Nclex review 1-5

The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which of the following dietary requirements should be considered by the nurse? 1. High protein, high fat, and high calories. 2. High protein, low fat, and high calories. 3. Low protein, low fat, and low carbohydrate. 4. High protein, high fat, and low carbohydrate.

(1) contains high fat (2) correct—impaired intestinal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients (3) not adequate for this child (4) contains high fat

A client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to observe which of the following? 1. Darker skin that is more pigmented. 2. Skin that is ruddy and oily. 3. Skin that is puffy and scaly. 4. Skin that is pale and dry.

(1) correct—increase in melanocyte-stimulating hormone results in "eternal tan" (2) not seen with Addison's disease (3) not seen with Addison's disease (4) not seen with Addison's disease

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

(1) done when cast is completely dry, prevents crumbling of plaster into cast (2) correct—minimizes swelling, elevated for first 24 to 48 hours, protects from pressure and flattening of cast (3) would delay drying of cast (4) maintaining mobility of fingers not most important after application of cast

A client who is positive for human immunodeficiency virus (HIV) is to be discharged and will be taking zidovudine (AZT) at home. Which of the following actions by the nurse is BEST? 1. Review the importance of adhering to a 4-hour schedule. 2. Advise the client to buy a timed pill dispenser. 3. Write the schedule of when the medicine should be taken. 4. Encourage self-medication prior to discharge.

(1) less helpful in the overall teaching-learning process (2) less helpful in the overall teaching-learning process (3) correct—planned and written schedule of administration is more effective for adherence to time frames (4) less helpful in the overall teaching-learning process ...

The nurse assesses a client diagnosed with a detached retina. Which of the following observations supports this diagnosis? 1. Loss of acuity in the peripheral visual field. 2. Increased lacrimation, blurred vision. 3. Conjunctivitis, dilated pupils bilaterally. 4. Photophobia, loss of a portion of the visual field.

(1) loss of peripheral vision occurs with glaucoma; loss of acuity occurs with cataracts (2) occurs with ocular infections (3) has no correlation with detached retina (4) correct—bright flashes of light and client stating that portion of visual field is dark are classic symptoms

An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to the client by the nurse? 1. "Take the medication on a full stomach or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for 2 weeks."

(1) should be taken on an empty stomach (2) correct—photosensitivity occurs with the use of this medication (3) should be taken as directed (4) unnecessary ...

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

(1) appropriate action; if client has for at least 4 hours, pH of gastric aspirate is 1 to 4 (2) correct—air injected to lungs, pharynx or esophagus may transmit similar sound (3) acceptable action (4) appropriate action; enables easier aspiration of fluid (5) correct—not considered acceptable procedure; if tube placed in lungs, may cause bubbling

Nephrotic syndrome

Loss of large amounts of plasma protein, usually albumin through the urine due to increased permeability of the glomerular membrane.

Cerebrovascular accident (CVA) and facial paralysis complications

Monitor for corneal abrasion r/t inability to close the eye voluntarily

Abduction

Movement away from the midline

Artificial active immunity

Production of one's own antibodies or T cells as a result of vaccination against disease

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

(1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (3) correct—important that accurate documentation be maintained on the internal radium implant (4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

A brace is ordered for a young teen with scoliosis. The nurse determines teaching is effective if the client makes which of the following statements? 1. "I will have my parents put bed-boards on my bed." 2. "I should decrease my caloric intake." 3. "I should only take showers." 4. "I will hold on the rail when going down the stairs."

(1) bed-boards maintain proper vertebral alignment but can't correct lateral curvature of scoliosis (2) diet should be high-calorie due to age of child and growth requirements; diet doesn't affect curvature of the spine (3) either tub bathing or a shower is permitted (4) correct—prevents falls, should also avoid slippery surfaces

A 4 lb 10 oz baby boy is delivered at 32 weeks' gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. The infant has mottling of the skin and acrocyanosis with irregular respirations of 60. The nurse should recognize that these findings indicate which of the following? 1. Hypoglycemia. 2. Cold stress. 3. Birth asphyxia. 4. Hypovolemia.

(1) blood sugar less than 25 mg/dL; would see cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma (2) correct—symptoms describe cold stress (3) would see meconium-stained amniotic fluid (4) would see symptoms of shock

Which of the following statements, if made to the nurse, indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis (CF)? 1. "The gene came from my husband's side of the family." 2. "The gene came from my wife's side of the family." 3. "There is a 50% chance that our next child will have the disease." 4. "Both of us carry a recessive trait for cystic fibrosis."

(1) both parents are carriers of the abnormal gene (2) both parents are carriers of the abnormal gene (3) there is a 25% chance of passing the disease on to any of their offspring (4) correct—cystic fibrosis is inherited by an autosomal recessive trait

The nurse recognizes which of the following as a positive response to fluoxetine HCl (Prozac)? 1. The nurse notes hand tremors and leg twitching. 2. The client states that he is able to sleep for longer periods of time. 3. The client has an increased energy level and participates in unit activities. 4. The nurse observes that the client is hypervigilant and scans the environment.

(1) can be side effect of the medication (2) not an effect of Prozac, can actually inhibit sleep; is useful with clients who experience increased sleeping and psychomotor retardation and lethargy (3) correct—fluoxetine HC (Prozac) is an "energizing" antidepressant; as client begins to demonstrate a positive response, he has an increased energy level, is able to participate more in milieu (4) can be side effect of medication ...

The nurse instructs the client about a low-sodium, low-cholesterol diet. The nurse determines the client teaching is effective if the client selects which of the following menus? 1. Canned vegetable soup, applesauce, and hot chocolate. 2. Cheeseburger, french fries, and skim milk. 3. Tomato and lettuce salad, roasted chicken, and lemonade. 4. Tuna fish sandwich, cottage cheese, and a cola.

(1) canned foods contain increased salt, and milk contains cholesterol (2) breads contain sodium, and dairy products and beef contain cholesterol (3) correct—fresh fruits and vegetables are low sodium, roasted chicken is low cholesterol (4) bread and carbonated beverages contain sodium

A client at 16 weeks' gestation undergoes an amniocentesis. The client asks the nurse what the physician will learn from this procedure. The nurse's response should be based on an understanding that which of the following conditions can be detected by an amniocentesis? 1. Tetralogy of Fallot. 2. Talipes equinovarus. 3. Hemolytic disease of the newborn. 4. Cleft lip and palate.

(1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle (2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot (3) correct—maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis (4) congenital deformity detected at birth, midline fissure or opening into lip or palate

The physician orders sucralfate (Carafate) 1 g PO bid for a client taking digoxin (Lanoxin) 0.25 mg daily. The client asks the nurse if both pills can be taken together at breakfast so that the client doesn't forget to take them. The nurse should advise the client to take which of the following actions? 1. Take the Carafate and Lanoxin before breakfast. 2. Take the Lanoxin 1 hour before breakfast and the Carafate 1 hour after breakfast. 3. Take the Carafate 1 hour before breakfast and the Lanoxin 1 hour after breakfast. 4. Take the Carafate and the Lanoxin after breakfast.

(1) Carafate forms a barrier on the gastrointestinal mucosa, would decrease absorption of other medications, separate by 2 hours (2) Carafate best results on empty stomach (3) correct—Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption (4) Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption ...

The nurse cares for a patient admitted with low back pain. The history indicates that the patient has hemophilia A. The nurse should question which of the following orders? 1. Ketorolac tromethamine (Toradol). 2. Codeine phosphate (Paveral). 3. Oxycodone terephthalate (Percodan). 4. Hydromorphone hydrochloride (Dilaudid).

(1) NSAID (nonsteroidal anti-inflammatory drug) used for short-term management of pain (2) analgesic used for moderate to severe pain (3) correct—contraindicated for persons with bleeding disorders, contains aspirin (4) narcotic analgesic used for moderate to severe pain

A client returns from surgery after a right mastectomy with an IV of 0.9% NaCl. Several hours later, the IV infiltrates. The nurse supervises a student preparing to insert a new peripheral IV catheter. The nurse should intervene in which of the following situations? 1. The student nurse selects a site where the veins are soft and elastic. 2. The student nurse selects a site on the distal portion of the left arm. 3. The student nurse selects a site close to the joint to provide for stability. 4. The student nurse holds the skin taut to stabilize the vein.

(1) acceptable site selection (2) acceptable site selection (3) correct inappropriate; movement in area could cause displacement (4) acceptable procedure

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

(1) although the patient requires a high level of nursing care, no indication that the patient is unstable (2) patient requires preoperative assessment and teaching, no indication that the patient is unstable (3) correct —epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting (4) requires monitoring but patient with epidural takes priority

A client with an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L has digoxin (Lanoxin) ordered. Which of the following actions, if taken by the nurse, is BEST? 1. Give the digoxin. 2. Hold the digoxin. 3. Notify the physician. 4. Recheck the pulse.

(1) although the pulse is normal, level of potassium must be considered (2) notify physician about low potassium (3) correct—hypokalemia can precipitate digoxin toxicity; physician should be called to obtain order for potassium supplement (4) notify physician about the potassium level

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

(1) an increase in sleep could indicate a complication with intracranial pressure (2) correct—early signs of increased intracranial pressure are alterations in orientation (3) negative Babinski is normal (4) ignores assessment of a potential complication; fluid would not be increased for a child with a closed head injury

The nurse observes a client who is taking phenelzine (Nardil) eat another client's lunch. After a few minutes, the client complains of headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which of the following medications? 1. Buspirone (BuSpar). 2. Fluoxetine (Prozac). 3. Prochlorperazine (Compazine). 4. Nifedipine (Procardia).

(1) antianxiety; side effects include light-headedness, confusion, hypotension, palpitations (2) SSRI antidepressant; side effects include palpitation, bradycardia, nausea and vomiting (3) antiemetic; side effect include drowsiness, orthostatic hypotension (4) correct—antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; side effects include dizziness, headache, nervousness

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

(1) antibiotic should be administered within 1 hour (2) unnecessary for safe infusion (3) correct—when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion

An older client with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question? 1. Propranolol (Inderal), 80 mg PO QID. 2. Verapamil (Nifedipine), 40 mg PO TID. 3. Tetrahydrozoline (Visine), 2 gtt both eyes TID. 4. Timolol (Timoptic solution), 1 gtt both eyes daily.

(1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma (2) calcium channel blocker used as antianginal; not contraindicated (3) correct—contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension (4) reduces aqueous formation and increases outflow, used for glaucoma

The nurse cares for a client receiving atorvastatin (Lipitor). It is MOST important for the nurse to report which of the following client statements to the physician? 1. "I no longer drink grapefruit juice." 2. "I have my liver enzymes checked regularly." 3. "I take a daily multivitamin." 4. "I take propranolol (Inderal)."

(1) appropriate action; grapefruit juice decreases the enzyme that breaks down atorvastatin (2) appropriate action (3) not contraindicated (4) correct—propranolol decreases the effectiveness of atorvastatin

The nurse in a long-term care facility reviews the nurse's notes in a client's chart. The nurse is MOST concerned by which of the following entries? 1. "Foley catheter draining clear urine and the pH is 6.5." 2. "The client's skin is blanched over the scapular areas." 3. "Vital signs are within normal limits." 4. "The client drinks three glasses of orange juice every day."

(1) appropriate charting of normal urine (2) correct—blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers (3) although the charting is not objective, blanching of the skin takes priority because it indicates a problem (4) appropriate charting

The nurse identifies which psychosocial stage should be a priority to consider while planning care for a 20-year-old client? 1. Identity versus identity diffusion. 2. Intimacy versus isolation. 3. Integrity versus despair and disgust. 4. Industry versus inferiority.

(1) appropriate for adolescents (2) correct—is the stage for 19- to 35-year-olds (3) for 65 years and older (4) for 6 to 12 years of age

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

(1) appropriate position (2) decreases swelling and pain (3) correct—client should not be positioned with operative side in a dependent position or against the bed (4) shield is appropriate

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

(1) appropriate procedure, prevents airborne contamination (2) insulin is the only medication that can be given, compatible with TPN (3) correct—applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur (4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour

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

(1) assessment of client's abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill (2) measures cognitive function (3) correct is most widely accepted examination to test for the presence of tardive dyskinesia (4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population

The nurse teaches a group of Boy Scouts how to prevent Lyme disease. Which of the following statements, if made by one of the Boy Scouts to the nurse, indicates that further teaching is necessary? 1. "When I go on a long hike, I should check any exposed skin for insects every 4 hours." 2. "When I hike in the woods, I should wear long pants, socks, and a long-sleeved shirt." 3. "I should remove any ticks by crushing them firmly against the skin." 4. "I should reapply insect repellant every couple of hours when hiking."

(1) assessment, should be done to check for ticks that transmit disease; pay particular attention to arms, legs, and hairline (2) protects exposed skin from ticks (3) correct—should not be crushed, remove tick with tweezers or fingers and flush down toilet; burning a tick could spread infection (4) protects exposed skin from ticks, avoid heavily wooded areas

A client received thrombolytic therapy, and the physician orders meperidine (Demerol) IM for pain. Before administering the injection, the nurse should take which of the following actions? 1. Confirm that all lab work has been completed. 2. Verify the order with the physician. 3. Check the client's PTT. 4. Determine that all of the thrombolytic agent has infused.

(1) assessment, unnecessary (2) correct—implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order (3) assessment, PTT should be monitored, but this is not a priority action (4) implementation, unnecessary

An infant is admitted with vomiting and diarrhea. The infant's anterior fontanelle is depressed and temperature is 103.2°F (39.5°C). Which of the following nursing actions is MOST appropriate? 1. Obtain daily weights and evaluate weight loss. 2. Observe the infant's ability to take in fluids. 3. Place a full bottle of Pedi-Lyte at the bedside. 4. Start an intravenous infusion.

