NCLEX practice test 1

Which of the following is the priority nursing diagnosis for a client with burns to 35% of the body surface area?

Risk for infection The greatest risk to a client with burns to over 25% of their body is infection and sepsis, which can be fatal. Therefore, the priority is to acknowledge that the client is at risk for infection and to implement interventions that address this. The other diagnoses, although applicable to a burn client, are not the priority.

A nurse is named as a defendant in a pediatric client case. What are guidelines for the nurse to follow prior to the trial? Select all that apply.

Use polite language while answering questions. Be prepared to answer questions about the case during the trial. The nurse involved as a defendant should be prepared to answer questions and use polite language. The nurse named as a defendant should not discuss the case with anyone except the defendant's attorney. The nurse should answer the questions and not volunteer any further information unless asked.

-Which situation indicates that more teaching is needed when a 10-year-old is hospitalized for the first time?

The parents choose to leave to let the child build a relationship with the staff. The parents leaving indicates more teaching is needed. The parents of an adolescent might leave to help the child maintain a fragile identity, but a 10-year-old child would prefer to have his parents with him. Expected outcomes of support and teaching for a child and parents new to the hospital would include the parents' relating readily to the staff and calmly with the child, the child accepting and responding positively to comforting measures, and the child discussing procedures and activities without evidence of anxiety.

A client with type 2 diabetes mellitus is prescribed capsaicin cream 0.075% What should the nurse include in a teaching plan for this medication?

"Apply capsaicin cream four times daily to decrease neuropathic pain sensations." This drug reduces amounts of substance P, which is involved in pain transmission. The nurse should teach the client to apply the cream four times daily for several weeks. The cream does not prevent dry skin, debride or treat infections.

A client with class II cardiac disease in active labor is planning on epidural anesthesia for labor and birth. After the anesthesiologist has explained the procedure and potential complications, the nurse determines that the client needs further instructions when she says:

"I may need to lie flat for 6 hours and drink plenty of fluids after I give birth." Lying flat and drinking fluids are interventions for client's experiencing headaches from spinal anesthesia. Such adverse effects do not occur with epidural anesthesia. Anesthesia and analgesia can slow the process of labor. Epidural anesthesia is associated with a decreased urge to void; therefore, catheterization of a full bladder may be necessary. Because the client is anesthetized, the client may not feel the urge to push so bearing-down efforts during the second stage of labor may be less effective.

When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client makes which statement?

"My husband will change the dressing three times per week, using sterile technique. The most important intervention for infection control is to continue meticulous catheter site care. Dressings are to be changed two to three times per week depending on institutional policies. Temperature should be monitored at least once a day in someone with a vascular access device. Hand washing before and after irrigation or any manipulation of the site is a must for infection prevention.

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?

A hemolytic allergic reaction caused by an antigen reaction Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.

After the discharge of a client from a surgical unit, the housekeeper brings a blue pill to the nurse. The pill was found in the sheets when the linens were removed from the client's bed. The nurse reviews the client's medication administration record, which shows that the client received this medication at 0800. What would be the nurse's priority action?

Complete an incident form and notify the physician. This is a medication error. The nurse must document the error so the cause of the error can be identified and a plan put in place so it does not happen again. The nurse should notify the doctor so he/she can determine whether the client needs to be contacted with follow-up instructions. The other options are incorrect, as they do not follow agency policy or nursing professional standards for medication administration.

A nurse in the infection prevention and control program is conducting an assessment of infection control practices. The nurse is evaluating the infection control actions taken on the unit for a client with a decreased white blood cell count. Which of the following infection control practices does the nurse consider most important for this client?

Diligent adherence to aseptic technique The client in this scenario is neutropenic, which places the client at risk for contracting an infection. All measures of aseptic technique must be used to protect the client. The other options do not provide complete protection for the client.

What is the nurse's priority when caring for a 10-month-old infant with meningitis?

Maintaining an adequate airway Maintaining an adequate airway is always a top priority. Maintaining fluid and electrolyte balance and controlling seizures and hyperthermia are all important, but not as important as an adequate airway.

A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful?

Stand next to her at the side of the bed. The client is alone and is progressing well in labor, as evidenced by her restless behaviors. She is refusing analgesia but will benefit from the 1:1 nursing care model if she is aware that the nurse is attending her at the bedside. Standing behind her will not provide a sense of nursing presence. Turning up the music or turning on the television is not appropriate unless the client requests them as a distracter.

