 1. To replace blood lost during the procedure. 2. To enhance excretion of the dye. 3. To restore cerebrospinal fluid levels. 4. To increase blood flow to the brain.

Question: What is the purpose of administering IV fluids after a myelogram using a water-soluble dye? Strategy: Think about each answer choice. Does it make sense? Needed Info: In a myelogram, contrast dye is injected into the spinal column. This causes the tissue under study to be visible. The spinal cord, subarachnoid space, and other surrounding structures can be visualized more clearly than in standard x-rays. After the procedure is completed, an intravenous infusion enhances renal excretion of the dye. (1) no blood loss (2) CORRECT - dilutes dye and enhances excretion by kidneys (3) none lost (4) not purpose.

The unconscious patient is admitted to the hospital for treatment of an injury sustained in an automobile accident. The patient has a cuffed tracheostomy tube and mechanical ventilation in progress. The nurse recalls that the purpose of the cuff on a tracheostomy tube is to accomplish which of the following? 1. Prevent displacement of the tracheostomy tube. 2. Maintain the alignment of the trachea with the lungs. 3. Separate the upper and lower airways. 4. Maintain the patency of the trachea.

Question: What is the purpose of the cuff on a trach tube? Strategy: Form a mental image of a tracheostomy tube with a cuff inserted into a trachea. Needed Info: Cuff: plastic balloon that encircles the tracheal tube to form a seal between the outer cannula and the trachea. (1) action of twill tapes tied at side of neck; need 2 people to change, or leave in place till new ties on; allow for 2 finger spaces between tie and neck (2) does not change position of trachea (3) CORRECT - seals off lumen; prevents aspiration (4) purpose of trach tube, not cuff.

The patient is admitted to the hospital after sustaining a severe head injury in an automobile accident. When the patient dies, the nurse observes the patient's spouse comforting other family members. Which of the following interpretations of the spouse's behavior is MOST justifiable? 1. The spouse has already moved through the stages of the grieving process. 2. The spouse is repressing anger related to the patient's death. 3. The spouse is experiencing shock and disbelief related to the patient's death. 4. The spouse is demonstrating resolution of the patient's death.

Question: What is the reason for the spouse's behavior? Strategy: "MOST justifiable" indicates that there may be more than one correct response. Think about each answer choice. Is it true? Needed Info: Stages of grief, popularly known as DABDA: 1) denial, 2) anger, 3) bargaining, 4) depression, 5) acceptance. The stages can be experienced in any order; they are not sequential. Acute period: 4 - 8 weeks, usual minimum time for resolution: 1 year. (1) usually takes a minimum of 1 year (2) anger is a possible stage, but the spouse's behavior does not support this interpretation (3) CORRECT - denial is the inability to comprehend reality of situation (4) too soon.

The nurse conducts the family therapy session with the patient being treated for depression. During the therapy session, the patient verbally expresses love toward the mother, but has an angry facial expression and pounds the table with a fist. The nurse understands that the discrepancy between the patient's body language and spoken language is BEST characterized as which of the following? 1. Ambivalence. 2. Scapegoating. 3. Double-bind communication. 4. Loose associations.

Question: What is this behavior called? Strategy: "Best categorized" indicates that there may be more than one correct response. Needed Info: Double-bind communication is characterized by simultaneous communication of two mutually conflicting verbal and nonverbal messages. (1) mixed feelings; confusing emotional experience (2) others blamed for problems (3) CORRECT - emotions communicated verbally are opposite of emotions communicated physically (4) disordered thought processes.

The patient admitted for treatment of bronchitis reports an allergy to sulfa drugs and to penicillin to the nurse. The nurse recognizes that which of the following medications is MOST appropriate for this patient? 1. Co-trimoxazole. 2. Sulfisoxazole. 3. Cephalexin. 4. Ciprofloxacin.

Question: What medication can be given to a patient with a sulfa and penicillin allergy? Strategy: Think about each answer choice. Needed Info: Patients with a sensitivity to penicillin should take cephalosporin medications cautiously due to a cross-allergy. Patients with an allergy to sulfa drugs should not take any sulfa-containing medications. (1) co-trimoxazole (Septra): sulfa medication; used for treatment of traveler's diarrhea, Pneumocystis jiroveci; used prophylactically for women with recurrent UTI; side effects: agranulocytosis, anemia, N + V, diarrhea, toxic nephrosis, rash, photosensitivity (2) sulfisoxazole (Gantrisin): sulfa medication; side effects: aplastic anemia, toxic nephrosis; force fluids (3,000 - 4,000/day) to prevent crystalluria; keep urine alkaline (3) cephalexin (Keflex): cephalosporin medication; side effects: diarrhea, rash, urticaria; take with food/milk (4) CORRECT - ciprofloxacin (Cipro): quinolone antibiotic; side effects: dizziness, seizures, HA, abdominal pain, rash, photosensitivity; give PO 2 hours after meals or 2 hours before or after antacids or medications continuing iron; avoid caffeine; force fluids 3,000 mL/24 hours

The nurse cares for the client with schizophrenia. The nurse recognizes that the patient has developed parkinsonian side effects of chlorpromazine. The nurse expects which of the following medications will be prescribed for the patient? 1. Diazepam. 2. Haloperidol. 3. Amitriptyline. 4. Benztropine.

Question: What medication is given to treat the parkinsonian side effects of chlorpromazine? Strategy: Think about the action of each drug. Needed Info: benztropine: anticholinergic, antiparkinsonian agent; side effects include drowsiness, blurred vision, nausea, constipation, urinary retention, dry mouth, agitation; nursing considerations include monitor intake and output, monitor for muscle weakness or inability to move certain muscle groups, monitor for central nervous system depression or stimulation, provide sugarless gum or lozenges for dry mouth. (1) diazepam: antianxiety medication; side effects: drowsiness, ataxia, cardiovascular collapse (2) haloperidol: antipsychotic medication; would exacerbate symptoms; side effects: extrapyramidal reactions, blurred vision, dry mouth, tardive dyskinesia (3) amitriptyline: antidepressant medication; side effects: drowsiness, dizziness, orthostatic hypotension, blurred vision, dry mouth, urinary retention, photosensitivity (4) CORRECT- benztropine: antiparkinsonian medication; manages extrapyramidal symptoms; side effects: sedation, dry mouth, urinary retention

The nurse cares for the client admitted to the hospital reporting fatigue and weight loss. Physical examination reveals pallor and multiple bruises on the arms and legs. The results of the client's test reveal acute lymphocytic leukemia and thrombocytopenia. Which of the following nursing diagnoses MOST accurately reflects the client's condition? 1. Potential for injury. 2. Self-care deficit. 3. Potential for self-harm. 4. Alteration in comfort.

Question: What nursing diagnosis is seen with acute lymphocytic leukemia and thrombocytopenia? Strategy: Think about each answer choice. Needed Info: Thrombocytopenia: decreased platelet count increases the client's risk for injury, normal count: 150,000 - 350,000 per mm3. Leukemia: group of malignant disorders involving overproduction of immature leukocytes in bone marrow; this shuts down normal bone marrow production of erythrocytes, platelets, normal leukocytes; causes anemia, leukopenia, and thrombocytopenia leading to infection and hemorrhage. Symptoms: pallor of nail beds and conjunctiva, petechiae (small hemorrhagic spots on skin), tachycardia, dyspnea, weight loss, fatigue. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegetables, small frequent meals, oxygen, good skin care. (1) CORRECT - low platelet count increases risk of bleeding from even minor injuries; safety measures: shave with an electric razor, use soft toothbrush, avoid subcutaneous or IM medications and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage (2) may feel weak; does not most address condition (3) implies risk for purposeful self-injury; not given any information, assumption (4) client is not comfortable, and comfort measures would address problem; does not most address condition.

The nurse cares for the patient in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. The nurse places the patient in which of the following positions? 1. Lithotomy. 2. Side-lying. 3. Semi-Fowler's. 4. Trendelenburg.

Question: What position should you place a patient in if there is a prolapse of the umbilical cord? Strategy: Picture the situation as described. Needed Info: Prolapsed cord: obstetrical emergency in which the umbilical cord is below the presenting part of the fetus. Compression of the cord causes fetal hypoxia resulting in CNS damage. (1) lying on back with thighs flexed on abdomen, legs separated and knees bent with feet in stirrups; used for examination of vagina or rectum (2) used to remove weight from vena cava to prevent maternal hypotension; does not help with prolapsed cord (3) aggravates prolapsed cord pressure. (4) CORRECT - supine on incline with head lower than hips and legs; or put finger against presenting part and shift weight off cord

The nurse cares for the patient who is being discharged after having a transurethral prostatectomy (TURP) for benign prostatic hypertrophy (BPH). The nurse's discharge teaching plan reinforces adherence to which of the following measures? 1. Avoiding vigorous exercise for 3 weeks. 2. Avoiding cold foods for 1 week. 3. Avoiding hot baths for 1 month. 4. Avoiding high-residue foods for 2 weeks.