(1) assessment; correct information, but is not what the question asks for (2) correct—assessment; will assist in determining if hydration can be done through oral fluids alone (3) implementation; does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee that the infant is taking fluids (4) implementation; would be implemented later

Lead poisoning antidote

-dimercaprol (also used for other poisonings - gold, arsenic, mercury) -EDTA -succimer (Chemet)

An older woman is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck's traction with a 7-pound weight. Which of the following instructions about moving should be given by the nurse to encourage the patient to participate in her care? 1. "Pull up on the overhead trapeze while you push down on your right foot to lift your body." 2. "With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently." 3. "I'll raise the head of the bed 45 degrees, and then you lean forward and rotate your hips to the left." 4. "Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."

(1) correct—body must move as single, straight unit (2) turning or twisting from the waist down interferes with countertraction (3) prevents proper pull of weights (4) can't turn from side to side; can only move up and down

A child returns to the recovery room after a bronchoscopy. The nurse should position the client in which of the following positions? 1. Semi-Fowler's position. 2. Prone with the head turned to the side. 3. Head of the bed elevated 45° with the neck extended. 4. Supine with the head in the midline position.

(1) correct—check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm) (2) would limit respiratory excursion and assessment of breathing (3) extension of neck could obstruct airway because tongue falls in back of mouth (4) not best position after procedure

To assist a parent to provide appropriate foods for a 3-year-old, the nurse identifies which of the following as the HIGHEST priority? 1. Provide the child with finger foods. 2. Allow the child to eat her favorite foods. 3. Encourage a diet higher in protein than in other nutrients. 4. Limit the number of snacks during the day.

(1) correct—child is going through autonomy versus shame and doubt stage; finger foods allow child the necessary independence for this stage (2) child may eat food without appropriate nutrients (3) inappropriate for a 3-year-old child (4) inappropriate for a 3-year-old child

The physician suggests play therapy for a 7-year-old child having some difficulty adjusting to the parents' impending divorce. The nurse identifies this type of therapy is effective for which of the following reasons? 1. Young children have difficulty verbalizing emotions. 2. Children hesitate to confide in anyone but their parents. 3. Play is an enjoyable form of therapy for children. 4. Play therapy is helpful in preventing regression.

(1) correct—children have difficulty putting feelings into words; play is how they express themselves

A mother brings her 10-year-old and 3-year-old daughters to the pediatrician's office because the younger girl complains of dysuria. The physician orders a catheterization to obtain a urine specimen. The nurse should take which of the following actions? 1. Describe the procedure to the child in short, concrete terms while talking calmly. 2. Allow the child to play with the equipment during the procedure. 3. Involve the girl's older sister in explaining the procedure. 4. Show the child a diagram of the urinary system.

(1) correct—children this age need simple explanations (2) might contaminate the equipment; must be a sterile procedure (3) not likely to listen to sister (4) not appropriate for this age

A client diagnosed with an adjustment disorder with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which of the following times? 1. During the morning hours. 2. During the middle of the day. 3. During the afternoon hours. 4. During the evening hours.

(1) correct—client with reactive depression has the highest level of physical and psychic energy in the morning (2) as the day progresses, energy level declines

The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse identifies which of the following symptoms is a common initial side effect of this medication? 1. Nausea. 2. Visual disturbances. 3. Tinnitus. 4. Ataxia.

(1) correct—common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence (2) seen with long-term use (3) ringing in the ears is seen with long-term use (4) unsteady gait rarely seen

A client is admitted with irritable bowel syndrome. The nurse anticipates that the client's history will reflect which of the following? 1. Pattern of alternating diarrhea and constipation. 2. Chronic diarrhea stools occurring 10 to 12 times per day. 3. Diarrhea and vomiting with severe abdominal distention. 4. Bloody stools with increased cramping after eating.

(1) correct—condition is often called spastic bowel disease; no inflammation is present (2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (4) bloody stools do not occur with irritable bowel syndrome

The nurse assists a nursing assistant in providing a bed bath to a comatose patient with incontinence. The nurse should intervene if which of the following actions is noted? 1. The nursing assistant answers the phone while wearing gloves. 2. The nursing assistant log rolls the patient to provide back care. 3. The nursing assistant places an incontinent pad under the patient. 4. The nursing assistant positions the patient on the left side, head elevated.

(1) correct—contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway

The home care nurse instructs the spouse of a client about how to perform a wet-to-dry abdominal dressing for the client because of an infected abdominal incision. The nurse should intervene if which of the following is observed? 1. The client's spouse wets the old dressing with sterile saline before removing it. 2. The client's spouse covers the wound with wet, sterile 4 × 4s. 3. The client's spouse irrigates the wound with hydrogen peroxide using a bulb syringe. 4. The client's spouse uses Montgomery straps to secure the dressing.

(1) correct—contraindicated, remove dry so wound debris and necrotic tissue are removed with old dressing (2) purpose of wet-to-dry dressing is to débride incision; wetting dressing before removal defeats purpose of dressing (3) irrigation of wound sometimes used (4) adhesive is attached to skin and laced to secure dressing, used when frequent dressing changes are anticipated

The nurse cares for a patient 36 hours after a traditional cholecystectomy. The nurse is MOST concerned if which of the following is observed? 1. The patient complains of severe abdominal pain in the right upper quadrant. 2. 500 mL of greenish-brown fluid drained from the T-tube in the last 24 hours 3. The patient has received an antiemetic twice since surgery. 4. Lab tests indicate an Hgb of 14 g/dL, Hct of 44%, and WBC of 6,000/mm3

(1) correct—could indicate peritonitis or wound infection (2) expected drainage, usually 500-1000 mL/day initially, will gradually decrease (3) some nausea expected (4) results within normal limits, normal Hgb: male 13.5-17.5 g/dL, female 12-16 g/dL, normal Hct: male 41-53%, female 36-46%, normal WBC 5,000-10,000/mm3

The nurse cares for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient in which of the following positions? 1. With the client's neck in a midline position and the head of the bed elevated 30°. 2. Side-lying with the client's head extended and the bed flat. 3. In high Fowler's position with the client's head maintained in a neutral position. 4. In semi-Fowler's position with the client's head turned to the side.

(1) correct—decreases intracranial pressure (2) decreases venous blood return (3) too elevated, would increase intracranial pressure (4) head should be maintained in neutral position ...

The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective? 1. The client swallows air and then eructates it while forming words with his mouth. 2. The client places a battery-powered device against the side of his neck. 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords. 4. The client covers the stoma in the tracheoesophageal fistula and moves his lips.

(1) correct—describes esophageal speech (2) describes electric larynx (3) method of speech for patient with a tracheostomy (4) describes tracheoesophageal fistula (TEF) ...

A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection. The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment includes which of the following? 1. Minimizes the bacterial count in the mouth. 2. Softens the mucous membranes of the tongue before surgery. 3. Stimulates the microcirculation of the mouth. 4. Hydrates the tissues of the gums.

(1) correct—destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes

The nurse cares for clients in the skilled nursing facility. Which of the following clients requires the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired 2 days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization.

(1) correct—duration of Coumadin 2 to 5 days, client at risk for a repeat CVA (2) anticoagulant takes priority, client still receiving pain medication (3) painful urination, may indicate infection (4) anticoagulant takes priority ...

An 8-year-old has been receiving chemotherapy for 6 months. During her nursing care she asks, "Am I going to die?" Which of the following responses by the nurse is BEST? 1. "Are you afraid of dying?" 2. "Why do you ask that question?" 3. "Only God knows that answer." 4. "We won't leave you alone."

(1) correct—encourages ventilation of thoughts and feelings regarding the concern (2) inappropriate (3) ignores the child's concern with dying (4) ignores the child's concern with dying

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

(1) correct—entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing) (2) doesn't address issue of breathing pattern needed during transition phase of labor (3) used in conjunction with controlled breathing for Lamaze (4) needs support and coaching of husband during transition phase of labor

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

(1) correct—extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis; highly contagious; infected employees cannot work until symptoms have resolved in 3 to 7 days (2) restrict from patient contact and the patient's environment (3) restrict from patient contact and the patient's environment (4) cannot work

A 6-month-old infant has had all of the required immunizations. The nurse knows that this would include which of the following? 1. Two doses of diphtheria, tetanus, and pertussis vaccine. 2. Measles, mumps, and rubella vaccines. 3. A booster dose of the inactivated polio vaccine. 4. Chickenpox and smallpox vaccines.

(1) correct—first dose of the DPT may be given at 2 months of age, the second is given around 4 months (2) MMR is given at 15 months (3) polio is given at 2 and 4 months and again at 12 to 18 months (4) recommended for first responders

The nurse cares for a 26-year-old woman immediately after delivery of 8-lb, 4-oz baby girl. The patient's history indicates that she was diagnosed with type 1 diabetes at age 12. The nurse expects which of the following changes to occur in the patient? 1. The blood sugar will fall because of a sudden decrease in insulin requirements. 2. The blood sugar will rise because of a rapid decrease in circulating insulin. 3. The blood sugar will gradually rise because of a decreased level of metabolic stress. 4. The blood sugar will gradually fall because of a decrease in food intake.

(1) correct—hormonal interference in glucose metabolism during pregnancy causes insulin requirements to increase then decrease after delivery (2) blood sugar will fall after delivery (3) blood sugar level will fall after delivery (4) fall in blood sugar not primarily caused by decrease in food intake

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

(1) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) indication of hyperthyroidism (3) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (4) correct—hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (5) indication of hypothyroidism (6) indication of hypoparathyroidism

A 10-year-old child weighing 50 lb (23.6 kg) returns from surgery for a skin graft to the left leg. The patient has an IV of D5W infusing into the left arm. The physician's orders read: "D5W 2,000 cc/24 h." It is MOST important for the nurse to take which of the following actions? 1. Call the physician to clarify the IV fluid order. 2. Keep accurate records of the patient's intake and output. 3. Set the controller on the IV pump to infuse at 84 gtt/min. 4. Monitor the patient for fluid and electrolyte balance.

(1) correct—implementation, amount is excessive for child and there are no electrolytes in fluid (2) implementation, may have serious electrolyte disturbances before discrepancies are seen in I and O (3) implementation, rate is correct for amount of fluid ordered, but amount is excessive for child and fluid is inappropriate (4) assessment, should not administer fluids as ordered because they are inappropriate in amount and content

A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Which of the following actions should the nurse take FIRST? 1. Loosely cover the wound, preferably with a sterile dressing. 2. Place a sandbag over the wound. 3. Monitor chest wound drainage. 4. Place a firm, airtight, sterile dressing over the wound.

(1) correct—implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not re-enter the pleural space (2) implementation, would prevent air from escaping (3) assessment, chest tube has not yet been inserted (4) implementation, would prevent air from escaping

The nurse observes a staff member enter the room of a client wearing a scrub suit. The nurse determines that the staff member is using the proper precautions if the staff member cares for which of the following clients? 1. A client diagnosed with cancer complaining of a sore mouth. 2. A client diagnosed with tuberculosis requiring administration of Rifampin. 3. A client diagnosed with rubella requiring an IM injection. 4. A client diagnosed with a draining abscess that is not covered with a dressing.

(1) correct—indicates Candida, standard precautions required (2) requires airborne precautions (3) requires droplet precautions (4) abscess with no dressing requires contact precaution

Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep.

(1) correct—indication that the client is approaching delirium tremens, which can be avoided with additional sedation (2) describes normal mild withdrawal symptoms (3) would contraindicate giving more sedation (4) describes expected symptoms of alcohol withdrawal, which will subside as the alcohol is excreted from the body

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

(1) correct—initial indications of hepatic dysfunction (2) seen with pancreatic problems (3) seen with renal problems (4) is not seen with liver problems

The nurse teaches nutrition classes at the community center. Which of the following foods should the nurse encourage a low-income client to eat to satisfy essential protein needs? 1. Legumes. 2. Red meat. 3. Seafood. 4. Cheese.

(1) correct—legumes are an economical source rich in protein (2) high in protein, but more expensive to purchase (3) high in protein, but more expensive to purchase (4) high in protein, but more expensive to purchase

A client is scheduled to have a parathyroidectomy. The nurse is MOST concerned if the client is observed eating quantities of food from which of the following food groups? 1. Milk products. 2. Green vegetables. 3. Seafood. 4. Poultry products.

(1) correct—low-calcium diet is recommended preoperatively (2) diet should be high in phosphorus and low in calcium (3) diet should be high in phosphorus and low in calcium (4) poultry is allowed in the diet

The nurse cares for a client receiving haloperidol (Haldol). The nurse should anticipate which of the following side effects? 1. Blood dyscrasia and extrapyramidal symptoms. 2. Hearing loss and unsteady gait. 3. Nystagmus and vertical gaze palsy. 4. Alteration in level of consciousness and increased confusion.

(1) correct—major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS) (2) not seen with haloperidol (3) not seen with haloperidol (4) not seen with haloperidol

The physician orders chlorpromazine (Thorazine) to control an alcoholic client's restlessness, agitation, and irritability following surgery. The nurse should check the order with the physician based on which of the following rationales? 1. The nurse believes that the client's symptoms reflect alcohol withdrawal. 2. The nurse does not know if the client is allergic to this medication. 3. The nurse knows that the client is not psychotic. 4. The nurse routinely checks on the doctor's orders.

(1) correct—medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences (2) not best rationale for checking with doctor about this order (3) not best rationale for checking with doctor about this order (4) not best rationale for checking with doctor about this order

The nurse makes patient assignments on the obstetrics unit. Which of the following patients should the nurse assign to an RN who has been reassigned to the obstetrics unit from outpatient surgery? 1. A patient at 16 weeks' gestation admitted with hyperemesis and receiving IV fluids. 2. A patient at 26 weeks' gestation in premature labor and receiving terbutaline (Brethine). 3. A patient at 32 weeks' gestation with a placenta previa and ruptured membranes. 4. A patient at 37 weeks' gestation with pregnancy-induced hypertension and epigastric pain.