A nurse is preparing a teaching plan for a client with thromboangiitis obliterans (Buerger's disease). Which goal is the highest priority for this client?

Stop smoking Buerger's disease is a nonatherosclerotic, recurrent inflammatory disorder of the small- and medium-sized arteries and veins of the upper and lower extremities. The disease occurs mostly in young men with a long history of tobacco use and chronic periodontal infection, but without other CVD risk factors such as hypertension, hyperlipidemia, and diabetes. Absolute cessation of nicotine is required to reduce the risk for amputation. Conservative management includes avoiding limb exposure to cold temperatures, a supervised walking program, antibiotics to treat any infected ulcers, and analgesics to manage the ischemic pain. Teach clients to avoid trauma to the extremities.

Which nursing action would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?

Teach the client to splint the rib cage when coughing. The pleuritic pain is triggered by chest movement and is particularly severe during coughing. Splinting the chest wall will help reduce the discomfort of coughing. Deep breathing is essential to prevent further atelectasis. Abdominal breathing is not as effective in decreasing pleuritic chest pain as is splinting of the rib cage. Incentive spirometry facilitates effective deep breathing but does not decrease pleuritic chest pain.

A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching?

Turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation. The synchronizer switch should be turned "off" when defibrillating. All other answers are correct and do not require further teaching.

Which I.M. injection site is appropriate for a 6-month-old infant?

Vastus lateralis muscle A nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis muscle. She should give the injection in the ventrogluteal area only in a child who has been walking for about 1 year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.

Which physiologic response should the nurse expect as unlikely to occur when a client is angry?

decreased BP Blood pressure, as well as respiratory rate and muscle tension, increases during anger because of the autonomic nervous system response to epinephrine secretion. Peristalsis decreases.

A neonate receives an Apgar score at 1 and 5 minutes of age. The 1-minute Apgar score is a good indication of:

how well the neonate tolerated labor. Apgar scores, given at 1 and at 5 minutes after birth, indicate how well the neonate tolerated labor and how well he made the transition to extrauterine life. These scores also provide the foundation for additional nursing interventions, if needed. Apgar scores aren't used to determine the gestational age of the neonate.

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:

laryngeal cancer is one of the most preventable types of cancer. Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer.

The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP:

massages the client's legs. Massaging the legs postoperatively is contraindicated because it may dislodge small clots of blood, if present, and cause even more serious problems. Ambulation, elasticized stockings, and moving the legs in bed all help reduce the risk of thrombophlebitis.

The nurse is caring for a 3-month-old infant, who had a cleft palate and cleft lip surgical repair. Which assessment data would indicate a postoperative complication from the surgery?

suture line surrounded by erythema There is a risk for infection in the suture line if it is not kept clean and dry. Signs of infection would include erythema or foul drainage from the suture line and fever. Crying intermittently is a normal assessment finding and the nurse should be prepared with liquids or formula. A suture line may be swollen in the immediate postoperative period, but its appearance will improve with time. A Logan bar may be used to hold the suture line in place.

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which points? Select all that apply.

Clopidogrel works by preventing platelets from sticking together and forming a clot. The client should report unexpected bleeding or bleeding that lasts a long time. The client may bruise more easily and may experience bleeding gums. Clopidogrel is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of clopidogrel; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of clopidogril; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking clopidogril.

A client with chronic back pain is admitted to the medical-surgical floor and is receiving multiple pain medications and an antidepressant for pain control. The physician's orders include a physical therapy consult for ambulation and back strengthening, magnetic resonance imaging (MRI) of the lumbar spine, and a computed tomography (CT) scan of the abdomen. How should the nurse schedule therapy and diagnostic tests?

Schedule the MRI of the lumbar spine first, then the physical therapy consult, and then the CT scan. The client was admitted for back pain; therefore, the MRI of the lumbar spine should take priority. Next, the nurse should schedule the physical therapy consult followed by the CT scan of the abdomen. The client has been tolerating the medications at home; therefore, the client isn't at an increased risk for falls. The client's needs should be placed before the needs of the other departments. The medications could place the client at risk for abdominal complications; however, the client was admitted for back pain, not abdominal pain, so the back pain takes priority.