Question: What should a patient be told to do after discharge for a TURP? Strategy: Think about the outcome of each answer choice. Needed Info: Hemorrhage most common complication after a TURP. During first 3 weeks post-op avoid: lifting more than 8 lbs, mowing lawn, riding in car more than 25 min, climbing stairs quickly, sexual intercourse, engaging in sports. (1) CORRECT - due to danger of bleeding (2) no dietary restrictions (3) no need to avoid; comforting (4) no dietary restrictions.

The nurse develops a care plan for the patient with dementia. The nurse recognizes that it is MOST important to include which of the following measures in the plan? 1. Leave the television on in patient's room all day. 2. Frequently orient patient to surroundings. 3. Provide patient with newspapers and magazines. 4. Assign a staff member to stay with patient while patient is awake.

Question: What should be done for a patient with dementia? Remember to establish priorities. It is necessary to meet physical needs and safety needs before addressing psychosocial needs. Strategy: Determine the outcome of each answer choice. Needed Info: Dementia: progressive loss of cognitive function. Decline in memory, learning, attention, judgment, orientation and language skills. Most common type is Alzheimer's disease. Affects 5 million people in US. Usually lasts between 7 and 15 years, before death. (1) provides sensory stimuli but no orientation (2) CORRECT - provides for safety needs (3) does not address safety needs or orientation (4) provides company but not orientation.

The patient is admitted to the hospital complaining of right-sided weakness and difficulty speaking. The patient reports a fall while at home. It is MOST important for the nurse's initial assessment of the patient to include evaluation for which of the following? 1. Nutritional deficiencies. 2. Ambulation problems. 3. Hearing difficulties. 4. Head injury.

Question: What should the nurse assess for in this situation? Strategy: Establish priorities. Remember your ABCs. Needed Info: Cerebrovascular accident (stroke): caused by thrombosis, embolism, ischemia, or hemorrhage. S/S: loss of movement, thought, memory, speech, or sensation. Aphasia: inability to use or comprehend language, due to damage in cerebral hemisphere. Dysarthria: problem with rate, rhythm, or articulation of speech due to loss of motor function of muscles for speech. Expressive aphasia: difficulty speaking. Nursing responsibilities: repeat directions, break down tasks into components, face patient, and speak clearly and slowly. Give patient time to respond. Assist with facial muscle exercises. (1) not highest priority (2) not highest priority; on bed rest during first 48 - 72 hours (3) not highest priority (4) CORRECT - safety most important

The home care nurse performs an assessment of the elderly client diagnosed with type 2 diabetes and hypertension. The client is following an 1,800-calorie ADA diet and takes furosemide 40 mg PO daily. The client's adult child tells the nurse that the parent has been complaining of dizziness. Which of the following actions does the nurse take FIRST? 1. Instruct the client to change positions slowly. 2. Advise the client to drink more fluids. 3. Obtain the client's blood pressure when lying or sitting, and then when standing. 4. Check the client's blood sugar.

Question: What should the nurse do if the client complains of dizziness? Strategy: "FIRST" indicates priority. Assess before implementing. Needed Info: Hypertension is persistent elevation of systolic blood pressure of 140 or higher mm Hg and diastolic blood pressure of 90 or higher mm Hg; furosemide (Lasix) is a loop diuretic that causes hypotension, hypokalemia, hyperglycemia, GI upset, and weakness. (1) appropriate action if client has postural hypotension due to diuretic therapy; assess before implementing (2) appropriate action if client has fluid volume deficit; assess before implementing (3) CORRECT - dizziness may indicate hypotension; elderly may be more sensitive to fluid loss due to diuretic therapy; obtain blood pressure in lying/sitting and standing positions to determine if client has postural hypotension (4) dizziness is symptom of hypoglycemia; after assessing for postural hypotension, a check of whether the dizziness is related to low blood sugar readings is warranted.

The nurse cares for the patient admitted to the intensive care unit (ICU) with a diagnosis of adult respiratory distress syndrome (ARDS) after a drug overdose. Positive end-expiratory pressure (PEEP) is initiated. Because the patient fights the ventilator, the physician orders vecuronium bromide. After administering the medication, it is MOST important for the nurse to take which of the following actions? 1. Administer analgesia as ordered. 2. Explain all procedures to the patient. 3. Maintain airborne precautions. 4. Administer complete eye care.

Question: What should the nurse do to prevent complications of vecuronium bromide? Strategy: Think Maslow. Needed Info: Adult respiratory distress syndrome (ARDS) is characterized by dyspnea and tachypnea followed by progressive hypoxemia despite oxygen therapy; positive end-expiratory pressure (PEEP): positive pressure is exerted during the expiratory phase of ventilation; vecuronium bromide (Norcuron) is a neuromuscular blocking agent used to provide skeletal relaxation during mechanical ventilation. (1) psychosocial; important because patient unable to communicate pain or discomfort; caring for eyes more important (2) psychosocial; client will be anxious due to mechanical ventilation; even though there is temporary paralysis due to drug, client is still able to hear; explain all care to client (3) physical; universal precautions used; no need for airborne (4) CORRECT - physical; client unable to blink due to vecuronium; eye care will prevent corneal abrasion

The patient is scheduled for a myelogram. The patient asks the nurse if there will be any discomfort during the test. Which of the following responses, if made by the nurse, is MOST accurate? 1. "No, this procedure will not hurt at all." 2. "Yes, this is one of the most painful procedures that you can have." 3. "This is an uncomfortable procedure, but you will receive general anesthesia so you will not be aware of the pain." 4. "This is an uncomfortable procedure, but you will be given medication before the test to lessen the discomfort."

Question: What should the nurse say about pain during a myelogram? Strategy: "MOST accurate" indicates that there may be more than one correct response. Needed Info: Myelogram: insertion of contrast medium into the subarachnoid space of spine via a lumbar puncture in order to visualize the vertebral column. Pretest: encourage fluids, check allergies. Antipsychotics, antidepressants, and anticoagulants may be withheld for several days. Diazepam (Valium) can be given during pre-op. Post-test: position the patient in a supine position with the head slightly elevated for several hours. (1) some discomfort involved (2) inaccurate and nontherapeutic (3) local anesthesia given to decrease discomfort. (4) CORRECT - usually given sedative

The nurse teaches the parent of the young child who has recently been diagnosed as having epilepsy about the condition. Which of the following statements, if made by the parent, indicates that further teaching is necessary? 1. "Epilepsy does not affect my child's mental capacities." 2. "Grand mal seizures do not cause brain damage." 3. "Epilepsy is a form of mental illness." 4. "Epilepsy can be controlled with medication."

Question: Which statement is NOT TRUE about epilepsy? Strategy: Be careful! This is a NEGATIVE question. Needed Info: Epilepsy: seizure disorder, characterized by abnormal, recurring, excessive and self-terminating electrical disturbances; Dx made after 2 or more seizures; strong genetic component (1) true statement (2) true statement (3) CORRECT - electrical disturbance in brain; can be controlled by medication; not a form of mental illness (4) true statement.

The nurse cares for the patient being treated for a myocardial infarction. The patient is receiving heparin 5,000 units subcutaneously every 12 hours. The nurse should assess the patient for which of the following? 1. Pallor or cyanosis. 2. Areas of ecchymosis and petechiae. 3. Varicose veins. 4. Edema and weight gain.

Question: What should you assess in a patient receiving heparin? Strategy: Think about the cause of each symptom and how it relates to heparin. Needed Info: Heparin: anticoagulant that inactivates thrombin and prevents the conversion of fibrinogen to fibrin. Side effects: hemorrhage, thrombocytopenia, hypersensitivity. Nursing responsibilities: check partial thromboplastin time (PTT) to monitor effect: 1.5 - 2 times control. Give subcutaneous into abdomen. Leave needle in place for 10 sec. Do not massage. Rotate sites. Never "piggyback" with other meds. Protamine sulfate is antagonist. Terminology: ecchymosis = bruise; petechiae = pinpoint hemorrhages; melena = black, tarry stool; epistaxis = nosebleed; hematuria = blood in urine. (1) unoxygenated blood in circulation (2) CORRECT - ecchymosis and petechiae can indicate hemorrhage; contact provider (3) incompetent valves appear as tortuous skin veins (4) not seen.

The nurse cares for the patient being treated for injuries sustained in a hunting accident. The patient has a tracheostomy tube in place. The nurse enters the patient's room and discovers that the tracheostomy tube has become dislodged and assesses that the patient is having difficulty breathing through the stoma. Which of the following actions does the nurse take FIRST? 1. Performs mouth to stoma breathing. 2. Hyperextends the patient's neck. 3. Places the patient in high-Fowler's position. 4. Administers oxygen.

Question: What should you do FIRST? Strategy: Remember your ABCs: airway, breathing, circulation. Needed Info: Tube extubation may occur during change of ties or coughing. (1) needs airway first (2) CORRECT - provides patent airway; call for help; place in semi-Fowler's (30 - 45 degrees), then check breath sounds; use hemostat to open airway (3) high-Fowler's position (90 degrees) is too upright; needs airway first (4) needs airway first.

The child is brought to the emergency department by the parents, who state the child fell off a bicycle. Upon examination, the nurse notes several bruises, lacerations, and burns in various stages of healing on the child's body, and the child is hypervigilant to touch. The nurse suspects child abuse. Which of the following statements MOST accurately reflects the nurse's responsibility in cases of suspected child abuse? 1. The nurse should not report child abuse without actual proof. 2. The nurse should report a case of suspected child abuse to proper authorities. 3. The nurse should not report suspected child abuse without discussing it with the child's parents first. 4. The nurse should confirm suspicions of child abuse with at least two other staff members before reporting it.