(1) correct—monitor IV therapy, administer antiemetics and nutritional supplements (2) monitor patient's response to medication and the status of the fetus (3) prepare for delivery, closely monitor fetal response (4) indicates impending seizures, prepare for delivery

The nurse assesses a pregnant client with a diagnosis of mitral stenosis and heart failure (HF). The nurse identifies that which of the following in the client's history has a direct correlation with the current problem? 1. History of rheumatic fever 4 years ago. 2. Presence of ventricular septal defect as an infant. 3. Heart disease in both the maternal and the paternal families. 4. Persistent ear infections and mastoiditis as a child.

(1) correct—most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve (2) does not contribute to mitral valve disease (3) does not contribute to mitral valve disease (4) does not contribute to mitral valve disease

A 25-year-old primigravida diagnosed with type 1 diabetes mellitus reviews the insulin regimen with the nurse. The nurse explains to the client that her insulin needs will change in which of the following ways? 1. Increase during pregnancy and decrease after delivery. 2. Decrease during pregnancy and increase after delivery. 3. Increase during pregnancy and remain increased after delivery. 4. Decrease during pregnancy and fluctuate after delivery.

(1) correct—needs increase during pregnancy due to hormonal interference in glucose metabolism (2) needs increase during pregnancy due to hormonal interference in glucose metabolism (3) insulin needs will decrease after delivery (4) needs increase during pregnancy

The nurse observes the fetal heart monitor for a client in active labor. The fetal heart tracing shows early fetal decelerations. The nurse is aware that this is 1. a slowing early in the contraction, and is usually a normal finding. 2. a slowing early in the contraction, and is usually an abnormal finding. 3. a slowing at the peak of the contraction, and is usually a normal finding. 4. a slowing at the peak of the contraction, and is usually an abnormal finding.

(1) correct—occurs in response to compression of fetal head; uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress (2) does not indicate fetal distress (3) slowing is early in the contraction (4) slowing is early in uterine contraction and is not abnormal

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

(1) correct—panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of "losing it" or going crazy

The nurse cares for patients on the psychiatric unit. An extremely angry patient with bipolar illness tells the nurse he just learned his wife has filed for divorce and he needs to use the phone. Which of the following responses by the nurse is MOST appropriate? 1. Allow the patient to use the phone. 2. Confront the patient about his anger and inappropriate plan of action. 3. Do not allow the patient to use the phone because he is an involuntary patient. 4. Set limits on the patient's phone use because he has been unable to control his behavior.

(1) correct—patient is able to use phone unless otherwise indicated by court order or physician's order (2) has not lost civil right to use phone (3) denies patient his civil rights (4) inappropriate

The nurse instructs a client who is receiving imipramine (Tofranil). It is MOST important for the nurse to instruct the client to immediately report which of the following? 1. Sore throat, fever, increased fatigue, vomiting, diarrhea. 2. Dry mouth, nasal stuffiness, weight gain. 3. Rapid heartbeat, frequent headaches, yellowing of eyes or skin. 4. Weakness, staggering gait, tremor, feeling of drunkenness.

(1) correct—possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication (2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication (3) not side effects of Tofranil (4) not side effects of Tofranil

When administering antipsychotic medications parenterally, the nurse should take which of the following actions? 1. Monitor the client's blood pressure while the client is sitting and standing before and after each dose is given. 2. Caution the client not to drink or operate machinery that requires mental alertness for safety. 3. Have an emergency cart available in case of an adverse reaction. 4. Reassure the client that side effects are only temporary.

(1) correct—primary concern with postural hypotension caused by medication and preventing an injury from a fall; monitoring vital signs will provide data to address this concern (2) not relevant with this classification of medications (3) not relevant with this classification of medications (4) not relevant with this classification of medications ...

The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. The nurse understands that the purpose of this nursing action includes which of the following? 1. Promote ventilation and prevent respiratory acidosis. 2. Increase oxygenation and removal of secretions. 3. Increase pH and facilitate balance of bicarbonate. 4. Prevent respiratory alkalosis by increasing oxygenation.

(1) correct—primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure

A client in a psychiatric facility describes seeing snakes on the walls of the room. Which of the following is an accurate nursing diagnosis? 1. Sensory-perceptual alterations: visual. 2. Altered thought processes. 3. Ineffective individual coping. 4. Impaired social interaction.

(1) correct—reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data

Which nursing intervention is a priority in preventing complications after a cesarean birth? 1. Turn, cough, and deep breathe. 2. Limit fluid intake. 3. Supply a high-carbohydrate diet. 4. Evaluate skin integrity.

(1) correct—represents preventive care for respiratory congestion resulting from anesthesia and shallow respirations due to the abdominal incision (2) fluids should be encouraged (3) will not prevent complications (4) does not address a common complication...

The nurse prepares the client for an IV pyelography (IVP) scheduled in 2 hours. The nurse should contact the physician if the client states which of the following? 1. "I take metformin (Glucophage) for type 2 diabetes." 2. "I completed the bowel prep last evening." 3. "I ate a light meal last evening." 4. "I had an IVP 3 years ago."

(1) correct—should discontinue 48 hours prior to procedure, contrast media can cause life-threatening lactic acidosis (2) appropriate action; removes feces, fluid, and air from bowel so kidneys, ureters, and bladder will not be obscured (3) appropriate action (4) no reason to contact the physician

The nurse cares for a client diagnosed with a recurrent urinary tract infection. The physician orders methenamine mandelate (Mandelamine). The nurse should instruct the client to limit intake of which of the following fluids? 1. Milk. 2. Cranberry juice. 3. Water. 4. Tea.

(1) correct—should limit intake of alkaline foods and fluids (2) should be increased to acidify urine (3) does not need to be restricted (4) does not need to be restricted

The nurse enters the room of a 17-year-old mother breast feeding her 6-lb, 7-oz infant girl. Which of the following observations, if made by the nurse, BEST indicates that mother-infant bonding is taking place successfully? 1. The mother is looking into her infant's eyes as she feeds her. 2. The mother and infant are laying side-by-side in the bed. 3. The mother appears to be relaxed and is reading a book on childcare. 4. The mother interrupts feeding the infant to talk to her roommate.

(1) correct—shows bonding behavior of eye-to-eye contact, proceeds to touching and holding (2) shows distance between mother and infant (3) doesn't involve communication between mother and infant (4) shows distance between mother and infant

A patient is treated in the telemetry unit for cardiac disease. The patient receives propranolol hydrochloride (Inderal) 20 mg PO at 9 A.M. When the nurse enters the room to give the medication to the patient, the nurse finds the patient wheezing with a nonproductive cough and shortness of breath. INITIALLY, the nurse should take which of the following actions? 1. Hold the medication and count the respirations. 2. Hold the medication and call the physician. 3. Take an apical pulse and then give the medication. 4. Give the mediation as ordered.

(1) correct—side effects include increased airway resistance; patient is experiencing bronchospasm; should assess and then call the physician (2) should assess the patient's condition first (3) patient is experiencing a side effect; medication should not be given (4) medication should be held; patient is experiencing a side effect

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

(1) correct—signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea (2) describes symptoms of circulatory overload (3) describes a febrile or pyrogenic reaction (4) describes an allergic reaction

The nurse obtains a history on a client with hyperthyroidism. The nurse should report which of the following assessments to the physician? 1. Anxiety with extreme nervousness. 2. Slow, sluggish pulse. 3. Cool, clammy skin. 4. Husky, slow speech.

(1) correct—signs and symptoms of hyperthyroidism are related to an increased metabolic rate (2) related to a decreased metabolic rate (3) related to a decreased metabolic rate (4) related to a decreased metabolic rate

The nurse makes patient assignments on a medical/surgical unit. The staff includes one RN, one RN pulled from the pediatric floor, an LPN/LVN, and a nursing assistant. Which of the following patients should be assigned to the RN from the pediatric floor? 1. A client 1 day postoperative after an appendectomy. 2. A client who had a detached retina surgically repaired 4 hours ago. 3. A client with a Sengstaken-Blakemore tube in place. 4. A client 2 days postoperative after a laminectomy with spinal fusion.

(1) correct—stable patient with expected outcome (2) requires frequent assessment for hemorrhage, instruct client to avoid sneezing, coughing, or straining at stool (3) requires frequent monitoring due to hemorrhage (4) requires assessment and teaching

The nurse completes client assignments for the day. The nurse should assign an LPN/LVN to which of the following clients? 1. A client who had a total hip replacement and requires assistance with ambulation. 2. A client with type I diabetes mellitus who has bilateral 4+ pitting edema of the feet. 3. A client with cholelithiasis scheduled for a cholecystectomy and receiving IV morphine. 4. A client 6 hours postoperative after cystoscopy to remove a mass in the bladder.

(1) correct—stable patient with expected outcome (2) requires the assessment skills of the RN (3) requires assessment and teaching (4) requires assessment skills of RN ...

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

(1) correct—stand slightly behind patient on strong side (2) incorrect positioning (3) use a gait belt to assist patient, don't place hands on patient's arms (4) stand slightly behind patient on strong side

A mother brings her 9-month-old infant to the pediatrician's office with complaints of a fever of 102.2°F (39°C) and frequent vomiting. The nurse expects which of the following reflexes to still be present? 1. Babinski's reflex. 2. Moro's reflex. 3. Tonic neck reflex. 4. Grasp reflex.

(1) correct—stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex; disappears after 1 year of age (2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape; disappears after 3 to 4 months (3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex; disappears by age 3 to 4 months (4) touching palms of hands or soles of feet causes flexion of hands and toes; palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of age

The nurse cares for a client who is receiving a tube feeding around the clock. Which of the following nursing actions is MOST appropriate? 1. Rinse the bag and change the formula every 4 hours. 2. Rinse the bag and change the formula every shift. 3. Change the bag and formula every shift. 4. Rinse the bag and change the formula every 2 hours.

(1) correct—there is an increased growth of organisms after 4 hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis

A client develops a low intestinal obstruction. The nurse anticipates which of the following findings? 1. Nausea, vomiting, abdominal distention. 2. Explosive, irritating diarrhea. 3. Abdominal tenderness with rectal bleeding. 4. Midepigastric discomfort, tarry stool.

(1) correct—there is distention above the level of obstruction and initially hyperactive bowel sounds; would be no stool, as motility distal to (below) the obstruction would cease (2) would be no diarrhea (3) would be no rectal bleeding, abdomen would be distended (4) would be no GI bleeding

Which of the following techniques is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain? 1. Remove the dressing layers one at a time. 2. Clean the wound with Betadine solution and hydrogen peroxide. 3. Clean the drain area first. 4. If the dressing adheres to the wound, pull gently and firmly.

(1) correct—to avoid dislodging drain, remove the dressing layers one at a time (2) do not clean a wound with both Betadine solution and hydrogen peroxide (3) cleansing of the wound is from the center outward to the edges and from the top to the bottom (4) incorrect; may dislodge drain ...

The nurse cares for clients in the outpatient clinic. Which of the following messages should the nurse return FIRST? 1. A mother reports the umbilical cord of her 5-day-old infant is dry and hard to the touch. 2. A mother reports the "soft spot" on the head of her 4-day-old infant feels slightly elevated when the baby sleeps. 3. A mother reports that the circumcision of her 3-day-old infant is covered with yellowish exudate. 4. A father reports that he bumped the crib of his 2-day-old infant and she violently extended her extremities and returned them to their previous position.

(1) expected outcome; falls off within 1 to 2 weeks; no tub baths until the cord falls off (2) correct—fontanelle should feel soft and flat; fullness or bulging indicates increased intracranial pressure (3) normal healing, don't remove exudate; clean with warm water (4) motor reflex is normal; disappears after 3 to 4 months

An adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include which of the following? 1. Explain that the client will walk with a prosthesis soon after surgery. 2. Encourage the client to share feelings and fears about the surgery. 3. Take the informed consent form to the client and ask the client to sign it. 4. Evaluate how the client plans to complete schoolwork during hospitalization.

(1) fails to recognize his immediate concerns (2) correct—discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning (3) client is underage; parents will need to sign the permit (4) is more appropriate for the postoperative period of time than for the preoperative period

Nursing management prior to an intravenous pyelogram (IVP) would include which of the following? 1. A fat-free meal the evening before the examination and radiopaque tablets at bedtime. 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter. 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. 4. Explaining the importance of following directions regarding voiding during the test.

(1) fat-free meal is associated with a gallbladder series (2) a retention Foley catheter may be in place, but not for the purpose of dilating the bladder sphincter (3) correct—because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered (4) there are few directions the client needs to follow during the test

The nurse anticipates a client diagnosed with a gastric ulcer to experience pain at which of the following times? 1. Two to three hours after a meal. 2. During the night. 3. Prior to the ingestion of food. 4. One-half to 1 hour after a meal.

(1) feature of a duodenal ulcer (2) feature of a duodenal ulcer (3) feature of a duodenal ulcer (4) correct—pain related to a gastric ulcer occurs about 0.5 to 1 hour after a meal and rarely at night; is not helped by ingestion of food

The nurse supervises the staff caring for four clients receiving blood transfusions. Which of the four clients should the nurse see FIRST? 1. A client complaining of a headache. 2. A client vomiting. 3. A client complaining of itching. 4. A client with neck vein distention.

(1) febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin (2) correct—hemolytic reaction; most dangerous type of transfusion reaction, symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and renal perfusion (3) allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give Benadryl, and administer oxygen (4) circulatory overload; treatment is to stop blood, position in an upright position, and administer oxygen ...