The nurse is ready to administer a partial fill of imipenem-cilastatin in the IV pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. The nurse should first:

determine when the client received the last dose of the imipenem-cilastatin. The nurse should first determine whether the client received the last dose of imipenem-cilastatin. If the client did not receive the last dose, the nurse should notify the health care provider (HCP) that the client did not receive the dose, receive prescriptions, document, implement the prescriptions, and complete an incident report. The nurse should not automatically discard the partial fill of imipenem-cilastatin found at the client's bedside until further investigation is done. The nurse should recognize the cost of medications such as imipenem-cilastatin and consult the pharmacist after identifying information on the partial fill bag that was found. After verifying all information, the nurse can administer the new partial fill of imipenem-cilastatin so that the client can receive the antibiotic on time.

Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids?

the importance of watching for signs of hyperglycemia Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise; insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism, resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone, and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state, which is a medical emergency manifested by signs of shock.

A client has a suspected slow gastrointestinal bleed. Because of this, the nurse specifically instructs the unlicensed assistive personnel to look for and report which symptom?

tarry stools A client with a suspected slow gastrointestinal bleed should be observed for tarry (black) stools, which indicate slow bleeding from an upper gastrointestinal site. The longer the blood remains in the system, the darker it becomes from the degradation of hemoglobin and release of iron. Hypotension does not occur with a slow gastrointestinal bleed. Bright red blood indicates bleeding from the lower gastrointestinal tract or profuse, massive gastrointestinal bleeding. Jaundice is not an indicator of gastrointestinal bleeding, but it is an indicator of liver or biliary tract dysfunction.

A client is admitted to the psychiatric unit accompanied by her husband. She brings six suitcases and three shopping bags. She orders the nurse to carry her bags. Her husband states she has been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client's husband?

the client's fluid and food intake Assessing nutritional status is a priority in this situation. Clients with bipolar disorder, manic phase, commonly do not have time to eat or drink because of their state of constant activity and easy distractibility. Altered nutritional status and constant physical activity can lead to malnutrition, weight loss, and physical exhaustion. These states can lead to death if appropriate intervention is not instituted. Financial status is neither important nor something that the nurse can modify. Clients with bipolar disorder, manic phase, have disturbed sleep patterns; however, their hydration and nutritional status are the first priority. A common behavior of clients with bipolar disorder, manic phase, is to exhibit hostility when their personal desires are limited, so it is not necessary to seek this information at this time.

A 1-day-old breastfed newborn has a bilirubin level indicating an intermediate risk for jaundice. Which statement by the infant's mother indicates an understanding of teaching regarding jaundice?

"I should breastfeed my baby as often as possible." Jaundice in a breastfeeding infant is common and is not pathological. Mothers should be taught to breastfeed as often as possible, at least every 2 to 3 hours and until the infant is satiated. Breastfed babies rarely need to be supplemented with formula. Mothers should be encouraged to continue breastfeeding their infants due to the numerous benefits it provides. Infants should never be placed in direct sunlight.

A client on a mental health unit becomes increasing agitated and barricades himself in a corner room holding another client hostage. Verbal exchanges indicate an escalation in client desperation. Which nursing actions would be taken at this time? Select all that apply.

Identify one nurse to interact with the client. Direct other clients away from the area. Discretely notify security to assist. Identify with the client's perspective and reason for agitation The goal of the interaction is to defuse client anxiety and maintain the safety of all on the unit. To complete this goal, the nurse must calmly work with the client while obtaining assistance from security in case the situation deteriorates. Identifying one nurse (one with a good client rapport) to work with the client decreases client anxiety as well as a calming voice tone (not authoritarian) and relaxed posture. Identifying with the client allows the client to feel understood. Security precautions include removing the others from the area and notifying security. Yelling would elevate client anxiety.

During a bedside shift report, the nurse finds that the client is receiving the wrong IV solution. Which action by the nurse is indicated?

Write up an incident report describing the error After starting the correct solution, the nurse should complete an incident report describing the specific error. The healthcare provider should be notified as well as the nurse manager; however, if the manager is not present and the error corrected, notification may take place after the report is complete. The solution should be changed to the correct fluids immediately upon discovery so that the error is not continued. The staff nurse does not report a routine error to the board of nursing; if there is concern for substance abuse or other issue, the nurse or manager may choose to involve the board.