Question: What should you do if you suspect child abuse? Strategy: "Most accurate" indicates that there may be more than one correct response. Think about the outcome of each answer choice. Needed Info: Each state has laws that specify the individuals who are "mandated reporters." Nurses are in this category. The laws also direct the nurse to the relevant place to make a report. Ongoing education by hospitals makes this responsibility clear. (1) must report suspected cases (2) CORRECT - state law (3) inaccurate (4) inaccurate.

In the dining room of the mental health center, the nurse observes the formerly homeless and malnourished patient diagnosed with chronic schizophrenia putting food into a plastic bag. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Reprimand the patient immediately. 2. Ask the patient why the food is being put into a plastic bag. 3. Inform the patient that snacks will be available later. 4. Distract the patient and redirect to another activity.

Question: What should you do in this situation? Strategy: "MOST appropriate" indicates that there may be more than one correct response. Determine the outcome of each answer choice. Needed Info: The behavior of the patient is consistent with a distorted view of reality. Concern about food availability leads to storing a personal cache of food. Way of coping with fear. (1) judgmental (2) nontherapeutic; "why" questions make patient defensive, feel threatened (3) CORRECT - reality orientation; talk with patient in nonthreatening way about the patient's needs (4) misses opportunity to reality test and reorient.

The nurse cares for the patient with moderate hearing loss. The nurse teaches the patient's family to use which of the following approaches when speaking to the patient? 1. Raise your voice until the patient is able to hear you. 2. Face the patient and speak quickly using a high voice. 3. Face the patient and speak slowly using a slightly lowered voice. 4. Use facial expressions and speak as you would normally.

Question: What should you do to communicate with a person with a moderate hearing loss? Strategy: Think about the outcome of each answer choice. Needed Info: Presbycusis: age-related hearing loss due to inner ear changes; decreased ability to hear high sounds. (1) would result in high tones patient unable to hear (2) speech should be done slowly, not quickly, and usually unable to hear high tones (3) CORRECT - also decrease background noise; speak at a slow pace, use nonverbal cues (4) nonverbal cues help, but need low tones.

The nurse cares for the child newly diagnosed with epilepsy. Which of the following items does the nurse have available at the bedside? 1. Suction machine and oxygen setup. 2. Catheterization set. 3. Intermittent positive pressure breathing machine (IPPB). 4. Restraints

Question: What should you have at the bedside for a child with a history of seizures? Strategy: Remember your ABCs. Needed Info: Epilepsy: seizure disorder characterized by abnormal, recurring, excessive, and self-terminating electrical disturbances; Dx made after 2 or more seizures; strong genetic component. (1) CORRECT - remove secretions, provide patent airway, provide oxygenation (2) can be incontinent; not done (3) inflates lungs through positive pressure; not necessary (4) muscle contractions could cause fracture; not done.

The patient is admitted to the hospital for evaluation of a gangrenous right foot. A right below-the-knee amputation is scheduled. The patient asks, "Why can't they just amputate my foot instead of my leg?" Which of the following statements, if made by the nurse, is MOST accurate? 1. "It is necessary to have good circulation in your leg for healing to occur." 2. "It will be easier to fit you with a prosthesis." 3. "This is the best method to control the infection." 4. "This will prevent further circulatory problems in your leg."

Question: What should you say to the patient? Strategy: "MOST accurate" indicates that there may be more than one correct response. Needed Info: Most amputations of lower extremities are a result of peripheral vascular disease resulting from diabetes or cardiac disease. (1) CORRECT - amputation done at most distal point that will heal; the most critical factor is circulation in remainder of extremity (2) not accurate (3) not accurate (4) underlying disease will continue.

The nurse cares for the patient receiving morphine sulfate by use of a patient-controlled analgesia (PCA) pump. When making evening rounds, the nurse finds the patient sleeping and the spouse at the bedside. The nurse observes that each time the patient grimaces, the spouse presses the button on the PCA machine. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Encourage the spouse to continue this practice. 2. Explain to the spouse that this should be done only once every hour while the patient is sleeping. 3. Explain the purpose of the patient-controlled analgesia to the spouse. 4. Instruct spouse to awaken the patient when patient grimaces and ask if patient is having pain.

Question: What should you say to the spouse? Strategy: "Most appropriate" indicates that there may be more than one correct response. Think about why the nurse would make each statement. Needed Info: PCA allows patients to control own administration of IV analgesics. (1) patient should push button (2) inappropriate; patient should push button (3) CORRECT - include family in teaching; spouse's behavior could result in morphine overdose (4) inappropriate.

The patient is being treated for heart failure (HF) and is placed on a 2 gram sodium diet. The nurse performs dietary teaching. Which of the following statements, if made by the patient, indicates that further teaching is necessary? 1. "Some medications and seasonings such as MSG contain sodium." 2. "Milk, fish, and celery are foods naturally high in sodium." 3. "I need to avoid soups and seasoned rice when eating at a restaurant." 4. "I can eat any food I like as long as I don't add additional salt to my food."

Question: What statement is WRONG about a low-salt diet? Strategy: Be careful! This is a negative question. Three statements are correct, one is wrong. Needed Info: Foods to avoid on a low-sodium diet: cured or smoked meat or fish, Kosher meats, peanut butter, processed cheese, salted crackers, seasoning mixes, tomato juice, canned foods. (1) true statement; read labels (2) true statement; intake restricted (3) true statement; plain foods better; soups and seasoned rice may contain significant amount of sodium (4) CORRECT - incorrect info; sodium can be found in many foods; it is not just in table salt itself; 2 g mild sodium restriction

The patient suffers a cerebrovascular accident (stroke) in the left temporal lobe and is admitted to the hospital. When performing an assessment of the patient, the nurse expects some patient impairment in which of the following? 1. Control of the left arm. 2. Glucose metabolism. 3. Corneal reflex in both eyes. 4. Speech.

Question: What symptom would you expect in patient with a CVA? What does the temporal lobe control? Strategy: Think about what functions the temporal lobe controls. Needed Info: CVA or stroke: disruption in blood supply to brain. Causes: thrombus, embolus, or hemorrhage. Risk factors: hypertension, diabetes, heart disease, smoking, substance abuse, obesity, stress, lack of exercise, high cholesterol levels. Usually seen after age 65. S/S: aphasia (impairment in ability to communicate through speech), alexia (difficulty reading), agraphia (impairment in ability to write), HA, syncope, motor or sensory disturbances (paresthesia, paralysis). (1) unaffected; nerve fibers cross in spinal canal, result in disabilities on opposite (contralateral) side (2) symptom of diabetes (3) function of fifth cranial nerve (trigeminal); caused by brain stem disorders (4) CORRECT - left hemisphere controls speech, math skills, analytical thinking

The nurse plans discharge teaching for the client with coronary artery disease (CAD). The client will continue taking warfarin sodium at home. Which of the following instructions does the nurse include in the teaching? 1. Have complete blood count every 1 - 4 weeks. 2. Test stools daily for blood. 3. Wear a MedicAlert bracelet. 4. Stop taking the warfarin sodium before going to the dentist.

Question: What teaching should be done with a patient who is going to be discharged on warfarin? Strategy: Think about the outcome of each answer choice. Needed Info: Coronary artery disease (CAD): narrowing of coronary arteries due to atherosclerosis. Risk factors: hereditary, smoking, age, gender (men higher risk), race (white higher risk), hypertension, elevated serum cholesterol, diabetes mellitus. warfarin sodium (Coumadin): smoking increases required dose; flu vaccine enhances effect for 1 month; fever, prolonged hot weather enhances effect; high-fat diet decreases effect of medication. (1) should have PT check, not complete blood count, every 1 - 4 weeks; (2) no need to check this often; should observe for blood (3) CORRECT - provides for safety; also teach to use soft toothbrush, electric razor (4) should continue to take, but tell dentist.

The nurse cares for the patient admitted to the hospital reporting severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness of the patient's intravenous therapy. The nurse recalls that which of the following laboratory tests BEST reflects hydration status? 1. Erythrocyte sedimentation rate (ESR). 2. White blood cell count (WBC). 3. Hematocrit (HCT). 4. Serum glucose.

Question: What test gives you the BEST indication of hydration status? Strategy: Think about what each value measures. How does it relate to hydration? (1) ESR: rate at which RBCs settle out of unclotted blood in 1 hour; indicates inflammation/necrosis; normal: men 0 - 15 mm/h, women 0 - 20 mm/h (2) WBC: indicates infection (normal 4,500 - 11,000/mm3); reduced: leukopenia, elevated: leukocytosis (3) CORRECT - percentage of red blood cells (RBCs) in the plasma; increased with dehydration, reduced with fluid volume excess; normal: men 40 - 54%, women 36 - 46%; other tests that indicate hydration: BP, urine specific gravity (normal: 1.005 - 1.030) (4) indicates insulin production (normal 60 - 110 mg/dL).