The nurse cares for an elderly client who has just had a prosthetic hip implant. The nurse should position the client in which of the following positions? 1. With the affected hip internally rotated and flexed. 2. With the affected hip adducted when turned. 3. In the supine position with the knees elevated 90 degrees. 4. Side-lying with the affected hip in a position of abduction.

(1) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period (2) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period (3) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period (4) correct—position of abduction should be maintained

A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occurs with aging? 1. Decreased frequency. 2. Nocturia. 3. Incontinence. 4. Hematuria.

(1) frequency increases because bladder capacity decreases (2) correct—decreased ability to concentrate urine increases urine formation and increased nocturnal urine production lead to need to awaken to void (3) ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence (4) blood in urine- sign of cancer, infection, or trauma of urinary tract, glomerular disease, renal calculi, bleeding disorders

The nurse assesses a client's neurosensory cerebellar functioning. Which of the following assessment techniques is correct? 1. Test the client's deep tendon reflexes to observe for weakness. 2. Check the client's pupils with a penlight and observe for constriction. 3. Have the client stand with eyes closed and observe for swaying. 4. Ask the client to show her teeth and stick out her tongue.

(1) general central nervous system response, not sensory involvement (2) evaluates for increased intraocular pressure (3) correct—coordination is governed by the cerebellum; this test evaluates neurosensory status (4) evaluates the facial and hypoglossal nerves

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

(1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program (2) not of primary importance in designing an effective behavior modification program (3) not of primary importance in designing an effective behavior modification program (4) not of primary importance in designing an effective behavior modification program

The nurse cares for a client admitted with a diagnosis of acute hypoparathyroidism. It is MOST important for the nurse to have which of the following items available? 1. Tracheostomy set. 2. Cardiac monitor. 3. IV monitor. 4. Heating pad.

(1) correct—tracheostomy set is the most important for the client's safety due to risk for laryngospasm (2) nice to have, but not the most important (3) nice to have, but not the most important (4) unnecessary

During preadmission planning for a client scheduled for a renal transplant, the client should be educated by the nurse regarding which of the following? 1. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively. 2. Arrange all live plants received postoperatively in one section of the room. 3. Continue intermittent peritoneal dialysis for 3 months following surgery. 4. Limit consumption of sodium-free liquids for 1 year postoperatively.

(1) correct—transplant clients require protective isolation following surgery (2) can't have live plants in the room at all (3) no need for dialysis following transplant (4) need to force fluids, not restrict them ...

A client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which of the following is necessary for the nurse to consider regarding the client's nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2. The client will be unable to maintain any oral intake as long as the tracheotomy is in place. 3. Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration. 4. Because the client is dependent on the ventilator, nutritional intake will be delayed.

(1) correct—tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator

The nurse works with a client who has just indicated a wish to kill herself. The client then asks the nurse not to tell anyone. Which of the following responses by the nurse is BEST? 1. Encourage the client not to do anything without thinking it through very carefully. 2. Explain to the client that anything she tells the nurse is kept strictly confidential. 3. Report this to staff members in order to protect the client. 4. Encourage the client to tell the nurse more about what she is feeling.

(1) does not answer client's immediate concern or give client accurate information about what the nurse will do (2) does not answer client's immediate concern or give client accurate information about what the nurse will do (3) correct—nurse must let the client know that this information will be shared with the staff so that the client's safety can be preserved (4) does not answer client's immediate concern or give client accurate information about what the nurse will do

In planning discharge teaching for a client after a lumbar laminectomy, the nurse should instruct the client to exercise regularly to strengthen which muscles? 1. Anal sphincter. 2. Abdominal. 3. Trapezius. 4. Rectus femoris.

(1) does not contribute to support of the lumbar spine (2) correct—strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine (3) does not contribute to support of the lumbar spine (4) does not contribute to support of the lumbar spine

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

(1) does not encourage verbal communication (2) inappropriate for the situation (3) correct—will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions (4) inappropriate for the situation

When caring for a client with myasthenia gravis, it is MOST important for the nurse to consider which of the following? 1. Prevent accidents from falls as a result of vertigo. 2. Maintain fluid and electrolyte balance. 3. Control situations that could increase intracranial pressure and cerebral edema. 4. Assess muscle groups toward the end of the day.

(1) does not experience vertigo (2) fluid and electrolytes usually not a problem for this patient (3) increased intracranial pressure is not associated with myasthenia gravis (4) correct—client has increased muscle fatigue, needs more assistance toward end of day

A 3-month-old infant is experiencing increased intracranial pressure (ICP). Which of the following assessment findings should the nurse report to the physician? 1. Pinpoint pupils. 2. High-pitched cry. 3. Decrease in blood pressure. 4. Absence of reflexes.

(1) does not indicate any immediate problem; as pressure increases, pupils may become dilated (2) correct—sign of increased intracranial pressure (3) does not reflect complication of increased intracranial pressure (4) does not reflect complication of increased intracranial pressure

Which of the following assessments does the nurse expect to make regarding the developmental stage of a 40-year-old male? 1. Cognitive skills are starting to decline. 2. A balance is found among work, family, and social life. 3. Bone mass begins to increase at this age. 4. The client starts to measure life accomplishments against goals.

(1) does not occur (2) occurs earlier in development (3) at age 40, bone mass begins to decrease (4) correct—may precipitate a mid-life crisis ...

The nurse cares for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions? 1. Assess drainage from Penrose drains. 2. Observe dressings for signs of excessive bleeding. 3. Elevate the stump for no less than 40 hours. 4. Provide cast care on the affected extremity.

(1) drains not usually used with amputations (2) rigid cast dressing frequently used to create a socket for prosthesis (3) elevation of extremity unnecessary; rigid cast dressing prevents swelling (4) correct—cast applied to provide uniform compression, prevent pain and contractures

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

(1) encourage the client to void before catheterizing (2) correct—boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder

The nurse plans care for a client on bed rest. To promote evening rest and sleep for this client, it is MOST important for the nurse to take which of the following actions? 1. Provide privacy. 2. Give back rubs at bedtime. 3. Assist with a bath every day. 4. Encourage daytime activities.

(1) excessive privacy can limit sensory input (2) will help client to relax but is not most important (3) should encourage client to do as much of his care as he can to maintain independence (4) correct—provides relief from tension, ensures client naps less during the day, helps client relax ...

The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED? 1. The boy holds his head erect when sitting on the examination table. 2. The boy tries to grasp a toy just out of reach. 3. The boy turns his head to try to locate a sound. 4. The boy smiles spontaneously when he sees his mother.

(1) expected at 3 months (2) correct—unexpected until 6 months of age (3) expected at 3 months of age (4) expected at 3 months of age

The nurse cares for a client after an electroconvulsive therapy (ECT) treatment. The nurse should report which observation to the client's physician? 1. Headache. 2. Disruption in short- and long-term memory. 3. Transient confusional state. 4. Backache.

(1) expected effect (2) expected effect (3) expected effect (4) correct—client undergoing ECT needs to be instructed about what s/he could experience during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the physician

An 11-year-old boy falls off his bicycle and sustains a minor head injury, which is treated at the outpatient clinic. The nurse instructs the boy's mother about his care at home. The nurse determines that further teaching is necessary if the mother makes which of the following statements? 1. "My son may have dizziness for 24 hours." 2. "My son can drink carbonated beverages if he vomits." 3. "My son may complain of nausea." 4. "My son will probably have a headache."

(1) expected for at least 24 hours (2) correct—vomiting unexpected; should be reported to physician immediately; also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours; should not get more intense

A client with an endotracheal tube requires suctioning. Which of the following statements is an accurate description of how the nurse should perform the procedure? 1. Insert the suction catheter 4 in into the tube. Apply suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenate the client. Insert the suction catheter into the tube, and suction while removing the catheter in a back and forth motion. 3. Explain the procedure to the patient. Insert the catheter gently while applying suction, and withdraw using a twisting motion. 4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.

(1) catheter is inserted until resistance is met; never suction longer than 10-15 seconds (2) use twirling motion when withdrawing catheter (3) suction is never applied when catheter is inserted (4) correct—insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion

The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST? 1. A woman in the first trimester of pregnancy complains of heartburn. 2. A man complains of heartburn that radiates to the jaw. 3. A woman complains of hot flashes and difficulty sleeping. 4. A boy complains of knee pain after playing basketball.

(1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing (2) correct—indicates chest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice

A college student comes to the college health services complaining of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumber puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis is made? 1. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, HCT 38%, WBC 18,000/mm3. 2. CSF with RBCs present, Hgb 10 g/dL, HCT 37%, WBC 8,000/mm3. 3. CSF cloudy, Hgb 12 g/dL, HCT 37%, WBC 7,000/mm3. 4. CSF clear, Hgb 15 g/dL, HCT 40%, WBC 11,000/mm3.

(1) correct—CSF normally clear, colorless; normal WBC 5,000 to 10,000 per mm3, normal Hgb (male 13.5 to 17.5 g/dL, female 12 to 16 g/dL), normal HCT (male 41 to 53%, female 36 to 46%) (2) indicates trauma or hemorrhage (3) WBC too low, not typical of bacterial meningitis (4) indicates viral meningitis

During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."

(1) correct—Erikson states that trust results from interaction with dependable, predictable primary caretaker (2) toddler stage concerns autonomy verses shame and doubt (3) preschool state concerns initiative versus guilt (4) latency or school age stage concerns industry versus inferiority

After receiving report, which of the following patients should the nurse see FIRST? 1. A patient in sickle-cell crisis with an infiltrated IV. 2. A patient with leukemia who has received 0.5 unit of packed cells. 3. A patient scheduled for a bronchoscopy. 4. A patient complaining of a leaky colostomy bag.

(1) correct—IV fluids are critical to reduce clotting and pain (2) no indication patient is unstable (3) stable patient (4) stable patient

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

(1) correct—KVO (20 cc/h) will keep access open (2) need to notify physician; rate still too much since patient is in fluid overload (3) IV line may be necessary; diuretics may be ordered (4) description indicates circulatory overload, not infiltration

The nurse cares for a client after delivering an 8 lb, 4 oz girl with diagnosed talipes equinovarus. The woman confides to the nurse, "I feel so bad that my baby is abnormal." Which of the following responses by the nurse is BEST? 1. "It's understandable that you feel this way, but there are treatments to correct your baby's problem." 2. "Your baby is not really abnormal. Her feet just look different because of the way the muscles pull." 3. "You have nothing to feel guilty about. The abnormality is not your fault." 4. "Don't feel bad. Your baby's abnormality can be corrected surgically."

(1) correct—accepts feelings and gives correct information, serial casting is used to treat infant (2) doesn't accept person's feelings, nontherapeutic (3) prematurely interprets person's feelings as guilt, nontherapeutic (4) nontherapeutic to tell person how to feel

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

(1) correct—acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children (2) acute systemic vasculitis in children under 5; standard precautions (3) connective tissue disease; standard precautions (4) standard precautions

The physician prescribes lithium carbonate (Lithobid) 300 mg PO QID for an adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse should encourage the client to maintain an adequate intake of which of the following? 1. Sodium. 2. Protein. 3. Potassium. 4. Iron.

(1) correct—alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity (2) doesn't interact with lithium (3) doesn't interact with lithium (4) doesn't interact with lithium

The nurse cares for clients in the pediatric clinic. The mother of a child calls the nurse to say that after administering Dimetane-DC cough syrup to her child, her child becomes very excitable and restless. Which of the following actions by the nurse is MOST appropriate? 1. Report the child's behavior to the physician to alert the physician to the potential need for a change in medication. 2. Instruct the mother to administer half the ordered amount in all future doses to limit this behavioral response. 3. Instruct the mother to give the child a glass of warm milk to dilute any medication left in the stomach. 4. Chart the child's response to the medication, and alert the staff about the mother's phone call.

(1) correct—although this type of response to antihistamines is not uncommon in young children, it is undesirable and must be reported to the physician so that a change in drug therapy can be initiated (2) is not within the realm of the nurse's scope of practice; physician must order dose changes (3) inappropriate (4) response must be charted, and the child's intolerance to the drug documented and reported to other nurses; this is not enough, physician must be alerted so that preventive action can be taken ...

A 2-year-old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse identifies which of the following as a priority nursing action? 1. Report the findings to the child protection agency. 2. Share this information only with other health care professionals. 3. Document this information in the chart. 4. Share the information with the pediatric social worker.

(1) correct—any suspicion of child abuse should be reported to the child protection agency (2) does not provide or plan for protection of the child (3) does not provide or plan for protection of the child (4) does not provide or plan for protection of the child

A child has a closed transverse fracture of the right ulna. Which of the following actions, if performed by the nurse before the application of a cast, is MOST important? 1. Check the radial pulses bilaterally and compare. 2. Evaluate the skin temperature and tissue turgor in the area. 3. Assess sensation of each foot while the child closes her eyes. 4. Apply baby powder to decrease skin irritation under the cast.

(1) correct—assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment; temperature indicates decreased circulation but is subjective and not most important (3) assessment; upper (not lower) extremity fracture (4) implementation; should not be done because it would increase skin irritation

Which of the following statements should the nurse make to a client who is going to self-administer continuous ambulatory peritoneal dialysis (CAPD) at home? 1. "Check your weight daily." 2. "Maintain clean technique at all times during the procedure." 3. "Milk the catheter to encourage extra fluid to be removed from the abdomen." 4. "Eat a well-balanced, low-protein diet."

(1) correct—assessment; daily weight necessary with peritoneum empty to assess fluid volume status, guidelines for weight gain/loss set by physician (2) implementation; strict aseptic technique required to prevent contamination, sterile = aseptic, clean = antiseptic (3) implementation; don't milk catheter, drainage by gravity only (4) implementation; encouraged to eat a high-protein diet because of protein loss with CAPD ...