A nurse is about to administer a client's morning dose of insulin. The client's order is for 5 units of regular insulin and 10 units of NPH (neutral protamine Hagedorn) insulin given as a basal dose. The client also is to receive an amount prescribed from the medium-dose sliding scale (shown image) based on morning blood glucose levels. The nurse performs a bedside blood glucose measurement and the result is 264 mg/dL (264 mmol/L). How many total units of insulin would the nurse administer to the client? Record your answer using a whole number.

21

The nurse is working with a client with depression and suicidal ideation. The nurse heard the client say, "I am disappointed because thought I'd be feeling better by now since I started medication and therapy a week ago." What would be the primary nurse therapist's most therapeutic response?

"It takes time and can be frustrating to experience the physical and emotional symptoms of depression all while you learn more about yourself and try new strategies as your medication takes effect." The validation of the client's experience, alongside some realistic information giving about the biologic, psychological, and social components of the illness, is the most therapeutic response. Responding casually that "it took a while to get into this state" assumes some sort of personal responsibility that is not complete, as does suggesting that the nurse is pleased the client is taking ownership and can move recovery along. This does not adequately address the biologic basis of the illness. Suggesting the client simply needs to wait for the medication to work, however, fails to recognize the psychological and social components of the illness and suggests a passive view of recovery.

The nurse is teaching a pregnant client about exercises that may be helpful during pregnancy. Which points should the nurse include in the instruction? Select all that apply.

Abdominal breathing lifts the abdominal wall off of the uterus. Pelvic rocking may help relieve lower back pain. Kegel exercises help improve vaginal contractility and bladder control. The nurse should explain that pelvic rocking exercises may help relieve lower back pain. Abdominal breathing exercises help relaxation and lift the abdominal wall off of the uterus. Kegel exercises help improve vaginal contractility and bladder control. The client may exercise regularly at least three times per week, but the duration of exercise should be limited to 35 minutes, especially in hot, humid, weather. The client should perform non-weight-bearing exercises such as swimming.

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?

Administer 100% oxygen by mask. Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature, thus steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate.

A client is taking an antacid for treatment of a peptic ulcer. Which statement best indicates that the client understands how to correctly take the antacid?

"It is best for me to take my antacid 1 to 3 hours after meals." Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain.

The nurse is assessing a client who had a cesarean birth 12 hours ago. Findings include a distended abdomen with faint bowel sounds × 1 quadrant, fundus firm at umbilicus, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The IV and Foley catheter have been discontinued, and the client received medication 3 hours ago for pain. The client can have pain medication every 3 to 4 hours. What should the nurse do first?

Ambulate the client from the bed to the hallway and back. The client should have more active bowel sounds by this time postpartum. Ambulation will encourage passing flatus and begin peristaltic action in the gastrointestinal track. Medicating the client should be evaluated prior to ambulating, but it is probably too soon because the last dose was 3 hours ago and her pain assessment rating is fairly low. Pain medications should not have codeine as a component as it decreases peristaltic activity. Incentive spirometry or asking the client to turn, cough, and deep breathe are appropriate to encourage good oxygen exchange in the lungs prior to ambulation, and walking can be used concurrently with these interventions. Participating in infant care is another way to encourage the mother to move about, but the primary goal would be to have her walk on the unit, a more purposeful activity.

A client with schizophrenia tells a nurse preparing him for discharge that he has no home or family and has been living on the street. Which action is most appropriate?

Asking the physician to refer the client to social services for further evaluation A homeless person may have complex underlying needs; a trained social worker must explore these needs and issues in order to provide the most appropriate interventions. Offering the client the names and numbers of shelters may be helpful, but the nurse isn't in a position to follow up on the client's care after discharge. Although having the client discuss his feelings may be therapeutic, there's a need at this point for direct intervention to ensure the client's safety and well-being. Documenting the information and informing the charge nurse is useful, but doesn't ensure appropriate intervention.

The nurse is reviewing the chart of a client with type 2 diabetes prior to a scheduled appointment. The chart states: Progress notes 10/15/16 0245 Client states that he has not been following his prescribed diabetes management program for the past 2 to 3 months. Client is aware of his blood glucose monitoring regimen and diet but has difficulty integrating each into his routines. Client denies recent changes in urinary function, sensation or vision. How can the nurse best determine this client's glycemic control since the last assessment?