The nurse manager is evaluating care given by the staff of a medical/surgical unit. The nurse manager should intervene if which of the following is observed? 1. A nursing assistant disposes of a patient's used tissue in the bedside container before opening the roommate's milk carton. 2. A student nurse washes hands for 15 seconds after removing gloves following inserting an indwelling urinary catheter. 3. A nurse puts on a gown, gloves, mask, and goggles prior to inserting a nasogastric tube. 4. An LPN/LVN visits with a client diagnosed with methicillin-resistant staphylococcus aureus (MRSA) wound infection while the client eats lunch.

Question: What will cause the spread of infection? Strategy: "Should intervene" indicates an incorrect action. Needed Info: Standard precautions are used to prevent nosocomial infections; wash hands as soon as gloves are removed, between patient contacts, between procedures or tasks with same patient, when touching blood, body fluids, or contaminated surfaces; masks, goggles, and gown if in danger of splashes. (1) CORRECT - contaminated hands cause cross-infections; instruct family about when hand washing is necessary and the correct procedure (2) wash hands for at least 10 seconds after removing gloves after a procedure (3) appropriate technique; splashes may occur (4) requires contact precautions; client in isolation may develop sense of loneliness; visiting with client during meals increases sensory stimulation

The nurse cares for the patient who is receiving warfarin sodium. It is MOST important for the nurse to have which of the following medications available? 1. Ferrous sulfate. 2. Protamine sulfate. 3. Vitamin E. 4. Vitamin K.

Question: What will counteract the actions of warfarin sodium? Strategy: Think about the action of each drug. Needed Info: Should check for hematuria (blood in urine), tarry stools, ecchymosis, petechiae, epistaxis (nosebleed). (1) used for iron deficiency; side effects: nausea, constipation; dilute liquid preparations in water or juice, not milk or antacids; absorption impaired by yogurt, cheese, milk, cereals, coffee, tea, whole grain breads (2) heparin antagonist; 1 mg neutralizes 90 - 115 units; give slowly IV over 1 - 3 min (3) fat-soluble vitamin; used in premature infants and patients with impaired fat absorption (4) CORRECT - Phytonadione (vitamin K) (Mephyton): promotes hepatic formation of prothrombin; controls abnormal bleeding; antidote for warfarin sodium (Coumadin) overdosage; side effects: transient hypotension, bronchospasm, anaphylaxis; used in newborns to prevent and treat hemorrhagic disease of newborns

The nurse does preoperative teaching with the client scheduled to have a transurethral prostatectomy (TURP) under spinal anesthesia. Which of the following statements about the result of the spinal anesthesia does the nurse include in the teaching? 1. "You will be unable to move your arms or legs immediately after surgery." 2. "You will require analgesics to relieve pain in your back." 3. "You will be unable to move your legs immediately after surgery." 4. "You will require a special machine to help you breathe immediately after surgery."

Question: What will result from the spinal anesthesia? Strategy: Think about each answer. Is it expected with spinal anesthesia? Needed Info: Spinal anesthesia: injection into the subarachnoid space. Complications: N + V, HA, resp paralysis, muscular weakness in legs. TURP: removal of enlarged portion of the prostate by the use of a resectoscope inserted through the urethra. (1) arms not affected below T-4 (2) not common problem (3) CORRECT - impulses temporarily blocked; will return (4) awake during procedure; no airway problem.

The nurse cares for the patient postoperatively after a transurethral prostatectomy (TURP) for treatment of benign prostatic hypertrophy (BPH). The patient has a continuous bladder irrigation (CBI) through a three-way urinary catheter with a 30 mL balloon tip. When changing the patient's bed, the nurse notices that the sheets are wet. Which of the following BEST explains this finding? 1. The patient is experiencing acute urinary retention. 2. The patient is experiencing autonomic dysreflexia. 3. The patient has a urinary tract infection. 4. The patient is having bladder spasms.

Question: What would cause leaking of the catheter for this patient? Strategy: Think about how each answer relates to a catheter. Needed Info: BPH: enlargement of the prostate gland that obstructs the urethra. TURP: removal of enlarged portion of the prostate by the use of a resectoscope inserted through the urethra. No incision is made. During the first 24 - 48 hours post-op, a continuous bladder irrigation (CBI) using isotonic fluids (normal saline) is used to keep catheter patent and remove clots and sediment. It should be regulated to provide for clear or pink urine. Traction may be applied to the catheter (by the physician) and the cath tubing taped to the thigh or abdomen. This prevents hemorrhage by applying pressure to the blood vessels. The Foley is usually removed after 2 - 3 days. Teaching: may initially have burning on urination, frequency, dribbling. Force fluids to 3,000 mL/day. Avoid alcohol, spicy foods, strenuous activities for 2 - 3 weeks. (1) urine would not be passed (2) seen after spinal cord injury; caused by distended bladder or colon; causes SNS discharge; results in hypertension, bradycardia, HA (3) would have foul smell, increased temp (4) CORRECT - passing urine around cath; normal to feel urge to void

The nurse is working with the family of the client with Parkinson's disease. The nurse knows that the client has autonomic system dysfunction. Which of the following signs and symptoms are cause by that problem? 1. Diarrhea. 2. Postural hypotension. 3. Depression. 4. Rigidity.

Question: When the client's autonomic system does not work right, what is the effect in the client's body? Strategy: Think about each answer choice. Needed Info: Parkinson's disease (PD) is a progressive, degenerative neurological disorder characterized by tremor, muscle rigidity, bradykinesia, and postural instability. Three kinds of dysfunctions: motor, autonomic system, and cognitive/psychologic. (1) autonomic system problems cause constipation, not diarrhea (2) CORRECT - autonomic system problems cause postural hypotension (3) psychologic system problems cause depression (4) motor problems cause rigidity.

The patient is admitted to the hospital with a fractured right femur. The patient is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The patient's nurse is teaching a student nurse about traction. The student nurse asks, "Where is the pulling force of the traction applied?" Which of the following responses by the nurse is MOST accurate? 1. "It is applied to the quadriceps muscle." 2. "It is applied to the bone distal to the fracture site." 3. "It is applied to the bone proximal to the fracture site." 4. "It is applied to the knee."

Question: Where is the force of the pull for a patient in balanced suspension traction for a fractured femur? Strategy: Review the concepts of traction and picture the traction equipment. Needed Info: Traction: pulling force on part of the body. Used to reduce, align, and immobilize fractures, and to relieve muscle spasms. Balanced suspension traction: exerts pull on affected part and supports extremity in hammock or splint; the splint is held in place by balanced weights attached to overhead bar. Traction provided by system of ropes, pulleys, and weights. Countertraction provided by patient's body weight. Pull of traction on extremity remains constant, despite changes in position. (1) applied to the bone, never muscle in skeletal traction (2) CORRECT - ensures proper alignment of bone fragments (3) inaccurate; would not provide proper alignment (4) inaccurate.

*The picture wouldn't upload to this side of the card, so it's on the answer side :( * The nurse performs a physical assessment on the adult with a history of a mitral murmur. Identify the area where the nurse places the stethoscope to auscultate the mitral murmur. 1. A 2. B 3. C 4. D

Question: Where should the nurse assess for a mitral valve murmur? Strategy: Examine the diagram carefully. Select the area to assess for a mitral valve murmur. Needed Info: The following anatomical landmarks are used to evaluate heart sounds. The Angle of Louis is located at the manubrial sternal junction at the second rib. The aortic and pulmonic areas are found at the second intercostal space. Erb's point is found at the third intercostal space. The mitral area is found at the fifth intercostal space at the left midclavicular line. The point of maximal impulse (PMI), or the impulse of the left ventricle, is felt most strongly on an adult at the left fifth intercostal space in the midclavicular line. (1) INCORRECT (2) INCORRECT (3) mitral valve murmur is assessed at the PMI (4) INCORRECT

The nurse cares for the unresponsive patient admitted to the intensive care unit with a suspected brain injury from a motorcycle accident. It is MOST important for the nurse to intervene if a staff member performs which of the following assessments of pupillary activity? 1. Doll's eye oculocephalic reflex. 2. Direct light response. 3. Conjugate gaze. 4. Corneal reflex.

Question: Which assessment is contraindicated for this client? Strategy: "Nurse to intervene" indicates an incorrect action. Needed Info: Brain injuries include concussion, contusion, laceration, and hematoma; evaluate level of consciousness, perform neurological assessment, elevate head of bed 30 degrees to decrease intracranial pressure, careful intake and output. (1) CORRECT - observe patient's eye movement as head is turned quickly from side-to-side; if eyes move in opposite direction from side to which head is turned, reflex is intact; contraindicated because it requires head to be turned from side-to-side; patient with suspected brain injury may also have a cervical spine injury (2) darken room; eyelid is held open with other eye covered; penlight is swung from patient's ear toward midline of face and shown directly into eye; pupil should constrict immediately; no reason to intervene (3) nurse holds one finger up and asks patent to follow it with eyes alone; nurse moves finger up, down, lateral, and oblique to evaluate if the patient's eyes track together to follow the finger; unable to perform assessment if client unconscious (4) cotton ball touched to cornea; an immediate blink reflex is normal: no contraindication.