The nurse cares for a homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which of the following observations by the nurse confirms this suspicion? 1. The nurse notes that the bladder is distended. 2. The client complains of a constant urge to void. 3. The nurse notes that the urine is concentrated. 4. The client complains of a burning sensation.

(1) correct—bladder distention is one of the earliest signs of obstructed drainage tubing (2) seen with a urinary tract infection (3) seen with dehydration (4) seen with a urinary tract infection

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

(1) gown unnecessary, trash should be left inside room (2) wash hands then remove mask, so microbes aren't transferred from hands to face (3) correct—hands should be washed before removing mask to prevent transfer of microbes to face (4) gown unnecessary

A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge?" 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication."

(1) hallucinations usually not seen with patients with bipolar disorder; seen with psychotic disorders (2) assumption that patient just wants attention (3) correct—side effects include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands) (4) indicates a side effect, not effectiveness of medication

The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster? 1. A 19-year-old with a broken tibia in Buck's traction. 2. A 50-year-old with a diabetic foot ulcer. 3. A 62-year-old heart transplant with suspected rejection. 4. An 84-year-old with chronic obstructive pulmonary disease.

(1) has an acute trauma, is not immunocompromised (2) has a bacterial infection, is not immunocompromised (3) correct—immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus (4) has chronic disease, is not immunocompromised ...

A nurse begins a therapeutic relationship with a client diagnosed with generalized anxiety disorder. It is MOST important for the nurse to obtain which of following information? 1. What the client's priorities are. 2. How the client views herself. 3. In what situations the client gets anxious. 4. If anyone in the client's family has had mental problems.

(1) helpful data; priority is to determine in what situations the client becomes anxious (2) helpful data; priority is to determine in what situations the client becomes anxious (3) correct—will provide necessary information in baseline assessment of client's anxiety (4) helpful data but not priority

The charge nurse notes a young child is placed on droplet precautions. The charge nurse identifies that the nurse cares for which of the following clients? 1. A child with cystic fibrosis. 2. A child with tonsillitis. 3. A child with bronchitis. 4. A child with pertussis.

(1) hereditary dysfunction of exocrine glands causing obstruction because of flow of thick mucus, standard precautions (2) inflammation of tonsils, standard precautions (3) inflammation of large airway, standard precautions (4) correct—droplet precautions required, private room, maintain spatial separation of 3 feet between patient and visitors

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

(1) inaccurate (2) inaccurate (3) correct—obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase his self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so (4) ritual is not a method of expressing anxiety but a strategy to avoid it

A patient is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows that the purpose of the cuff on the tracheostomy tube includes which of the following? 1. Guarantees secure placement of the tracheostomy tube in the airway. 2. Prevents ischemia of the tracheal wall by distributing the pressure applied to it. 3. Decreases the chance of aspiration into the trachea. 4. Protects the trachea from ischemia and edema.

(1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct—seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema

The nurse reviews histories in the prenatal clinic. The nurse identifies which of the following pregnant women is MOST likely to have an Rh-incompatibility problem? 1. An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man. The woman has never received RhoGAM. 2. An Rh-negative woman who conceived with an Rh-positive man. The woman has Rh antibodies. 3. An Rh-positive woman who previously aborted a fetus at 12 weeks' gestation and did not receive RhoGAM. The woman currently conceived with an Rh-positive man. 4. An Rh-negative woman who never received RhoGAM. The woman currently conceived with an Rh-negative man.

(1) incompatibility only seen with Rh-negative woman (2) correct—Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus's blood cells (3) incompatibility only seen with Rh-negative woman (4) infant would be Rh-negative like parents, so there would be no incompatibility

A family member of a client who has sustained an electrical burn states, "I don't understand why my brother has been here a week. The burn does not look that bad." Which of the following responses by the nurse is BEST? 1. "Electrical burns are more prone to infection." 2. "Electrical burns are always much worse than they look on the outside." 3. "Cardiac monitoring is important because electrical burns affect cardiac function." 4. "Electrical burns can be deceptive because underlying tissue is also damaged."

(1) incorrect regarding electrical burns (2) not the most accurate statement (3) is true in the immediate post-burn phase, not a week later (4) correct—electrical burn injuries are typically more injurious to underlying tissue, such as nerve and vascular tissue, which require complex and timely treatment

While planning care for an elderly client with dementia, which of the following is a priority for the nurse? 1. Encourage dependency with activities of daily living. 2. Provide flexibility in schedules due to his confusion. 3. Limit reminiscing due to poor memory. 4. Speak slowly in a face-to-face position.

(1) independence should be encouraged (2) schedules need to be routine, reinforced, and repeated; flexibility leads to confusion (3) reminiscence and life reviews help client resume progression through grief process associated with disappointing life events, and increases self-esteem (4) correct—is most effective when communicating with an elderly client

The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload? 1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready. 2. Cool skin, respiratory crackles, pulse 86 and bounding. 3. Complaints of a headache, abdominal pain, and lethargy. 4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus.

(1) indicates dehydration (2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement (3) symptoms could be from causes other than volume overload (4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen

For a client with a neurologic disorder, which of the following nursing assessments is MOST helpful in determining subtle changes in the client's level of consciousness? 1. Client posturing. 2. Glasgow coma scale. 3. Client thinking pattern. 4. Occurrence of hallucinations.

(1) indicates increased intracranial pressure (2) correct—Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client

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

(1) indicates reaction formation (2) correct—client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform (3) indicates denial (4) indicates projection

A client has partial-thickness and full-thickness burns over 75% of his body. The nurse is MOST concerned if which of the following is observed? 1. Epigastric pain. 2. Restlessness. 3. Tachypnea. 4. Lethargy.

(1) insignificant for burn client (2) may be due to pain (3) correct—body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain

The nurse cares for a patient admitted 2 days ago with a diagnosis of closed head injury. If the patient develops diabetes insipidus, the nurse will observe which of the following symptoms? 1. Decerebrate posturing, BP 160/100, pulse 56. 2. Cracked lips, urinary output of 4 L/24 h with a specific gravity of 1.004. 3. Glucosuria, osmotic diuresis, loss of water and electrolytes. 4. Weight gain of 5 lb, pulse 116, serum sodium 110 mEq/L.

(1) late signs of increased intracranial pressure or brain damage (2) correct—signs of dehydration, increased output, low specific gravity, normal 1.010 to 1.030 (3) signs of hyperglycemia due to diabetes mellitus (4) symptoms of SIADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus

The nurse counsels an elderly client who comes to the outpatient clinic for a routine examination. The history indicates the client takes a laxative tablet twice a day and a laxative suppository once a day. The nurse should suspect which of the following about the client? 1. The client has an anal fixation resulting from recent loss of a spouse. 2. The client is depressed because of alterations in intestinal absorption and excretion. 3. The client is experiencing excessive concern with body function because of physical changes. 4. The client has regressed because of a fear of losing the ability to have bowel movements.

(1) makes judgment without information (2) constipation common finding in elderly; no information about depression (3) correct—physical changes occur in late adulthood causing changes in body image; constipation frequent problem of elderly, but reaction by this client is excessive (4) no information provided about regression ...

A client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 mL/h. It is MOST important for the nurse to take which of the following actions? 1. Massage the client's legs to increase circulation. 2. Elevate the knee gatch to reduce stress on the suture line. 3. Apply thigh-high TED hose to promote venous return. 4. Decrease fluid intake to 1,200 mL to prevent circulatory overload.

(1) massage may cause emboli (2) would cause external pressure on the popliteal space, hip should not be flexed beyond 90° (3) correct—use of antiembolic hose and/or sequential compression devices decreases venous stasis and reduces risk of thrombus formation (4) adequate fluid intake (1,500 mL) prevents dehydration

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

(1) may be due to changes in body image or pain (2) expected, not indicative of an infection (3) correct—pain is characteristic of inflammation and infection (4) warm skin above operative site would indicate infection

The nurse cares for a client who presents with confusion, mood lability, impaired communication, and lethargy. The nurse should question which of the following orders? 1. Dexamethasone suppression test. 2. Thyroid studies. 3. Drug toxicology screen. 4. Trendelenburg test.

(1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol (4) correct—test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation

After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contacts to identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?"

(1) may be part of follow-up (2) correct—means of transmission of chlamydia may or may not have been made clear to both partners; nurse should assess this first; is a sexually transmitted disease (3) most cultures used today have few false positives (4) would be done later in the nursing assessment

The nurse assesses a client diagnosed with a spinal cord injury. Which of the following assessment findings by the nurse suggests the complication of autonomic dysreflexia? Select all that apply. 1. Urinary bladder spasm pain. 2. Severe pounding headache. 3. Profuse sweating. 4. Tachycardia. 5. Severe hypotension. 6. Nasal congestion.

(1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not perceived (2) correct—severe headache results from rapid onset of hypertension (3) correct—especially of forehead (4) pulse will slow (5) BP will increase (6) correct—also causes piloerection (goose flesh)

A client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows that which of the following BEST describes the client's need for the repetitive acts of hand-washing? 1. Hand-washing represents an attempt to manipulate the environment to make it more comfortable. 2. Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body. 3. Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety. 4. Hand-washing helps maintain the client in an active state to resist the effects of depression.

(1) not a manipulation on the client's part (2) not an accurate statement regarding the compulsive behavior of this client (3) correct—compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing (4) client is not subject to depression but to high levels of anxiety

A client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm3, RBC 5.1 mL/mm3, calcium 5 mEq/L. Based on the lab values, the nurse determines which of the following is the priority nursing diagnosis? 1. Risk for activity intolerance related to decrease in red cells. 2. Risk for infection related to low white cell count. 3. Risk for anxiety secondary to hypoparathyroid disease. 4. Risk for fluid volume deficit due to decreased fluid intake.

(1) not a priority (2) correct—clients with a low WBC count are susceptible to infection (3) not correctly stated as a nursing diagnosis and is not appropriate (4) not a priority for this client

A client has a three-way Foley catheter following a transurethral resection. The nurse should rapidly infuse the irrigating solutions if which of the following is observed? 1. The urinary output is increased. 2. Bright-red drainage or clots are present. 3. Dark-brown drainage is present. 4. The client complains of pain.

(1) not a reason to infuse irrigating solution rapidly (2) correct—three-way Foley catheter should be irrigated rapidly when bright-red drainage or clots are present; irrigation rate should be decreased to about 40 gtt/min when the drainage clears (3) not an indication to infuse irrigating solution rapidly (4) not an indication to infuse irrigating solution rapidly

The nurse receives report from the previous shift. Which of the following clients should the nurse see FIRST? 1. A client receiving a blood transfusion who complains of a dry mouth. 2. A client is scheduled to receive heparin and the PTT is 70 seconds. 3. A client is receiving ciprofloxacin (Cipro) and complains of a fine macular rash. 4. A client is receiving IV potassium and complains of burning at the IV site.

(1) not an immediate concern (2) PTT is within normal limits; should give medication (3) correct—indicates hypersensitivity reaction; should stop medication and notify the physician (4) should decrease rate to prevent irritation of the vein, but hypersensitivity reaction requires first attention

A client has surgery for cancer of the colon, and a colostomy is performed. Before discharge, the client states that he will no longer be able to swim. Which of the following responses by the nurse is BEST? 1. "You should begin looking for other areas of interest." 2. "You will have to wear a watertight dressing over the stoma." 3. "You cannot go into water that covers the stoma area." 4. "You may resume all previous activities."

(1) not appropriate for a client after a colostomy (2) not appropriate for a client after a colostomy (3) not appropriate for a client after a colostomy (4) correct—all activities that the client participated in before the colostomy may be resumed after appropriate healing of the stoma or incisions

While a 2-day-old infant is in surgery for repair of spina bifida, the infant's mother expresses concern to the nurse because the doctor told her the infant would be confined to a wheelchair. Which of the following statements, if made by the nurse, is BEST? 1. "Physical therapy can restore the function to affected muscles." 2. "Orthopedic devices will allow your child to strengthen lower extremity muscles." 3. "Corrective surgery will return function to the affected muscles." 4. "The corrective surgery will not change your child's physical disability."

(1) not appropriate or true regarding this condition (2) not appropriate or true regarding this condition (3) not appropriate or true regarding this condition (4) correct—spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele

A client diagnosed with Addison's disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which of the following statements about Addison's disease? 1. The client requires increased sodium intake to prevent hypotension. 2. A decrease in sodium intake may lead to seizures. 3. Steroid replacement causes rapid loss of sodium. 4. Sodium intake should be increased during periods of stress.

(1) not as important as answer choice 4 (2) not a correct statement for this condition (3) steroid replacement increases sodium retention (4) correct—with decrease in aldosterone, there is an increased excretion of sodium; sodium intake should be increased

A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14, para 2 gravida 2, and regular periods every 28 to 30 days. The client is divorced and works full time as a bank teller. The nurse identifies the MOST probable cause of the client's symptom is which of the following? 1. Emotional trauma and stress. 2. Onset of menopause. 3. Presence of uterine fibroids. 4. Possible tubal pregnancy.

(1) not enough information given in question to assume that symptoms are caused by stress (2) correct—ovarian function gradually decreases and then stops, usually 45 to 50 years old (3) benign tumors arising from muscle tissue of uterus, menorrhagia (excessive bleeding) most common symptom along with backache, constipation, dysmenorrhea (4) usually see history of missed periods or spotting with abdominal pain ...

The nurse plans care for a client immediately after a cesarean section. Which of the following nursing goals is MOST important? 1. Prevent infection. 2. Prevent fluid and electrolyte imbalances. 3. Provide for pain management. 4. Prevent hazards of immobility.