Review the results of the client's HbA1c An HbA1c provides an overview of a person's blood glucose level over the previous 2 to 3 months. Glycosylated hemoglobin values are reported as a percentage of the total hemoglobin within an erythrocyte. The time frame is based on the fact that the usual life span of an erythrocyte is 2 to 3 months. The client's description of health maintenance will not determine adherence to the prescribed schedule. Fasting glucose gives a point-in-time result. A 24-hour food recall is subjective, and does not help the nurse gauge the client's overall adherence.

A nurse is caring for a client who is experiencing alcohol withdrawal. Which statement best indicates that the client understands the need for long-term treatment?

The client agrees to detoxification, rehabilitation, and participation in an aftercare program. Detoxification, rehabilitation, and participation in an aftercare program are the only options that address the client's long-term treatment needs. Supportive counseling, family involvement, and support-group participation are important aspects of the treatment process, but they don't address the client's need for long-term treatment.

A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100°F (37.8°C); pulse, 100 bpm; respirations, 18 breaths/minute. Which medication would the nurse expect the primary health care provider (HCP) to prescribe?

intravenous penicillin Because group B streptococcus is a gram-positive bacterium, the HCP probably will prescribe intravenous penicillin to treat the mother's infection and prevent fetal infection. Gentamicin sulfate, which acts on gram-negative bacteria, would be inappropriate. Administering a corticosteroid, such as betamethasone, is inappropriate because the premature rupture of the membranes enhances fetal lung maturity. The lack of amniotic fluid causes early maturation of lung tissue. Cefaclor, which is available only in the oral form, is used for upper and lower respiratory tract infections and urinary tract infections by gram-negative staphylococci.

A client has a nasogastric tube inserted at the time of abdominal-perineal resection with permanent colostomy for colon cancer. When should the nurse tell the client that the tube will most likely be removed?

passage of gas and fecal material from the colostomy A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Neither absence of stomach drainage nor absence of nausea and vomiting is a criterion for judging whether gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery.

A nurse is caring for a client with diabetes insipidus. The nurse should anticipate administering:

vasopressin Vasopressin is given subcutaneously to manage diabetes insipidus. Insulin is used to manage diabetes mellitus. Furosemide causes diuresis. Potassium chloride is given for hypokalemia.

A client with newly diagnosed chronic obstructive pulmonary disease (COPD) presents to the clinic for a routine examination. The nurse teaches the client strategies for preventing airway irritation and infection. Which statement by the client best indicates that teaching was successful?

"I should avoid using powders." There are many considerations when a client is diagnosed with COPD. A client with COPD should avoid exposure to powders, dust, and smoke from cigarettes, pipes, and cigars. The client should stay away from crowds should avoid aerosol sprays as a precaution. The client should also obtain immunizations against pneumococcal pneumonia as well as influenza. A combination of measures is needed to maintain the client's highest level of respiratory function.

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

Applying knee splints Applying knee splints prevents leg contractures by holding the joints in a functional position. Elevating the foot of the bed doesn't prevent contractures. Hyperextending a body part for any length of time is inappropriate; doing so can cause contractures. Performing shoulder ROM exercises can prevent contractures in the shoulders but not in the legs.

A nurse is scheduled to perform an initial home visit to a new client who is beginning home intravenous therapy. As the nurse is getting out of her car and beginning to approach the client's building, a group of men begin following and jeering at her. Which of the following is the nurse's best response to this situation?

Leave the area in her car, provided she can get to it safely. The nurse's safety is paramount, and the nurse's best response to a perceived threat when performing a home visit is to remove herself from the situation, provided this can be achieved without incurring further risk.

A nurse preparing to administer medications on the respiratory floor is using the computerized medication-dispensing system. Her password isn't working. The nurse should:

ask computer support to reset her password. A nurse should never give her password to anyone. It's inappropriate for the nurse to delegate medication administration to a nursing assistant. The nurse shouldn't override the machine to dispense the medications; doing so is unsafe and could cause medication errors.