The nurse is presented with a group of patients in the emergency department (ED). Which of the following clients does the nurse see FIRST? 1. The client who reports being raped 30 minutes ago and is exhibiting self-blame, anxiety and feelings of worthlessness. 2. The client who reports a miscarriage last evening and has spotting of blood on her underwear. 3. The client who told the family of intent to commit suicide and has easy access to a gun. 4. The client who witnessed a child stabbed to death and is experiencing anxiety and difficulty coping.

Question: Which client should the nurse see first? Strategy: Remember Maslow. Determine most unstable client. Needed Info: Clients with physical needs take priority over clients with psychosocial needs. (1) follow emergency room protocol, may include clothing, hair samples, NPO; focus on here and now; be alert for potential internal injuries, e.g., hemorrhage (2) after spontaneous abortion, scant, dark discharge may persist for 1 - 2 weeks; instruct client to report any heavy, profuse, or bright red bleeding (3) CORRECT - client has expressed intent, and the risk of danger is great due to the lethal weapon; nurse should see this patient first (4) client experiencing a situational crisis; important to focus on the here and now; help client to become aware of feelings and validate them.

The client with a history of cholelithiasis and recurrent urinary tract infections is admitted to the medical unit with reports of fatigue. A small lump is discovered in the client's neck and the physician orders diagnostic testing. The nurse recognizes that which of the following tests should be performed FIRST? 1. Cholecystogram. 2. Intravenous pyelogram (IVP). 3. Myelogram. 4. Thyroid scan.

Question: Which diagnostic test should be performed first? Strategy: Think about how each test is performed. Needed Info: Cholelithiasis is presence of stones in the gallbladder; symptoms include intolerance to fatty foods, indigestion, nausea, vomiting, flatulence, eructation, and severe pain in the upper right quadrant of the abdomen. (1) iodide-containing contrast medium used to visualize the gallbladder (2) radiopaque iodine contrast medium used to visualize kidneys, ureters, and bladder (3) contrast dye is introduced into spinal subarachnoid space, so spinal cord and nerve roots are outlined and dura mater distortions are also visible (4) CORRECT - must be performed before radiographic exams, which use contrast substances; these would interfere with the interpretation of the thyroid scan which measures uptake of radioactive iodine by the thyroid

The adolescent is brought to the emergency room with a compound fracture of the left femur. Vital signs are BP 80/60, pulse 120, respirations 26, temperature 99.0°F (37.2°C). The nurse expects the physician to initially order which of the following fluids? 1. D10 in water. 2. D5 in 0.45% NaCl. 3. Lactated Ringer's solution. 4. 0.45% NaCl.

Question: Which fluids are best? Strategy: Think about the action of each fluid. Needed Info: Hypovolemic shock occurs because bone is vascular; can rapidly develop; nursing considerations: immobilize joint below and above fracture; assess for S/S shock--tachycardia, hypotension, cool, clammy skin, cyanosis, restlessness, decreased alertness; administer large amounts of isotonic fluids. (1) need isotonic fluid, not hypertonic fluid (2) hypertonic fluid; need isotonic fluid (3) CORRECT - need isotonic fluid to restore circulating blood volume; may also use 0.9% NaCl (normal saline solution) (4) hypotonic solution; isotonic fluid is needed at this time.

The nurse changes the dressing of the woman who had a mastectomy two days ago. After the nurse removes the old dressing, the woman turns her head away. Which of the following nursing diagnoses is MOST appropriate? 1. Powerlessness. 2. Knowledge deficit. 3. Dysfunctional grieving. 4. Body image disturbance.

Question: Which nursing diagnosis is most appropriate? Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. Needed Info: Stages of body image readjustment include psychological shock (denial and anger), withdrawal (passive and dependent), acknowledgment (beginning of grief process), and integration (integrate body changes into new image). (1) may feel powerless, but client is most likely reacting to change in body (2) no indication of knowledge deficit (3) no indication of dysfunctional grieving. (4) CORRECT - mastectomy may cause client to question her femininity, attractiveness, and self-esteem; encourage client to verbalize; encourage client to participate in planning of care

The nurse knows that it is important to identify patients at significant risk of developing a deep vein thrombosis (DVT). Which patient would the nurse assess as having the lowest risk profile? 1. A 67-year-old carpenter undergoing a left total knee replacement. 2. A 22-year-old woman who weighs 230 lbs and is 2 months pregnant with her second child. 3. A 44-year-old woman with ovarian cancer experiencing vomiting from chemotherapy. 4. A 50-year-old executive following removal of cataracts.

Question: Which patient is least likely to develop a deep vein thrombosis? Strategy: Think about risk factors. Needed Info: Deep vein thrombosis can cause pulmonary embolism; occurs in patients undergoing joint replacement, pregnancy, ulcerative colitis, heart failure, the immobilized patient, and patients with severe infections. To prevent, early ambulation, antithrombosis stockings, and anticoagulants are used. (1) age, surgery (up to 70% experience DVT as a complication), and immobility puts him at significant risk (2) obesity and pregnancy puts her at significant risk (3) cancer and dehydration put her at significant risk. (4) CORRECT - the patient with cataracts is not immobile after surgery, usually done in an outpatient setting

The nurse cares for patients on the surgical unit. When planning care, the nurse anticipates that which patient will have the MOST difficulty adjusting psychologically? 1. The 13-year-old girl who has a wart removed from her nose. 2. The 26-year-old man who has palliative surgery for stage 4 cancer of the pancreas. 3. The 42-year-old woman who has an elective hysterectomy. 4. The 60-year-old man who has a colostomy for severe diverticular disease.

Question: Which patient will feel most threatened by surgery? Strategy: "MOST difficulty" indicates that discrimination is required to answer the question. Needed Info: Stages of body image readjustment include psychological shock, withdrawal, acknowledgment, and integration. (1) adolescents fear being different from their peers; body image is a concern, which the surgery enhanced (2) CORRECT - average survival rate after diagnosis of cancer of the pancreas is 4.1 months; of all the patients, he is the only one facing a near-term death; the other patients derive some long-term benefit from their operations (3) loss of uterus will affect body image, but the client with the terminal illness has greater challenges (4) body image disturbance is common after colostomy, but the client will not have the debilitating and painful symptoms of his disease.

The nurse approaches the paranoid schizophrenic client on the psychiatric unit to perform an ordered venipuncture to obtain a blood specimen. The client becomes agitated and says to the nurse, "You pretend to take blood, but I know you really want to inject me with a poison that will kill me." Which of the following responses by the nurse is BEST? 1. "No, I do not want to kill you. Why do you think that drawing blood is going to kill you?" 2. "Calm down. I drew your blood last week and nothing bad happened to you, did it?" 3. "You sound frightened. The physician wants to ensure that your medications are working properly." 4. "Look, the tube is empty. I can't inject you with anything if the tube is empty."

Question: Which response is most therapeutic? Strategy: "BEST" indicates discrimination is required to answer the question. Needed Info: Delusions are persistent false beliefs; allow client to verbalize delusion, do not argue or try to convince client that delusion is not real. Point out feeling tone of delusion and provide activities to divert attention from delusion. (1) encourages discussion of delusion; directly counters client's perception; does not acknowledge underlying feelings (2) confrontational and challenging (3) CORRECT - acknowledges client's feelings; gives a clear matter-of-fact response directly related to the reason for the blood draw (4) responds to content of the delusion; assumes that client can engage in logical thinking.

The client scheduled for a cardiac catheterization says to the nurse, "I know you were in here when the doctor had me sign the consent form for the test. I thought I understood everything, but now I'm not so sure." Which of the following responses by the nurse is BEST? 1. "Why didn't you listen more closely?" 2. "You sound as if you would like to ask more questions." 3. "I'll get you a pamphlet about cardiac catheterization." 4. "That often happens when this procedure is explained to clients."

Question: Which response is most therapeutic? Strategy: "BEST" indicates that discrimination is required to answer the question. Needed Info: Informed consent is obtained by the individual who will perform the test; explanation of the test and expected results, anticipated risks, discomforts, potential benefits, and possible alternatives are discussed; consent can be withdrawn at any time. (1) "why" questions are nontherapeutic; does not respond to client's feelings or concerns; judgmental (2) CORRECT - directly responds to client's statement by paraphrasing; implies encouragement of expression of client's concern (3) may be helpful, but first the nurse needs to clarify the client's concerns by discussion (4) does convey acceptance and lets the client know that client's response is not abnormal, but response is closed and does not allow client to express feelings or concerns.

The nurse cares for the client diagnosed with genital herpes. After the client is informed of the diagnosis, the client begins crying. Which of the following responses by the nurse is BEST? 1. "We have support groups that may help you talk about some of your feelings." 2. "I see that you are upset. Share with me your thoughts." 3. "While herpes is a difficult disease, at least you don't have AIDS." 4. "I think the physician should explain more to you about genital herpes."

Question: Which response is most therapeutic? Strategy: "BEST" indicates that discrimination is required. Needed Info: Genital herpes: caused by herpes simplex virus; symptoms: painful, vesicular genital lesions and difficulty voiding; nursing care: offer emotional support, sitz baths, monitor Pap smears on a regular basis; treatment: Acyclovir. (1) passing the buck; nurse should acknowledge the client's feelings and allow the client to verbalize; support group may be suggested later (2) CORRECT - reflects the client's feelings and allows the client to verbalize concerns (3) minimizes the client's diagnosis and feelings (4) passing the buck; the nurse should explain the disease.