(1) not highest priority initially, usually not seen until 48-72 hours after surgery (2) correct—hemorrhage and shock are the most life-threatening conditions that occur after surgery (3) not highest priority initially, not life-threatening (4) not highest priority initially, not life-threatening

The nurse obtains a history from the father of a 6-year-old boy with a history of epilepsy who was admitted with uncontrolled seizures. It is MOST important for the nurse to ask which of the following questions? 1. "What part of the body was affected by the seizure?" 2. "What is the family history of seizure disorders?" 3. "What was your son doing before the seizure?" 4. "How long has it been since his last episode of seizures?"

(1) not most important question (2) should be included in detailed history, but will not prevent an immediate reoccurrence (3) correct—seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, drugs) (4) should be included in detailed history, but will not prevent an immediate reoccurrence

A client with acquired immunodeficiency syndrome (AIDS) is admitted with a tentative diagnosis of late AIDS dementia complex. The nursing assessment is most likely to reveal which of the following? 1. Hyperactive deep tendon reflexes. 2. Peripheral neuropathy affecting the hands. 3. Disorientation to person, place, and time. 4. Impaired concentration and memory loss.

(1) not relevant to this condition (2) not relevant to this condition (3) correct—approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation (4) is a sign of early-onset dementia

An older client receives total parenteral nutrition (TPN) for several weeks. If the TPN were abruptly discontinued, the nurse expects the patient to exhibit which of the following? 1. Tinnitus, vertigo, blurred vision. 2. Fever, malaise, anorexia. 3. Diaphoresis, confusion, tachycardia. 4. Hyperpnea, flushed face, diarrhea.

(1) not seen (2) suggestive of infection (3) correct—insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination (4) not seen

The nurse cares for clients in the emergency department of an acute care facility. Four clients have been admitted during the previous 10 minutes. Which of the following admissions should the nurse see FIRST? 1. A client complaining of chest pain that is unrelieved by nitroglycerine. 2. A client with full-thickness burns to the face. 3. A client with a fractured hip. 4. A client complaining of epigastric pain.

(1) not the highest priority; airway most important (2) correct—face, neck, chest, or abdominal burns result in severe edema, causing airway restriction (3) airway is most important (4) requires further assessment; airway is a priority

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

(1) not the most common occurrence (2) not the most common occurrence (3) correct—most common complication following a myocardial infarction is dysrhythmia, with ventricular types being the most serious (4) client would most probably experience a decrease rather than an increase in blood pressure

The nurse cares for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked". The nurse should assess which of the following cranial nerves? 1. III. 2. V. 3. VII. 4. XI.

(1) oculomotor; provides innervation for extraocular movement (2) trigeminal; provides sensation to facial muscles (3) correct—facial; provides motor activity to the facial muscles (4) spinal accessory; provides innervation to the trapezius and sternocleidomastoid muscles ...

The nurse evaluates the nutritional intake of an adolescent girl attending camp. The adolescent eats each day three meals, and each meal averages about 900 calories and 3 mg of iron. Which of the following descriptions, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height? 1. Her diet is low in calories and high in iron. 2. Her diet is low in calories and low in iron. 3. Her diet is high in calories and low in iron. 4. Her diet is high in calories and high in iron.

(1) only 1,200 to 1,500 kcal/day required, and 15 mg/day of iron (2) only 1,200 to 1,500 kcal/day required (3) correct-900 × 3 = 2,700 calories/day and women need 1,200 to 1,500 kcal/day (men need 1,500 to 1,800 kcal/day); 3 mg × 3 = 9 mg/day of iron and women need 15 mg/day of iron (men need 10 mg/day); with pregnancy 30 mg/day required (4) 18 mg/day of iron required

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

(1) patients with fractures are considered "clean"; don't place with an infectious patient (2) don't know the cause of the fever (3) correct—generalized nonfollicular infection that involves deeper connective tissue, both patients have infections (4) elderly are high risk for developing pneumonia

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

(1) performed as part of assessment, does not address patient's limited ability to respond to possible infection (2) correct—implementation, decreases exposure to microorganisms (3) implementation, done with all patients to protect health care workers (4) performed as part of ongoing assessment

The nurse cares for a client just returning to the postsurgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which of the following actions? 1. Determine the stage of loss and grief. 2. Analyze the quality and quantity of pain. 3. Instruct the client to cough and deep breathe. 4. Ask the client to lift his head off the pillow.

(1) physical needs take priority (2) not most important (3) implementation; should first assess (4) correct—should assess whether there are any remaining effects of neuromuscular blocking agents; may block ability to breathe deeply ...

A client taking chlorpromazine (Thorazine) should be instructed to notify the nurse immediately if the client experiences which of the following? 1. Dry mouth and nasal stuffiness. 2. Increased sensitivity to heat. 3. Difficulty urinating. 4. Weight gain and constipation.

(1) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem (2) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem (3) correct—is an anticholinergic reaction that may become a severe health problem unless treated (4) possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem

The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination? 1. Avoid strenuous activity. 2. Eat more foods with increased bulk. 3. Decrease fluid intake to decrease urinary losses. 4. Use oral laxatives so that a bowel pattern emerges.

(1) regular exercise program facilitates bowel elimination (2) correct—contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis (3) normal fluid intake of 1,500 ml/day facilitates bowel elimination (4) laxatives used as last resort because they become habit-forming

The nurse cares for a client diagnosed with schizophrenia who has become increasingly withdrawn to the point of mutism. It is MOST important for the nurse to take which of the following actions? 1. Ignore the client until he is ready to respond. 2. Sit with the client for brief periods of time. 3. Read to the client in a quiet area of the unit. 4. Encourage the client to play dominos with the group.

(1) rejects the client (2) correct—nurse should maintain contact with client but not make demands to communicate or participate in activities (3) not going to benefit this client (4) not going to benefit this client

An adult client is admitted to the hospital unit diagnosed with hepatitis A. The nurse knows that the client's overall care during hospitalization should include which of the following? 1. Contact precautions. 2. Airborne precautions. 3. Standard precautions. 4. Droplet precautions.

(1) required with patient care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the patient's environment (2) unnecessary; used with pathogens transmitted by airborne route (3) correct—standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence (4) unnecessary; used when pathogens transmitted by infectious droplets

The nurse observes a student nurse caring for a client. In addition to following standard precautions, the student nurse is wearing a gown and gloves. The nurse determines care is appropriate if the student nurse performs which of the following activities? 1. Gives isoniazid (INH) to a client with tuberculosis. 2. Administers an IM injection to a client with rubella. 3. Delivers a food tray to a client with hepatitis. 4. Changes the dressing for a client with a draining abscess.

(1) requires airborne precautions, particulate respirator (2) requires droplet precautions; nurse should wear a mask (3) requires standard precautions (4) correct—requires contact precautions

A nursing assistant reports to the RN that a patient with anemia complains of weakness. Which of the following responses by the nurse to the nursing assistant is BEST? 1. "Listen to the patient's breath sounds and report back to me." 2. "Set up the patient's lunch tray." 3. "Obtain a diet history from the patient." 4. "Instruct the patient to balance rest and activity."

(1) requires assessment; should be performed by the RN (2) correct—standard, unchanging procedure; decreases cardiac workload (3) involves assessment; should be performed by the RN (4) assessment and teaching required; performed by the RN

The nurse responds to a train derailment. After making an initial assessment, which of the following clients should the nurse see FIRST? 1. A pregnant woman who states that her clothing is wet. 2. A young man with blood pulsating from a cut on the right leg. 3. A preschool child who is screaming and crying uncontrollably. 4. An unconscious woman with the right leg shorter than the left leg.

(1) requires further assessment; could be amniotic fluid or could be urine. (2) correct—indicates arterial bleeding; apply direct pressure; high risk for shock (3) stable patient (4) possible hip fracture; no indication of respiratory difficulty stated

The nurse obtains a client's temperature of 103°F(39.4°C). The nurse knows body compensatory mechanisms include which of the following? 1. Decreased respiratory rate and bradycardia. 2. Normal blood pressure and pulse. 3. Increased respiratory rate and tachycardia. 4. Diaphoresis with cool, clammy skin.

(1) respirations and heart rate will increase with fever (2) blood pressure and pulse usually increase with fever (3) correct—hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate (4) diaphoresis may occur, but the skin will be warm

A middle-aged female client begins outpatient therapy sessions for management of a phobic disorder. The nurse identifies which of the following interventions is MOST effective to reduce the client symptoms? 1. Antianxiety medication. 2. Group psychotherapy. 3. Systematic desensitization. 4. Biofeedback.

(1) may be used for social phobia or social anxiety disorder (2) may benefit from cognitive-behavioral therapy (3) correct—phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavior modification; systematic desensitization is a form of behavior modification; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety-producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response (4) one learns to control the autonomic nervous system; is usually more useful for reducing stress associated with physiologically based disorders

The nurse cares for a client diagnosed with sickling crisis. The nurse instructs the client about how to use patient-controlled analgesia (PCA). The nurse determines teaching is effective if the client states which of the following? 1. "If I start feeling drowsy, I should notify the nurse." 2. "This button will give me enough to kill the pain whenever I want it." 3. "If I start itching, I need to call you." 4. "This medicine will help me feel no pain."

(1) may feel sleepy due to medication (2) preset dose administered with preset lock-out times (3) correct—itching is a common side effect of narcotics used in PCA pain management (4) indicates a need for further teaching or clarification

The nurse cares for a 2-month-old infant diagnosed with reflux. Which of the following nursing actions is MOST appropriate? 1. Hold the next feeding. 2. Teach the mother CPR. 3. Maintain a normal feeding schedule. 4. Elevate the head of the bed.

(1) may not be necessary if positioning is effective (2) inappropriate (3) client's feedings should be changed to small-volume, frequent feedings (4) correct—infant with reflux should be maintained in an upright position; head of the bed should be raised at a 30° angle

The nurse caring for a client on suicide precautions makes the following observations: the client is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on these data, which of the following nursing actions is MOST appropriate? 1. Recommend that the physician decrease the client's medication dosage. 2. Recommend that the treatment team reevaluate the client's treatment plan. 3. Give the client privileges to walk around the hospital by himself. 4. Ask the family to begin planning for the client's discharge.

(1) may reverse the client's progress (2) correct—data suggest that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full-data picture (3) may be the team's decision, but not until a thorough review of the case is completed (4) premature

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

(1) medication is never added to the infant's formula feeding (2) correct—is a convenient method for administering medications to an infant (3) medication is never added to the infant's formula feeding (4) infant is never placed in a reclining position during procedure due to potential for aspiration

The nurse cares for a patient with a three-chamber water-seal drainage system (Pleur-evac). When the nurse checks the patient, the nurse notices that the fluid in the water-seal chamber does not fluctuate. Which of the following actions by the nurse is BEST? 1. Milk the tube gently toward the collection chamber. 2. Anticipate the need for a chest x-ray. 3. Add water to the water seal chamber to re-establish the system. 4. Clamp the chest tube and call the physician.

(1) milking is done only with order of physician to clear obstruction due to clots, fluid is clear (2) correct—fluctuations stop with re-expansion of lung, x-ray will confirm (3) should be kept at level of 2 mL to maintain negative pressure (4) only clamp tube when checking for air leaks or changing equipment

The physician orders morphine sulfate 8 mg IM q 3 to 4 h for pain PRN. In which of the following situations should the nurse consider withholding the medication until further assessment is completed? 1. The patient complains of acute pain from a partial-thickness burn affecting the lower left leg. 2. The patient's blood pressure is 140/90, pulse is 90, and respiration is 28. 3. The patient's level of consciousness fluctuates from alert to lethargic. 4. The patient exhibits restlessness, anxiety, and cold, clammy skin.

(1) morphine used for moderate to severe pain; medication should be given (2) BP slightly elevated, respirations elevated, may be the result of pain; medication should be given (3) correct—morphine depresses CNS, especially respiratory center in medulla (4) may be the result of pain

The nurse checks for placement of a nasogastric (NG) tube prior to initiating a tube feeding for a client. Which of the following results indicates to the nurse that the tube feeding can begin? 1. A small amount of white mucus is aspirated from the NG tube. 2. The contents aspirated from the NG tube have a pH of 3. 3. No bubbles are seen when the nurse inverts the NG tube in water. 4. The client says he can feel the NG tube in the back of his throat.

(1) mucus may be from lungs (2) correct—stomach contents are acidic (3) not a safe way to check placement (4) not a reliable indication

The nurse prepares a child diagnosed with Addison's disease for discharge. The child's mother asks how long her daughter must continue receiving replacement therapy. Which of the following responses by the nurse is BEST? 1. "For approximately 6 months." 2. "For approximately 1 year." 3. "Until she reaches puberty." 4. "For the rest of her life."

(1) needed for lifetime to prevent recurrence of adrenal insufficiency (2) needed for lifetime to prevent recurrence of adrenal insufficiency (3) needed for lifetime to prevent recurrence of adrenal insufficiency (4) correct—disease is caused by deficiency in glucocorticoids, will always need corticosteroids and mineralocorticoids

A client has an order for furosemide (Lasix) 40 mg IV push via a heparin lock. Which of the following nursing actions is MOST appropriate? 1. Use a 16- to 18-gauge 1-inch needle for administration. 2. Administer the medication over 1-2 minutes. 3. One mL of 1:1,000 heparin flush should be administered before the medication. 4. A primary IV should be started prior to medication administration.

(1) needle gauge is too large (2) correct—furosemide (Lasix) given IV push should be administered slowly over 1-2 minutes (3) lock is flushed with heparin after administration of the medication (4) unnecessary

A client undergoes an appendectomy and the nurse performs discharge teaching. The nurse determines that teaching is effective if the client states which of the following? 1. "I shall eat a diet low in protein, high in carbohydrates, low in fats." 2. "I shall eat a diet high in protein, high in calories, high in vitamin C." 3. "I shall eat a diet high in protein, low in calories, low in fat." 4. "I shall eat a diet low in protein, low in carbohydrates, high in vitamin D."