A client has had a total hip replacement. Which sign most likely indicates that the hip has dislocated?

shortening of the affected leg The most likely indication of a dislocated hip is a shortening of the affected leg. Other indications of dislocation include increasing pain, loss of function to the extremity, and deformity. Abduction of the leg after total hip replacement is a desirable position to prevent dislocation. Loosening of the prosthesis does not necessarily indicate that the hip has dislocated. External rotation of the hip can occur without the hip's being dislocated. However, a neutral position of rotation is the desired position.

The nurse is preparing a community presentation on oral cancer. Which is a primary risk factor for oral cancer that the nurse should emphasize in the presentation?

use of alcohol Chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless tobacco are other significant risk factors. Additional risk factors include chronic irritation such as a broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis. Use of mouthwash, lack of vitamin B12, and lack of regular teeth cleaning appointments have not been implicated as primary risk factors for oral cancer.

A client recently diagnosed with cancer informs the nurse that she values and finds comfort in her faith. The nurse is aware that faith is best defined as which of the following?

A belief in something for which there is no proof or material evidence. Faith is a belief in something for which there is no proof or material evidence. Hope is a positive outlook even in the bleakest moments. Religion is an organized belief system about a higher power. Spiritual beliefs are practices associated with all aspects of a person's life.

Clients receiving a monoamine oxidase inhibitor must avoid tyramine, a compound found in which foods?

Aged cheese and Chianti wine Aged cheese and Chianti wine contain high concentrations of tyramine. Green, leafy or yellow vegetables, figs, cream cheese, and fruit are low in tyramine.

Which medication can control the extrapyramidal effects associated with antipsychotic agents?

Amantadine Amantadine is an anticholinergic drug used to relieve drug-induced extrapyramidal adverse effects, such as muscle weakness, involuntary muscle movement, pseudoparkinsonism, and tardive dyskinesia. Other anticholinergic agents used to control extrapyramidal reactions include benztropine mesylate, trihexyphenidyl, biperiden, and diphenhydramine. Perphenazine is an antipsychotic agent; doxepin, an antidepressant; and clorazepate, an antianxiety agent. Because these medications have no anticholinergic or neurotransmitter effects, they don't alleviate extrapyramidal reactions.

The nurse assesses an infant who has a fever of 101° F (38.3° C) and who has an upper respiratory infection. The child is "fussy" and pulling on her ear. Which are the nurse's best actions? Select all that apply.

Perform an ear exam. Administer amoxicillin orally for 10 days. Administer acetaminophen. The symptoms that are described are for acute otitis media. The child has a temperature and meets criteria to be treated with antibiotics. The healthcare provider will diagnosis this finding with an otoscopy and encourages the use of acetaminophen for pain and fever. Follow-up should occur after the antibiotic treatment is completed, and the use of heat is encouraged.

A nurse is preparing to auscultate fetal heart tones in a pregnant client. Abdominal palpation reveals a hard, round mass under the left side of the rib cage; a softer, round mass just above the symphysis pubis; small, irregular shapes in the right side of the abdomen; and a long, firm mass on the left side of the abdomen. Based on these findings, what is the best place to auscultate fetal heart tones?

Left upper abdominal quadrant In this client, abdominal palpation reveals that the fetus is lying in a breech position with its back facing the client's left side. Because fetal heart tones are best heard through the fetus's back, the nurse should place the fetoscope or ultrasound stethoscope in the left upper abdominal quadrant for auscultation. Although placement in other locations might allow auscultation of fetal heart tones, the tones would be less clear.

After suctioning a client with a tracheotomy tube, the nurse performs an assessment to determine the effectiveness of the suctioning. Which findings indicate that no further interventions are needed?

Respiratory rate drops from 24 breaths/minute to 16 breaths/minute. Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, increased pulse rate, and bubbling breath sounds indicate respiratory secretion accumulation.

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? All options must be used.

Splint the incisional site. Inhale through the nose. Exhale through pursed lips. Cough deeply from the lungs. The client must first splint the incision to avoid increased intolerable pain or he or she may not cooperate with the pulmonary ventilation. The next step is to inhale oxygen to expand the alveoli for a few seconds and then exhale carbon dioxide in successive steps 5 to 10 times. The client should try to cough on the end of the exhalation to remove retained secretions from the larger airways.

A nurse is taking an admission history, including a medication list, from a client. The listing of which herbal medication would prompt the nurse to ask the client more questions regarding any history of depressive symptoms?