At the advice of the physician, the client with hypertension attends classes to help quit smoking. One month later when the client visits the clinic, the nurse notes a package of cigarettes in the client's pocket. Which of the following statements, if made by the nurse, is MOST appropriate? 1. "I see that you have cigarettes in your pocket." 2. "Please give me the cigarettes." 3. "I will have to report this to the physician." 4. "You will have to enroll in another class."

Question: Which response is most therapeutic? Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. Needed Info: Therapeutic communication is listening to and understanding the client while promoting clarification and insight; important for nurse to understand the client's verbal and nonverbal messages, listen for client's perception of the problem, and facilitate verbalization. (1) CORRECT - encourages client to verbalize issues and concerns; nonjudgmental (2) authoritarian (3) no need to involve physician at this point (4) need more information before determining a course of action.

The nurse cares for the client receiving vincristine sulfate. The nurse recognizes it is MOST important to assess for which of the following? 1. Fatigue and nausea. 2. Polyphagia and polydipsia. 3. Paresthesia and difficulty with gait. 4. Diarrhea and alopecia.

Question: Which side effect poses a safety issue with the client? Strategy: "MOST important" indicates a priority question. Needed Info: Vincristine sulfate (Oncovin) is an antineoplastic agent; side effects include peripheral neuritis, loss of reflexes, bone marrow depression, alopecia, and GI symptoms; avoid IV infiltration and extravasation; check reflexes, motor and sensory function; allopurinol (Zyloprim) given to increase excretion and decrease buildup of uric acid. (1) does not cause fatigue; does cause nausea and vomiting; not the priority (2) symptoms of diabetes; not caused by vincristine (3) CORRECT - indicate a peripheral neuropathy; to ensure client safety, support client when ambulating (4) diarrhea can be symptomatically treated; alopecia does occur; reassure client that it is usually reversible.

The patient is admitted to the hospital with a diagnosis of carcinoma of the colon and undergoes a colon resection. Two days postoperatively, the patient becomes confused and agitated. It is determined that the patient is delirious. The nurse recalls that delirium is BEST described by which of the following statements? 1. Delirium is characterized by acute onset with symptoms lasting for hours or weeks. 2. Delirium is characterized by gradual onset with symptoms lasting for months or years. 3. Delirium is characterized by either acute or gradual onset with symptoms lasting from several months to several years. 4. Delirium is characterized by either acute or gradual onset with symptoms lasting for several days.

Question: Which statement is TRUE for delirium? Strategy: Think about each answer choice. Needed Info: Delirium: onset rapid, often at night; manifestations fluctuate over 24-hour period: awareness, orientation, recent memory, sleep/wake cycle disturbed; associated with illness or meds. Dementia: onset insidious, develops over years, not associated with physical illness. Alertness not impaired. Nursing responsibilities: ensure safety, meet patient's physical needs. (1) CORRECT; delirium has acute onset with symptoms lasting for hours or weeks (2) inaccurate; delirium has rapid onset (3) inaccurate; delirium has rapid onset and shorter duration of symptoms (4) inaccurate; delirium has rapid onset.

The client comes to the emergency department reporting chest pain that occurs nightly while the client is at rest. The client is diagnosed with resting angina. The nurse instructs the client about how to decrease the anginal attacks. Which of the following statements, if made by the client to the nurse, indicates that teaching is successful? 1. "I am going to sign up for meditation classes at the community center." 2. "I am going to take a brisk walk after dinner every night." 3. "I am going to take a part-time job at a day care center." 4. "I am going to take over-the-counter diet pills to lose weight."

Question: Which statement is correct? Strategy: Think about what the client's words mean. Needed Info: Angina is chest pain due to ischemia that does not cause permanent damage; symptoms include pain that may radiate down left arm; arm pain associated with stress, exertions, or anxiety; administer antianginal exercise program to reduce blood pressure and pulse rate; percutaneous transluminal coronary angioplasty (PCTA), coronary artery bypass graft surgery (CABG) may be performed. (1) CORRECT - will decrease and manage stress; focus on breathing will have calming effect on client as well as assist with oxygenation; will not produce chest pain, shortness of breath, or undue fatigue (2) should not engage in physical exercise for 2 hours after meals (3) may involve too much physical activity and stress (4) obesity is a risk factor of angina, but over-the-counter diet pills contain sympathomimetic substances that can increase heart rate.

The nurse reviews the charts of four antepartal women. The nurse recognizes that which woman is at MOST risk for having a child with a cleft lip and palate? 1. A 22-year-old Asian woman who is having a girl. 2. A 35-year-old African American woman who is having a boy. 3. A 25-year-old Native American woman who is having a boy. 4. A 40-year-old Caucasian who is having a girl.

Question: Which woman is at greatest risk for having a child with a cleft lip and cleft palate? Strategy: Think about each answer. Needed Info: Cleft lip: small or large fissure in facial process of upper lip or up to nasal septum, including anterior maxilla; cleft palate: midline, bilateral, or unilateral fissures in hard and soft palate. (1) individuals of Asian background are more likely than African Americans or Caucasians to have a child with cleft lip and palate; less likely to be found in a girl (2) African Americans are least likely to have a child with cleft lip and palate (3) CORRECT - Native Americans have the highest incidence of cleft lip and palate; males are more likely than females to have both (4) Caucasians are less likely to have a child with cleft lip and cleft palate; more common in males.

The woman delivers a 6 lb 10 oz infant. The mother observes the nurse in the delivery room place drops in the infant's eyes. The mother asks the nurse why this was done. Which of the following responses by the nurse is BEST? 1. "The drops will constrict your infant's pupils to prevent injury." 2. "The drops will remove mucus from your infant's eyes." 3. "The drops will prevent infections that might cause blindness." 4. "The drops will prevent neonatal conjunctivitis."

Question: Why are eye drops placed in a newborn's eyes? Strategy: "BEST" indicates that discrimination may be required to answer the question. Needed Info: Prophylactic care of newborn includes administration of antibiotic eye drops containing erythromycin and tetracycline. Eye irritation may occur, but it is not common and is self-limiting. (1) erythromycin or tetracycline do not cause miosis (2) does not remove mucus from baby's eyes (3) CORRECT - precaution against ophthalmia neonatorum (inflammation of the eyes due to gonorrheal or chlamydia infection) (4) conjunctivitis is inflammation of the conjunctiva.

The nurse at the community mental health center cares for the new client with a diagnosis of depression. The physician prescribes amitriptyline. One week after starting amitriptyline, the client reports to the nurse that there has been no improvement. Which explanation, if made by the nurse, is MOST accurate? 1. "It takes two to four weeks for the medication to work." 2. "You may need more medication." 3. "Your depression is probably deepening." 4. "This medication probably is not the right one for you."

Question: Why are the patient's symptoms not relieved? Strategy: "MOST accurate" indicates that there may be more than one correct response. Think about each statement. Is it true about amitriptyline? Needed Info: Amitriptyline (Elavil): tricyclic antidepressant; take full dose at bedtime; delay of 2 - 4 weeks before effects seen; side effects: drowsiness, dizziness, orthostatic hypotension, blurred vision, dry mouth, urinary retention, constipation, sweating; nursing responsibilities: monitor for risk of suicide. (1) CORRECT - broken down by liver; drowsiness precedes antidepressant effect by several weeks, so med may improve sleep patterns before other symptoms (2) too early to know (3) inaccurate (4) not nursing decision.

One afternoon in the hospital day room, the nurse overhears the newly admitted patient with chronic schizophrenia say to another patient, "I hate you. Get away from me or I'll kill you." Which of the following interpretations of this behavior, by the nurse, is MOST justifiable? 1. The patient does not like the other patient. 2. The patient is angry. 3. The patient feels threatened. 4. The patient feels powerful.

Question: Why is the patient acting like this? Strategy: "MOST justifiable" indicates that there may be more than one correct response. Think about each answer choice and how it relates to schizophrenia. Needed Info: Chronic schizophrenia distorts the way a patient thinks, acts, expresses emotions, perceives reality, and relates to others. The patient can misinterpret what the other patient's behavior meant. (1) assumption; not most justifiable (2) assumption; not most justifiable (3) CORRECT - patient not in usual environment; patients with schizophrenia hear voices and have trouble interpreting reality (4) assumption and unlikely.

The patient is postoperative orthopedic surgery. The physician orders morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. The nurse checks the PCA pump to determine how many times the patient has triggered the system. Which of the following explanations BEST explains why the patent triggered the system 11 times but received only 6 injections? 1. The patient is developing an addiction to morphine. 2. The patient does not understand how to use the pump. 3. The patent is developing a tolerance to morphine. 4. The amount of narcotic prescribed is not controlling the patient's pain.