(1) needs high-protein diet to maintain anabolic state, diet should contain adequate carbohydrates and be low in fat (2) correct—supplemental vitamin C, iron, and multivitamins aid in wound healing and formation of RBCs (3) needs high calories to promote wound healing (4) needs high protein and high-calorie diet to maintain anabolic state

The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery? 1. The nurse restrains an agitated, confused patient in the emergency room with a physician's order. 2. The nurse chases a patient who tries to run away while outside for a walk. 3. The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance. 4. The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison.

(1) restraining a client to prevent injury to self or others is appropriate (2) appropriate behavior (3) restraining a client to prevent injury to self or others is appropriate (4) correct—battery is harmful or offensive touching of another's person; unless court ordered, clients have the right to refuse medication, even if client is psychotic

The nurse anticipates which of the following when assessing a client with a diagnosis of a ruptured lumbar disc? 1. Sensation loss in an upper extremity. 2. Clonic jerks in the affected foot. 3. Paresthesia in the affected leg. 4. Chorea in the upper and lower extremities.

(1) results from cervical lesions (2) can occur in a person who has been paralyzed from a spinal cord injury (3) correct—lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities (4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain

An adult woman has missed her menstrual period. The client's last menstrual period began May 8 and ended May 12. The nurse determines that the client's EDC (estimated date of confinement) is which of the following? 1. February 1. 2. February 15. 3. February 19. 4. March 14.

(1) should add 7 days (2) correct—when using the Naegele rule, add 7 days to first day of last menstrual period and subtract 3 months (3) incorrectly started with the last day of the menstrual cycle (4) incorrect

A patient received meperidine (Demerol) 75 mg IM 2 hours ago for complaints of pain. The patient turns on the call light and tells the nurse he has to go to the bathroom. The physician ordered bathroom privileges. The nurse should take which of the following actions? 1. Obtain a bedside commode for the patient's use and provide privacy. 2. Help the patient to sit on the side of the bed before proceeding to the bathroom. 3. Provide a bedpan for the patient's use and pull the curtains. 4. Ask two nurses to assist the patient to the bathroom.

(1) should ambulate patient safely to prevent hazards of immobility (2) correct—side effects of medication include decreased BP, orthostatic hypotension, bradycardia (3) easier for patient to use bathroom than to use bedpan (4) an additional nurse not necessary, before ambulating should sit on side of bed to allow body to adjust to change in position

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

(1) should be given Narcan for low respiratory rate (2) problem is low respirations; this may be administered after medication (3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action (4) unnecessary

A neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively, is admitted to the nursery. Because the infant's mother is diagnosed with a type 1 diabetes, the nurse knows the infant is at GREATEST risk for developing which of the following? 1. Hypovolemia. 2. Hypoglycemia. 3. Hyperglycemia. 4. Cold stress.

(1) no change in blood volume for infant of diabetic mother (2) correct—fetus produces increased insulin to match mother's increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia (3) infant would be at risk of hypoglycemia due to increased insulin production (4) thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic mother

The nurse prepares a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching is successful? 1. "The dye used in the test will turn my urine green for about 24 hours." 2. "I will be put to sleep for this procedure. I will return to my room in two hours." 3. "This procedure will take about 90 minutes to complete. There will be no discomfort." 4. "The wires that will be attached to my head and chest will not cause me any pain."

(1) no dye is used for an MRI (2) client is not anesthetized for this procedure (3) correct—procedure takes approximately 90 minutes, not painful (4) indicates misunderstanding of MRI because no wires are used

The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day postoperative tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions? 1. Direct the LPN/LVN to obtain the child's vital signs. 2. Ask the mother if the child's sutures are still intact. 3. Tell the nursing assistant to take the child for a walk. 4. Check to see when the child last received pain medication.

(1) no indication that there are any problems (2) passing the buck (3) implementation; should first assess (4) correct—young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observed

The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33 weeks' gestation. Based on this result, the nurse anticipates which of the following? 1. Administration of ritodrine hydrochloride (Yutopar). 2. Initiation of an oxytocin (Pitocin) drip. 3. Delivery of the infant by cesarean section. 4. Continuation of bedrest until otherwise indicated.

(1) no longer necessary, as the results indicate sufficient lung maturity for safe delivery (2) although the lungs are mature enough for safe delivery, client would either be allowed to progress naturally to a vaginal delivery or would be sectioned, but not induced (3) correct—because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants (4) is no longer necessary with adequately mature lungs

The nurse teaches a well-baby class to a group of parents with toddlers. The nurse should encourage the parents to do which of the following? 1. Exercise their children daily. 2. Use a playpen whenever possible. 3. Provide a safe play area for their children. 4. Teach their children noncompetitive activities.

(1) no specific exercise program is necessary; children of this age in good health are naturally active (2) limits a child's interaction with the outside world, should be used judiciously (3) correct—safety is fundamental issue with this age group; they are exploratory in their play (4) unnecessary; children learn by observing and by participating

An older adult receives dexamethasone (Decadron) 3 mg PO TID for chronic lymphocytic leukemia. It is MOST important for the nurse to report which of the following findings to the physician? 1. PT 12 seconds and Hgb 15 g/dL. 2. BUN 18 mg/dL and creatinine 1.0 mg/dL. 3. K+ 3.4 mEq/L and Ca+ 5.5 mEq/L. 4. AST (SGOT) 18 U/L and ALT (SGPT) 12 U/L.

(1) normal PT 11 to 15 sec, normal Hgb male: 13.5 to 17.5 g/dL, female: 12.1 to 16.0 g/dL (2) normal BUN 10 to 20 mg/dL, normal creatine 0.6 to 1.2 mg/dL (3) correct—normal K+ 3.5 to 5.0 mEq/L, normal Ca+ 4.5 to 5.3 mEq/L, indicates hypokalemia and hypercalcemia (4) normal AST (SGOT) 8 to 20 U/L, normal ALT (SGPT) 8 to 20 U/L

The nurse cares for a client after an ileostomy. The nurse is MOST concerned if which of the following is observed? 1. The ileostomy functions without daily irrigations. 2. The stoma appears to be tight, and there is a decreased amount of stool. 3. A small amount of mucus is seen around the anal area. 4. There is weight gain of 5 lb over a 3-week period of time.

(1) normal process, ileostomies are not irrigated (2) correct—important to report these findings to the physician; may indicate an obstruction or stoma stricture (3) anal area is not functional but some mucus may be seen (4) should not concern nurse

The nurse prepares a dopamine (Intropin) infusion on a client. Before beginning the infusion the nurse should take which of the following actions? 1. Evaluate the urine output. 2. Obtain the client's weight. 3. Determine the patency of the IV line. 4. Measure pulmonary artery pressures.

(1) not a critical assessment at this time (2) contains correct information, but is not a priority (3) correct—if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious side effects (4) not a critical assessment at this time

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

(1) affected male inherits gene from his mother and can transmit it only to his daughters (2) it is not an autosomal recessive trait (3) correct—hemophilia is a sex-linked disorder (4) there is a 50% chance that the mother will pass the trait to each of her children

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

(1) constipation is not a problem because the client has diarrhea (2) correct—skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this (3) not most important (4) may be risk of fluid volume deficit due to diarrhea and secretions

A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. The nurse knows that 1. these tests are valuable screening tests for prostatic cancer. 2. the level of PSA is decreased in clients with renal stones. 3. the tests reflect the level of renal involvement in acid-base problems. 4. the level of PSA is elevated in clients in early-stage renal failure.

(1) correct—PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA

A client comes to the health clinic and tells the nurse that the client has taken acetaminophen (Aspirin-Free Excedrin) daily for 5 months. The nurse is MOST concerned by which of the following lab results? 1. AST (SGOT) 30 units/L, ALT (SGPT) 27 units/L. 2. Hgb 16.2 g/dL, Hct 46%. 3. WBC 7,000/mm3. 4. BUN 9 mg/dL.

(1) correct—can cause liver damage, normal AST (formerly SGOT) 8 to 20 units/L, normal ALT (formerly SGPT) 8 to 20 units/L (2) normal Hgb male 13.5-17.5 g/dL, female 12-16 g/dL, normal Hct male 41 to 53%, female 36 to 46% (3) normal WBC 5,000 to 10,000/mm3 (4) normal BUN 7 to 18 mg/dL

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

(1) correct—immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side (2) head of the bed should be elevated 15-20° because the supine position can increase problems with immobility (3) client is on strict bedrest (4) would interfere with the traction

A clinic nurse obtains a health history from a client newly diagnosed with Buerger's disease. The nurse expects the client's complaints to include which of the following? 1. Heart palpitations. 2. Dizziness when walking. 3. Blurred vision. 4. Digital sensitivity to cold.

(1) no cardiac involvement (2) dizziness not seen; intermittent claudication (pain with exercise) seen (3) optic nerve not affected (4) correct—vasculitis of blood vessels in upper and lower extremities

A client is in cardiogenic shock after a myocardial infarction (MI). Which of the following is a correctly stated nursing diagnosis for the client? 1. Activity intolerance: related to impaired oxygen transport. 2. Altered tissue perfusion related to decreased heart-pumping action. 3. Altered cardiac output related to cardiac ischemia. 4. Potential fluid volume deficit related to decreased intake.

(1) not best (2) correct—correctly stated, appropriate nursing diagnosis (3) altered cardiac output is not a commonly accepted nursing diagnosis (4) not appropriate for this client ...

The home care nurse performs an assessment of a client diagnosed with pneumonia secondary to chronic pulmonary disease. Which of the following nursing goals is MOST appropriate? 1. Maintain and improve the quality of oxygenation. 2. Improve the status of ventilation. 3. Increase oxygenation of peripheral circulation. 4. Correct the bicarbonate deficit.

(1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state (2) correct—to improve the quality of ventilation refers to levels of carbon dioxide and oxygen

Reaction formation and symbolization

Development of conscious attitudes and behavior patterns into opposite of what one really wants to do) and

A patient is returned to the room at 10 AM following laparoscopic gall bladder surgery. The nurse plans to get the patient out of bed for the first time at 6 PM. In preparation for this activity, the nurse should take which of the following actions? 1. Ask the patient to cough and deep-breathe at 4 PM. 2. Offer pain medication to the patient at 5:30 PM. 3. Turn the patient from side to side at noon and 4 PM. 4. Encourage the patient to use the incentive spirometer.

(1) should turn, cough, and deep-breathe patient every 2 hours to prevent postoperative complications, but would not help with ambulation (2) correct—reduction of pain will allow patient to cooperate with activities designed to reduce postoperative complications such as ambulation (3) should turn patient every 2 hours to prevent postoperative complications, but would not help with ambulation (4) used to promote complete lung expansion and prevent respiratory complications following surgery, but would not help with ambulation

The nurse instructs a client diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should include which of the following instructions? 1. Use a new, sterile catheter each time the client performs a catheterization. 2. Perform the Valsalva maneuver before doing the catheterization. 3. Perform the catheterization procedure every 8 hours. 4. Limit oral fluids to reduce the number of times a catheterization is needed.

(1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder (2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization (3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours (4) should encourage fluids...

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

(1) should use soft-bristled toothbrush so gums are not injured (2) should be avoided, causes dryness of mucous membranes (3) correct—will hydrate the mucous membranes and keep mouth clean (4) most commercial mouthwashes contain alcohol, would dry mucous membranes

A middle-aged woman is brought to the emergency department after being raped in her home. The client asks the nurse to call her husband to come to the emergency department. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements? 1. Supportive and helpful to the victim. 2. Disconnected from and apathetic toward the victim. 3. Frustrated and feeling vulnerable, but denying need for help. 4. Emotionally distressed and needing assistance.

(1) significant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so (2) rarely feel disconnected (3) usually family members will need and respond well to psychological intervention (4) correct—sexual assault by rape is a crisis situation for victim and family members and friends

A client is admitted for regulation of insulin dosage. The client takes 15 units of Humulin N insulin at 8 A.M. every day. At 4 P.M., which of the following nursing observations indicates a complication from the insulin? 1. Acetone odor to the breath, polyuria, and flushed skin. 2. Irritability, tachycardia, and diaphoresis. 3. Headache, nervousness, and polydipsia. 4. Tenseness, tachycardia, and anorexia.

(1) signs of hyperglycemia (2) correct—Humulin N insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur (3) signs of hyperglycemia (4) signs of hyperglycemia

The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings indicates a possible complication? 1. There is swelling under the sutures. 2. There is crusting around the incision line. 3. The incision line is red. 4. The incision line is approximated.

(1) slight swelling is expected during healing (2) slight crusting of incision line is normal (3) correct—should be pink, not red; indicates possible infection; other signs include increased warmth, tenderness, pain, and purulent or odorous drainage (4) shows healing is taking place

Which of the following is a correct instruction by the nurse to the parent of a 4-year-old client regarding collecting a specimen to be tested for pinworms? 1. Collect the specimen 30 minutes after the child falls asleep at night. 2. Save a portion of the child's first stool of the day and take it to the physician's office immediately. 3. Collect the specimen in the early morning with a piece of Scotch tape touched to the child's anus. 4. Feed the child a high-fat meal, and then save the first stool following the meal.

(1) specimen should be collected early in the morning after the child awakens (2) unnecessary; pinworms are not routinely found in the stool (3) correct—pinworms crawl outside the anus early in the morning to lay their eggs (4) inappropriate for this situation ...