St. John's wort St. John's wort has been found to have serotonin-elevating properties, similar to prescription antidepressants and is sometimes used to treat depression. The nurse, however, should keep in mind that close monitoring may be necessary. Ginkgo biloba is used to enhance mental acuity. Echinacea has immune-stimulating properties. Ephedra is a naturally occurring stimulant that is similar to ephedrine. The U.S. Food and Drug Administration and the Canadian Food and Drug Act and Regulations prohibit the sale of products containing ephedra.

The nurse is teaching the mother of a newborn to develop her baby's sensory system. To further improve the infant's most developed sense, what should the nurse instruct the mother to do?

Stroke the newborn's cheek with her nipple to direct the baby's mouth to nipple. Currently, touch is believed to be the most highly developed sense at birth. It is probably why neonates respond well to touch. Auditory sense typically is relatively immature in the neonate, as evidenced by the neonate's selective response to the human voice. By 4 months, the neonate should turn the eyes and head toward a sound coming from behind. Visual sense tends to be relatively immature. At birth, visual acuity is estimated at 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Taste is well developed, with a preference toward glucose; however, touch is more developed at birth.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)?

abdominal distention Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate's immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis.

The nurse should teach the client with erectile dysfunction (ED) to alter his lifestyle by doing which?

avoiding alcohol Avoidance of alcohol can improve the outcome of therapy. Alcohol and smoking can affect a man's ability to have and maintain an erection. The client should be encouraged to follow a healthy diet, but no specific diet is associated with improvement of sexual function. The client should cease smoking, not just decrease smoking. Increasing attempts at intercourse without treatment will not facilitate improvement. The client should be reassured that ED is a common problem and that help is available.

The nurse is to instill drops of phenylephrine hydrochloride into the client's eye prior to cataract surgery. What is the expected outcome?

dilation of the pupil and constriction of blood vessels Instilled in the eye, phenylephrine hydrochloride acts as a mydriatic, causing the pupil to dilate. It also constricts small blood vessels in the eye.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem. Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

The nurse is caring for an adolescent who has been admitted several times with uncontrolled type 1 diabetes. The child is now stabilized and is preparing for discharge. Which of the following should be the priority focus for the nurse when conducting discharge teaching?

management of the therapeutic regimen The priority immediately after recovery is therapy management, including reviewing that the interruption of insulin administration may result in diabetic ketoacidosis. The multiple admissions imply that the adolescent either does not understand the consequences of the disease or is making choices that are not consistent with the health teaching. This is an opportunity to review those choices.

The client comes to the clinic reporting activity restriction and sexual dysfunction. Tests are completed and a diagnosis of L5-S1 herniated disk impinging on the right nerve root is made by the healthcare provider. What assessment findings should the nurse expect to note?

pain radiating down the right leg The nurse would expect pain to radiate across the lower back and down the right leg with the right nerve root. In addition to sciatica pain, this type of herniated disc can lead to weakness when raising the big toe and possibly in the ankle, also known as foot drop. Numbness and pain can also be felt on top of the foot. The right nerve root does not govern sensations felt in the left leg or pelvis or radiating up the right leg.

A nurse is providing dietary teaching for the parents of a child with celiac disease. Which statement by the parents indicates effective teaching?

"Our child should avoid eating prepared puddings." Teaching is effective if the parents identify prepared puddings as a food their child should avoid. A child with celiac disease mustn't consume foods containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other options don't contain gluten and are permitted on a gluten-free diet.

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding should most concern the nurse?

Blood pressure of 146/90 mm Hg A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction and other problems that make the fetus less able to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman older than age 30 doesn't have a greater risk of fetal complications if her general condition is healthy before pregnancy. Syphilis that has been treated doesn't pose an additional risk to the fetus.

A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms?

Magnesium sulfate Magnesium sulfate is the drug of choice to treat hypertension of pregnancy because it reduces edema by causing a shift from the extracellular spaces into the intestines. It also depresses the central nervous system, which decreases the incidence of seizures. Terbutaline is a smooth muscle relaxant used to relax the uterus. Oxytocin is the synthetic form of the pituitary hormone used to stimulate uterine contractions. Calcium gluconate is the antagonist for magnesium toxicity.

When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice?

Create a poster presentation on the topic with a required posttest. A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the posttest will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way might be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not assure that the information is read.