Question: Why did the patient receive only 6 injections of medication? Strategy: "Best" indicates that there may be more than one correct response. Think about the outcome of each answer choice. Needed Info: PCA allows patients to control administration of IV analgesics. Preloaded pump system administers preset amount of medication when button is pushed by patient. Predetermined lock-out time interval. Amount of medication is displayed on front of machine. Reduces pulmonary complications, and patient is more alert. (1) develops over long period (2) more likely is pressing button to get pain relief (3) develops over long period. (4) CORRECT - patient is pressing button before lock-out time has expired because is in pain; system keeps track of number of requests for medication

The patient receiving paroxetine for obsessive-compulsive disorder tells the nurse that there is dizziness when standing up from a sitting or lying position. The nurse should recognize that this problem is PRIMARILY due to which of the following? 1. Paroxetine can cause hypoglycemia. 2. Paroxetine can affect the cerebellum. 3. Paroxetine can affect the vestibular branch of the auditory nerve. 4. Paroxetine can cause orthostatic hypotension.

Question: Why does paroxetine cause dizziness? Strategy: Think about each answer choice and its relationship to dizziness. Needed Info: Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) type of antidepressant. Effects felt in 1 - 4 weeks. Not addictive. Sudden discontinuation could lead to withdrawal symptoms. (1) inaccurate; does not change glucose metabolism (2) inaccurate (3) inaccurate (4) CORRECT - sudden drop in BP with change in position from sitting or lying to standing

The patient with a fractured right femur has traction applied through the use of a Steinmann pin through the femur. Balanced suspension traction is used with a Thomas splint and a Pearson attachment. The nurse explains to the patient that the purpose of the pin is which of the following? 1. To maintain alignment of the fracture. 2. To hold the Thomas splint in place. 3. To hold the Pearson attachment in place. 4. To immobilize the femur.

Question: Why is a pin used for a fractured femur? Strategy: Visualize the type of traction described. Needed Info: Pin: inserted directly through skin into the bone. Nursing responsibilities: check skin for redness, odor, and drainage. Change dressing and clean with hydrogen peroxide and/or saline if ordered. (1) CORRECT - provides pull directly to bone; results in realignment of bone (2) splint elevated at 45 degree angle to bed; supports thigh (3) fastened to Thomas splint at knee joint; knee is flexed 45 degrees; lower leg lies in Pearson attachment parallel to bed (4) purpose of traction itself.

The nurse plans teaching for the client scheduled for an amniocentesis. It is MOST important for the nurse to include which of the following statements? 1. "The test assesses gestational age using the biparietal circumference." 2. "The test determines the gender of the baby." 3. "The test is used to detect possible birth defects." 4. "The test should not be completed if you have a history of previous miscarriages."

Question: Why is an amniocentesis done? Strategy: Think about each answer. Needed Info: Amniotic fluid is aspirated by needle inserted through the abdominal and uterine walls and is done after 14 weeks gestation to diagnose genetic disorders or neural tube defects; instruct client to empty bladder. (1) age determined by ordering a sonogram, not an amniocentesis; after 30 weeks, can assess the lecithin/sphingomyelin ratio to determine fetal lung maturity (2) can be done but that is not the primary reason (3) CORRECT - completed to determine genetic disorders or neural tube defects; takes 2 - 4 weeks to obtain results; complications include premature labor, infection, Rh isoimmunization (4) not a contraindication.

The nurse plans to administer furosemide 20 mg IV to the patient diagnosed with chronic renal failure. The nurse recalls that the PRIMARY purpose of this medication is which of the following? 1. To increase the blood flow to the renal cortex. 2. To decrease the circulatory blood volume. 3. To increase excretion of sodium and water. 4. To decrease the workload on the heart.

Question: Why is furosemide given to a patient diagnosed with chronic renal disease? Strategy: Think about the action of furosemide. Needed Info: Chronic renal failure is progressive, irreversible kidney injury caused by hypertension, diabetes mellitus, lupus erythematosus, and chronic glomerulonephritis; symptoms include anemia, acidosis, azotemia, fluid retention, and urinary output alterations; nursing care includes monitoring potassium levels, daily weight, intake and output, and diet teaching about regulating protein intake, fluid intake to balance fluid losses, and some restrictions of sodium and potassium. Furosemide (Lasix) is a potassium-wasting diuretic, which increases renal potassium excretion. Monitor blood pressure, serum electrolytes, weight, I + O. Do not give at bedtime. (1) Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle (2) Furosemide used to treat fluid overload due to chronic renal failure (3) CORRECT - Furosemide is administered in order to augment the kidney's excretory functioning (4) correcting the fluid overload will decrease the workload on the heart, but the primary reason Furosemide is given to patient diagnosed with chronic renal failure is to augment the kidneys' excretory functioning.

The 65-year-old patient is recovering from a right below-the-knee amputation. The patient observes the "figure eight" bandage on the residual limb. The patient asks the nurse why the bandage is applied in this manner. Which of the following explanations, if made by the nurse, is the MOST important reason? 1. "It decreases the possibility of infection." 2. "It helps to minimize postoperative pain." 3. "It reduces the possibility of clot formation." 4. "It reduces postoperative swelling."

Question: Why is the bandage after a BKA applied in a figure eight? Strategy: Picture a BKA with the bandage. Needed Info: Pressure to an operative site reduces postoperative swelling. To promote a return to better circulation, the pressure bandage is changed at regular intervals. As secondary effects, this activity reduces pain caused by swelling and the possibility of clot formation in the residual limb. (1) antibiotics first 48 - 72 hours do this (2) not primary purpose; pain medications play this role (3) reducing the possibility of clot formation happens secondary to the primary purpose of reducing postoperative swelling. (4) CORRECT - hastens venous return, controls edema; must be worn at all times except bathing; must be removed and reapplied several times a day

The client is admitted to the hospital reporting persistent lower back pain. The nurse puts the client in bed in semi-Fowler's position with the hips and knees moderately flexed. The nurse recognizes the PRIMARY rationale for this position is to accomplish which of the following? 1. Relieve tension at the lumbo-sacral region. 2. Maintain proper alignment of the vertebral joints. 3. Improve breathing for better oxygen supply to the sacral musculature. 4. Increase blood flow to the spinal cord.

Question: Why is this position used for this patient? Strategy: Picture the patient as described. Determine the outcome of each answer choice. Needed Info: Causes of low back pain: herniated nucleus pulposus, muscle sprain. S/S: knifelike pain, sensory changes. Diagnosis: CT scan or MRI. Treatment: muscle relaxants, NSAIDS, analgesics, heat, traction (separates vertebrae to relieve pressure on nerve), transcutaneous electrical nerve simulation (TENS), surgery. (1) CORRECT - knees flexed relieves pressure on sciatic nerve or disk (2) done in any position; does not relieve pain (3) done to increase comfort (4) no change.

Healing Touch:

Realign energy flow

Sanguineous:

Red

A client has just returned to his room after undergoing exploratory abdominal surgery. The nurse notes watery red drainage on his dressing. The nurse will describe the drainage as:

Sanguineous

The nurse is providing information to a client who is taking chlorpromazine. What is the most important information for the nurse to provide?

Schedule routine medication checks. It is important to continually assess for adverse reactions and continued therapeutic effectiveness. The dosage should be changed if ordered by the primary care provider. While chlorpromazine can exacerbate serious sunburns, medication should not be discontinued without an order from the provider. Adverse reactions should be immediately reported to the provider.

A nurse is performing a preoperative assessment. Which client statement should alert her to the presence of risk factors for postoperative complications?

Smoking one pack of cigarettes per day reduces the activity of the cilia lining the respiratory tract, increasing the client's risk of ineffective airway clearance after surgery.

A home health nurse is working with a patient who quit his job after injury- life has no meaning and lonely- everyone has left him- what is this a sign of:

Spiritual Distress

A client who is 10 weeks pregnant develops spotting; however, the cervix remains closed. The nurse should suspect which of the following?

Spotting in the first trimester may indicate that the pregnancy is in jeopardy. Bed rest and avoidance of physical and emotional stress are recommended. Abortion is usually inevitable if the bleeding is accompanied by pain with dilation and effacement of the cervix. An inevitable abortion is associated with cervical dilation. An ectopic pregnancy is in the fallopian tubes, and a false positive pregnancy could reflect a missed abortion.

A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

Systemic absorption of atropine can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isn't known to cause hypotension or apnea.

Which instruction about levothyroxine administration should a nurse teach a client?

The nurse should instruct the client to take levothyroxine on an empty stomach (to promote regular absorption) in the morning (to help prevent insomnia and to mimic normal hormone release).

A child who is of preschool age is diagnosed as having severe autism. The most effective therapy involves which intervention?

The preschool-aged child with severe autism will benefit from one-on-one play therapy. The therapist can develop a rapport with this child with nonverbal play. Antipsychotic medications are not indicated for the autism client. The child has difficulty with interpersonal relationships; therefore, group psychotherapy and social skills groups would not be effective.

When assessing a toddler's growth and development, the nurse understands that a child in this age-group displays behavior that fosters which developmental task?

The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task whereas developing trust is the infant's task. Developing industry is the task of the school-age child.

Characteristic normal urine:

Transparent

Can you use essential oils for Asthma: True or False

True

Series of "small successes is positive way to help clients True or False

True

A client with schizophrenia believes his room is bugged by the Central Intelligence Agency (Canadian Security Intelligence Service) and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and has not been employed in the past 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?

Trust versus mistrust. This client's paranoid ideation indicates difficulty trusting others. The stage of autonomy versus shame and doubt deals with separation, cooperation, and self-control. Generativity versus stagnation is the normal stage for this client's chronologic age. Integrity versus despair is the stage for accepting the positive and negative aspects of one's life, which would be difficult or impossible for this client.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

People in crisis - can they work through crisis if someone works with them

Yes

A college student was referred to the campus health service because of difficulty staying awake in class. What should be included in the nurse's assessment? Select all that apply: a) Amount of sleep he usually obtains during the week and on weekends b) How much alcohol he usually consumes c) Onset and duration of symptoms d) Whether or not his classes are boring e) What medications including herbal remedies, he is taking

a) Amount of sleep he usually obtains during the week and on weekends c) Onset and duration of symptoms e) What medications, including herbal remedies, he is taking

The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process: a) Assessment b) Diagnoses c) Implementation d) Evaluation

a) Assessment

Coping with stress differs from adaption to stress in that: a) coping is a more immediate, short term response to stress b) Coping is a later response to stress

a) Coping is a more immediate, short term response to stress

To reduce shearing force for a bedridden client. It is most important for the nurse to: A) Put bed in high Fowler's position b) Pull the client up in at least once an hour

a) Put bed in high Fowler's position

In which maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior (LOA) position?

below the umbilicus on the left side. As the uterus contracts, the abdominal wall rises and, when external monitoring is used, presses against the transducer. This movement is transmitted into an electrical current, which is then recorded. With the fetus in the LOA position, the cardiotransducer should be placed below the umbilicus on the side where the fetal back is located and uterine displacement during contractions is greatest. If the fetal back is near the symphysis pubis, the fetus is presenting as a transverse lie. If the fetus is in a breech position, the fetal back may be at or above the umbilicus.

At which age does a child begin to accept that he or she will someday die: c) 9-12 years old d) 12-18 years old

c) 9-12 years old

A client with diabetes who needs to learn to inject his own insulin states, "Ive had a good night's sleep, so let's tackle that syringe." The client if showing: a) Feedback c) Readiness

c) Readiness

The nurse receives change-of-shift report about the following four patients. Which patient will the nurse assess first: a) A patient who has malnutrition associated with 4+generalized pitting edema b) A patient whose potential nutrition has 10 mL of solution left in the infusion bag d) A patient who is receiving continuous internal feedings and has new onset crackles throughout the lungs

d) A patient who is receiving continuous internal feedings and has new onset crackles throughout the lungs

During which stage of NREM sleep would you expect a client to be most difficult to arouse: c) Stage III d) Stage IV

d) Stage IV

Which of the following are considered defense mechanisms: b) denial c) Sublimation

d) denial

To help alleviate spiritual distress effectively, the nurse must: b) offer to pray with the client d) find out what the client perceives his/her spiritual needs to be

d) find out what the client perceives his/her spiritual needs to be

The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse would expect that the client has:

decreased breath sounds on the affected side.

While examining a 12-month-old child, the nurse notes that the child can stand independently but cannot walk without support. The nurse should:

do nothing because this is a normal finding in a child this age.

The mother of an infant with a cleft lip asks when the repair will be scheduled. What is the nurse's best response?

during the first 6 months of life

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions.

When determining the parents' compliance with treatment for their infant who has otitis media, the nurse should ask the parents if they are:

holding the child upright when feeding with a bottle.

Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms?

hypertension. Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method.

A primigravid client at 38 weeks' gestation comes to the labor room because "my water broke." The health care provider (HCP) asks the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. The nurse's next action should be to:

notify the HCP that the membranes are ruptured. Nitrazine paper responds to alkaline fluids by changing blue; amniotic fluid is alkaline so the color verifies that the membranes are ruptured. The nurse notifies the provider that membranes are ruptured so that a plan of action can be developed. Rupture of membranes in the absence of labor increases the risk of infection. Vaginal examinations are limited until labor is initiated. Wearing a sanitary pad increases potential for infection. Documentation of the Nitrazine test is completed after notifying the provider.

A person calls the neonatal intensive care unit stating that his son is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his son's condition. The nurse should:

obtain more data before giving the caller any confidential information.

The nurse should instruct a woman taking folic acid supplements for folic acid-deficiency anemia that:

oral contraceptive use, pregnancy, and lactation increase daily requirements. Oral contraceptive use, pregnancy, and lactation are situations that increase demand for folic acid. With supplementation, a response should cause the reticulocyte count to increase within 2 to 3 days after therapy has begun. It is not necessary to take folic acid on an empty stomach. A client may safely take both iron and folic acid supplementation.

A charge nurse observes two nurses using inappropriate technique when starting an I.V. on a child. The charge nurse should first:

talk with the nurses about proper technique and the risk of infection resulting from improper technique. A nurse has the responsibility to do no harm. If a nurse observes other health care professionals implementing inappropriate practices, the charge nurse should address the problem. The charge nurse's first action should be to counsel the nurses on correct I.V. techniques. If the behaviors continue, the nurse manager should be notified. The situation should not be ignored. Interrupting the nurses during the procedure may unduly cause the parents to lose trust in the nurses' care. The charge nurse should not talk with the child's parents regarding the incident unless a situation develops that requires the parents to be informed.

When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which teaching and learning principle should the nurse address first?

building the teaching on the child's current level of knowledge

A client with chronic schizophrenia is admitted to the hospital on an emergency detention. The client states to the nurse, "I didn't do anything wrong. I was just carrying out the orders God gave me to paint an X on the door of all sinners." Several hours after being admitted, the client wants to leave the hospital. In addition to explaining that the staff is concerned about the client's health and safety, which of the following should the nurse tell the client?

"The court has mandated that you undergo a 72-hour evaluation." Clients admitted on an emergency detention must remain hospitalized for the time allotted for the evaluation. In this case, the time is 72 hours. The 72 hours do not include weekends or holidays. If the treatment team completes the evaluation in less than the allotted time, they may decide to discharge the client or may institute further commitment procedures. Clients cannot sign themselves out of the hospital during this period. Family members also cannot authorize the client's release. A client on an emergency detention can be held involuntarily for 72 hours. An immediate detention is good for only 24 hours.

A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should:

initiate a time-out.

The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a:

low potassium level.

A client with pneumonia is experiencing pleuritic chest pain. The nurse should assess the client for:

moderate pain that worsens on inspiration.

A client who has been using benzodiazepines for anxiety wants to add an alternative therapy. The nurse suggests biofeedback. What is the best description of biofeedback?

It is a way to concentrate on the body's response during a stressful situation.

The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response?

Keep the individual on the line in order to gather more information about the details of the threat. If a bomb threat is received, the nurse should keep the caller on the line and talking as long as possible in order to gather information about the location of the bomb and a description of the bomb and the caller. The threat must be reported promptly, but the nurse should not hang up in order to do this.

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention?

Massage the fundus. Postpartum hemorrhage results in excessive vaginal bleeding and signs of shock, such as pallor and a rapid, thready pulse. Placental separation causes a sudden gush or trickle of blood from the vagina, rise of the fundus in the abdomen, increased umbilical cord length at the introitus, and a globe-shaped uterus. Uterine involution causes a firmly contracted uterus, which cannot occur until the placenta is delivered. Cervical lacerations produce a steady flow of bright red blood in a client with a firmly contracted uterus. The priority measure to correct postpartum hemorrhage is to massage the fundus. Packing the uterus with sterile gauze is contraindicated. The physician will have to be called but the nurse must first intervene.

A nurse is caring for a client undergoing opiate withdrawal, which causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with:

Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as such opiates as cocaine, heroin, and morphine. Barbiturates, amphetamines, and benzodiazepines are highly addictive and using these drugs would make detoxification treatment necessary.

A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next?

Notify the physician and security immediately.

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of:

Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of nursing informatics is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care.

The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for a client?

Pneumonia. By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis.

A 12-year-old has a fractured femur and is immobilized in traction as shown in the figure. What should the nurse do?

Provide opportunities for age-appropriate activities.

Which desired outcome demonstrates effective parent teaching about disciplining a toddler?

The parents will call immediate attention to undesirable behavior. Explanation: Calling immediate attention to undesirable behavior reflects effective teaching. This approach helps the child learn socially acceptable behavior and maintain self-esteem and a positive self-concept while learning to adapt to the rules of the larger group and society. Rules should be established clearly and enforced consistently. To reinforce desirable behavior, parents should voice requests for behavior in positive terms and use a normal speaking voice and tone when talking to or reprimanding the child. Screaming and shouting should be minimized.

A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:

check the tubing to ensure that the client is not lying on it or kinking it. In this case, there may be some obstruction to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from reexpanding and can cause a mediastinal shift to the opposite side. The nurse's first response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a health care provider's prescription. The normal position of the drainage bottles is 2 to 3 feet (61 to 91.4 cm) below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done.

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection?

chicken and orange slices

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:

hypokalemia.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

Placing the client in respiratory isolation. Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the:

client's safety needs. The highest priority for a client who has ingested PCP is meeting his safety needs as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which nursing intervention is likely to be most effective?

teaching the client relaxation exercises to use before bedtime. The best action by the nurse to help a client who has difficulty falling asleep would be to teach the client relaxation exercises to use before bedtime to reduce anxiety and promote relaxation.