The nurse has withdrawn a narcotic medication from the dispenser at a skilled nursing facility. The medication is ordered as needed. When the nurse enters the client's room, the client refuses the medication while the family is visiting. How will the nurse proceed with the correct procedure? Select all that apply.

Destroy the narcotic tablet immediately with a second nurse. Offer the option to have the narcotic when the client feels it is needed. The nurse will destroy the narcotic tablet immediately with a second nurse and offer the option to have the narcotic when the client feels it is needed to respect refusal and dispose of narcotic safely. The client has the right to refuse the narcotic. The narcotics must be stored safely and should not be relabeled by the nurse or kept for later administration.

A nurse is administering a newly prescribed IV antibiotic to a client who suddenly develops wheezing and dyspnea. Which of the following is the nurse's priority action?

Discontinue the antibiotic infusion The nurse should first discontinue the antibiotic because it is the most likely cause of the allergic reaction. Next, oxygen should be administered followed by administration of epinephrine and/or diphenhydramine as ordered.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of a urinary tract infection (UTI). Which assessment finding is an early symptom of UTI in a client with a spinal cord injury?

Fever and change in urine clarity Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next?

Notify the health care provider (HCP) immediately. Ortolani maneuver involves flexing the neonate's knees and hips at right angles and bringing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani sign, suggesting a possible hip dislocation. The nurse should notify the HCP promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. It should be noted that many institutions now limit performing the Ortolani's maneuver to APNs or HCPs. Determining the length of the mother's labor provides no useful information related to the nurse's finding. Keeping the infant under the radiant warmer is necessary only if the neonate's temperature is low or unstable. Checking for hypoglycemia is not indicated at this time, unless the neonate is exhibiting jitteriness.

A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.

Teach diaphragmatic, pursed-lip breathing. Administer low-flow oxygen as needed. Encourage alternating client activity with rest periods. Teach the use of postural drainage and chest physiotherapy. Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because a client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows clients to perform activities without distress. If the client has difficulty mobilizing copious secretions, the nurse would teach the client and family members how to perform postural drainage and chest physiotherapy. Fluid intake would be increased to 3,000 ml/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client would be placed in high Fowler's position to improve ventilation.

A six-month-old infant is being admitted with a diagnosis of bacterial meningitis. What considerations should be made, by the nurse, regarding the infant's room assignment? Select all that apply.

The child will need to be on droplet precautions. A private room is required. The room should be near the nurses' station. An infant, diagnosed with bacterial meningitis, should be placed on droplet precautions in a private room until that child has received IV antibiotics for 24 hours. This infant would be contagious. Bacterial meningitis can be quite serious; therefore, the infant's room should be near the nurses' station for close monitoring and easier access. The infant's parents would be permitted to visit as long as they wear the proper PPE. Although a window in the door is ideal, it is not a requirement.

The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors?

The tremors sometimes disappear with purposeful and voluntary movements. Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.

The nurse notes that a neonate's Apgar score at 5 minutes was 9. The nurse interprets this as indicating which information about the neonate?

the neonate was in stable condition Apgar scores are generally determined at 1 and 5 minutes after birth by someone who has not assisted with the birth of the neonate. The maximum score is 2 on each of five signs, including heart rate (greater than 100 bpm), color (completely pink), respiratory effort (good, crying), reflex irritability (cough, sneeze, cry), and muscle tone (well flexed). A total score lower than 4 requires vigorous resuscitation, a score of 4 to 6 means that the infant required some stimulation and oxygenation, and a score of 7 to 10 is considered good, indicating that the neonate is in stable condition. There is a high correlation between a low Apgar score and neonatal morbidity and mortality, primarily because of neurologic morbidity.

A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, which rationale best explains why a pregnant client would lie on her left side when resting or sleeping in the later stages of pregnancy?

to prevent compression of the vena cava The weight of the pregnant uterus is sufficiently heavy to compress the vena cava, which could impair blood flow to the uterus, possibly decreasing oxygen to the fetus. The client may experience supine hypotension syndrome (faintness, diaphoresis, and hypotension) from the pressure on the inferior vena cava. The side-lying position puts the weight of the fetus on the bed, not on the woman. The side-lying position has not been shown to prevent fetal anomalies, nor does it facilitate bladder emptying or digestion.