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

(1) sperm doesn't resemble atypical cells that the test is designed to find (2) correct—douching would affect appearance of cells in vaginal smear, would make test inaccurate (3) will concentrate urine but won't affect Pap smear (4) part of routine GYN exam, but not related to Pap smear

The nursing team consists of an RN, two LPN/LVNs, and a nursing assistant. The RN should care for which of the following clients? 1. An infant 2 days postoperative after repair of cleft lip requiring a tube feeding. 2. A preschool child 3 days postoperative after surgical removal of Wilms' tumor requiring a bath. 3. A school-aged child diagnosed with osteomyelitis requiring a dressing change. 4. A teenager with a head injury, Glasgow coma scale is 5, requiring personal care.

(1) stable patient with an expected outcome, assigned to the LPN/LVN (2) standard, unchanging procedure, assign to the nursing assistant (3) stable patient with an expected outcome, assign to the LPN/LVN (4) correct—Glasgow coma scale of 5 indicates coma, client requires frequent assessment

The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients? 1. A patient with a chest tube ambulating in the hall. 2. A patient with a colostomy requiring assistance with an irrigation. 3. A patient with a right-sided cerebral vascular accident (CVA) requiring assistance with bathing. 4. A patient refusing medication to treat cancer of the colon.

(1) stable patient with an expected outcome; assign to the LPN/LVN (2) stable patient with an expected outcome; assign to the LPN/LVN (3) standard, unchanging procedure; assign to the nursing assistant (4) correct—requires assessment skills of the RN

The home care nurse plans activities for the day. Which of the following clients should the nurse see FIRST? 1. A new mother is breastfeeding her 2-day-old infant who was born 5 days early. 2. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis. 3. An elderly woman discharged from the hospital 3 days ago with pneumonia. 4. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.

(1) stable situation, not a priority (2) assess for bleeding gums, hematuria, not the priority (3) assess breath sounds, encourage fluids, cough and deep breathe (4) correct—symptoms of pulmonary edema; requires immediate attention

A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus? 1. The child places his head close to the table when drawing. 2. The child rubs his eyes frequently. 3. The child closes one eye to see a poster on the wall. 4. The child is unable to see objects in the periphery of his visual field.

(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range (2) suggestive of refractive error (3) correct—visual axes are not parallel, so the brain receives two images (4) suggestive of cataracts or problem with peripheral vision

The nurse cares for clients in the medical clinic. A nursing assessment of a client with a hiatal hernia is MOST likely to reveal which of the following? 1. A bulge in the lower right quadrant. 2. Pain at the umbilicus radiating down into the groin. 3. A burning sensation in the midepigastric area each day before lunch. 4. Complaints of awakening at night with heartburn.

(1) suggests an inguinal hernia (2) suggests an inguinal hernia (3) pain usually does not develop during the day with an empty stomach (4) correct—classic symptom of hiatal hernia associated with reflux

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

(1) symptom of acute asthma attack, doesn't indicate deterioration of status (2) expected with acute asthmatic attack, doesn't indicate deterioration of status (3) correct—pulse increase is due to decrease in oxygenation of tissues (4) subjective symptom, unreliable indicator of deterioration of status

A 4-year-old child is admitted with drooling and an inflamed epiglottis. During the assessment, the nurse identifies which of the following symptoms as indicative of an increase in respiratory distress? 1. Bradycardia. 2. Tachypnea. 3. General pallor. 4. Irritability.

(1) tachycardia occurs early in hypoxia (2) correct—increase in the respiratory rate is an early sign of hypoxia, also for tachycardia (3) pallor is not specific for hypoxia (4) client may be anxious and restless, but is generally not described as irritable

A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the patient to make which of the following statements about symptoms? 1. "I have been having difficulty with my hearing." 2. "I lose my balance easily." 3. "I can't tell the difference between a sweet and sour taste." 4. "It is not easy for me to remember names and faces."

(1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic (2) correct—cerebellum maintains balance (3) CN IX, glossopharyngeal responsible for differentiation of taste (4) not specific symptom of cerebellum dysfunction

The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis? 1. Tenderness at the IV site. 2. Increased swelling at the insertion site. 3. Reddened area or red streaks at the site. 4. Leaking of fluid around the IV catheter.

(1) tenderness at the IV site is common (2) increased swelling at the insertion site may indicate infiltration (3) correct—characterized by inflammation and reddened areas around site and up length of vein (4) not indicative of phlebitis ...

The nurse should include which of the following in a teaching plan for a client receiving tetracycline? 1. Take the medication with milk or antacids to decrease GI problems. 2. The medication should always be taken with meals. 3. Use a maximum-protection sunscreen when outdoors. 4. Crackers and juice will help decrease gastric irritation.

(1) tetracycline should never be taken with milk or antacids because these inhibit the medication's action (2) should take with full glass of water at least 1 hour before or 2 hours after meals (3) correct—because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure (4) should take with full glass of water at least 1 hour before or 2 hours after meals

The RN makes nursing assignments for the burn unit. Which of the following indicates the MOST appropriate assignment for a client with a positive cytomegalovirus (CMV) titer? 1. A nurse with an upper respiratory infection. 2. A young nurse who is 8 weeks pregnant. 3. A male nurse who is CMV-negative. 4. An older nurse with 30 years of experience.

(1) those with a cytomegalovirus-positive titer are often immunosuppressed clients who should be protected from other pathogens (2) CMV is fetotoxic; should inform client of risks (3) this nurse is at increased risk for developing the disease (4) correct—most appropriate option due to decreased risk ...

The nurse in the outpatient clinic instructs a client diagnosed with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the right leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg.

(1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane (2) correct—to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down (3) should advance cane and weak leg first (4) weaker leg and cane advance first

The nurse instructs a client with newly diagnosed type 1 diabetes how to treat hypoglycemia at home. The nurse should instruct the client to do which of the following actions if symptoms of hypoglycemia occur? 1. Eat a candy bar. 2. Drink 1/2 cup fruit juice followed by a protein snack. 3. Inject 10 units of Humulin R. 4. Inject glucagon.

(1) too concentrated a carbohydrate, will cause hyperglycemia (2) correct—will correct hypoglycemia and stabilize blood sugar (3) treatment for hyperglycemia (4) used if person becomes unconscious

The nurse cares for a client diagnosed with rheumatoid arthritis. The plan of care should include which of the following? 1. Cold packs, immobilization, and hand splints. 2. Maintain flexion of the joints and proper body mechanics. 3. Analgesics, physical therapy, and a soft mattress on the bed. 4. Heat, range-of-motion exercises, and weight reduction.

(1) treatment for acute strain or fracture (2) joints need extension and rotation in addition to flexion to maintain full range of motion (3) medications used are anti-inflammatory in addition to analgesics, a firm mattress should be used (4) correct—goal is to prevent contractures and minimize deformity with a balance of rest and activity

A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is because of which of the following? 1. Provides an avenue for nutrients to flow past an obstructed area. 2. Prevents fluid and gas accumulation in the stomach. 3. Administers drugs that can be absorbed directly from the intestinal mucosa. 4. Removes fluid and gas from the small intestine.

(1) tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction (2) describes a tube such as a Levin or Salem Sump, which decompresses the stomach (3) tube provides for decompression instead of instillation of medications (4) correct—Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus

The nurse should explain to a client that glipizide (Glucotrol) is effective for diabetics who 1. can no longer produce any insulin. 2. produce minimal amounts of insulin. 3. are unable to administer their injections. 4. have a sustained decreased blood glucose.

(1) type 1 insulin-dependent diabetic is unable to produce insulin (2) correct—oral hypoglycemic agents are administered to type 2 (non-insulin-dependent) clients who are able to produce minimal amounts of insulin (3) type 1 diabetics who cannot administer their injections need alternate plans to be made for them to receive the injection from a family member (4) Glucotrol is administered for an increase in blood glucose

The nurse knows that which of these plans is MOST successful in caring for a client with dementia? 1. Teach new skills for adjusting to the aging process. 2. Adjust the environment to meet the client's individual needs. 3. Encourage competitive activities to keep the client physically strong. 4. Provide unstructured activities with frequent changes to increase stimulation.

(1) unable to learn new skills (2) correct—client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability (3) requires skills the client with dementia does not have (4) requires skills the client with dementia does not have

The nurse in the pediatrician's office observes a child in the waiting room. The nurse notes that the child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. The nurse identifies the child's chronological age to be which of the following? 1. 1 year old. 2. 2 years old. 3. 3 years old. 4. 5 years old.

(1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) correct—able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child

An elderly patient is admitted to the hospital for treatment of a fractured femur. The patient's spouse tells the nurse that the patient has become very hard of hearing. The nurse might expect the patient to exhibit which of the following characteristics? 1. The patient prefers to be left alone. 2. The patient appears suspicious of strangers. 3. The patient communicates best in writing. 4. The patient's speech is difficult to understand.

(1) unrelated to hearing deficit (2) correct—suspiciousness results from interference with communication (3) writing may be difficult for patient, depends on intellectual capacity (4) diminished hearing late in life does not cause speech difficulties

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

(1) use of creams not recommended, could cause breast tissues to become tender, sebaceous glands keep skin pliable (2) doesn't prepare breasts for feeding (3) correct—prepares nipples for stretching action of sucking during breast feeding, soap avoided to prevent drying (4) could cause breast tissues to become tender

The nurse prepares to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique? 1. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter. 2. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn. 3. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway. 4. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.

(1) use suction 90-120 mm Hg and #12 or #14 suction catheter (2) use a twirling motion to remove catheter while applying suction (3) correct—break in sterile procedure, suction mouth after trachea (4) hyperoxygenates client to prevent hypoxia from procedure

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

(1) usual finding for the older adult (2) usual finding for the older adult (3) correct—ventricular gallop is the earliest sign of HF (4) may be normal in all age groups

A client is scheduled for electromyography (EMG). What should the nurse tell the client about the procedure? 1. "Your hair will be carefully washed prior to the procedure." 2. "This is a noninvasive procedure that takes about 30 minutes." 3. "A sedative will be given to you shortly before the procedure." 4. "You will not be allowed to eat 4 to 6 hours before the procedure."

(1) usually performed on the legs (2) correct—electrodes are attached to legs, length of time for impulse transmission is measured (3) may impair test results (4) procedure does not involve general anesthesia or GI system

A teenager diagnosed with anorexia nervosa is admitted to the hospital. In planning to care for the client, the nurse would expect the client to 1. view her appearance as "skinny." 2. be hypoactive and withdrawn. 3. want to talk about and plan her meals. 4. have a close relationship with her mother.

(1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct—display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa

A charge nurse develops assignments for the evening shift. The nurse notes that a client with a tracheostomy with purulent drainage and a pending culture and sensitivity (C&S;) is sharing a room with a client diagnosed with neutropenia. Which of the following actions by the charge nurse is MOST appropriate? 1. Assign an experienced nurse to care for both clients in the same room. 2. Assign each client a separate nurse. 3. Place the client diagnosed with neutropenia in a private room and assign the same nurse to care for both clients. 4. Place the client diagnosed with neutropenia in a private room and assign different nurses to care for each client.

(1) should be in a private room away from roommate with infection (2) should be in a private room away from roommate with infection (3) should be cared for by different nurses (4) correct—infection in a neutropenic individual may cause morbidity and fatality; place the neutropenic client in a private room; limit and screen visitors and hospital staff with potentially communicable illnesses

The nurse cares for a patient who experienced a thermal injury 2 weeks ago. The nurse is MOST concerned if which of the following is observed? 1. Increased heart rate and elevated blood pressure. 2. Temperature of 100.6°F (38.1°C) and decreased respiratory rate. 3. Increased heart rate and decreased respiratory rate. 4. Increased respiratory rate and decreased blood pressure.

(1) should be investigated further, but alone do not represent significant compromise (2) should be investigated further, but alone do not represent significant compromise (3) should be investigated further, but alone do not represent significant compromise (4) correct—may indicate burn wound sepsis, a life-threatening complication of thermal injury

A client has a subclavian triple lumen catheter used for administration of total parenteral nutrition (TPN). The physician orders all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should take which of the following actions? 1. Clamp off the lumen and label it as "clotted off." 2. Gradually increase the pressure on the irrigating solution. 3. Aspirate blood from the lumen to restore patency. 4. Secure the lumen with a Luer-Lock cap and notify the physician.

(1) should be reported to the physician to see if patency can be re-established before it is labeled as clotted off (2) force should never be used to irrigate the catheter (3) blood should not be aspirated from the catheter (4) correct—streptokinase may be used to dissolve clot; if unsuccessful, lumen is labeled as clotted off

A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which of the following responses by the nurse is BEST? 1. "It is best to buy new shoes in the morning." 2. "Have each foot measured every time you buy new shoes." 3. "Buy shoes a half-size larger than your foot size so the fit is roomy." 4. "Buy vinyl shoes because they won't lose their shape easily."

(1) should buy shoes in the afternoon when feet are larger than in the morning (2) correct—feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger) (3) buy correct shoe size (4) leather shoes recommended because they "breathe," vinyl could cause foot to perspire and aggravate fungal infections

The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. Which of the following situations require the nurse's IMMEDIATE attention? 1. A client with bipolar disorder walks into the day room in her underwear and begins dancing. 2. A client with depression says to the nurse, "My plan is complete, and I'm ready to go for it." 3. A client recovering from substance abuse complains that another client is harassing him. 4. A client with schizophrenia tells the nurse that it's "God's will" that he destroy the "evil TV."

(1) should remove to quiet area, decrease environmental stimuli (2) correct—could indicate impending suicide; requires immediate follow-up (3) potential suicide is more immediate concern (4) command hallucination; potential suicide takes priority

When caring for a client with a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which of the following the MOST important initial goal for the client? 1. Within 3 to 5 months, the client will state that the memory of the event is less vivid and distressing. 2. The client will indicate a willingness to keep a follow-up appointment with a rape crisis counselor. 3. The client will be able to describe the results of the physical examination that was completed in the emergency room. 4. The client will begin to express her reactions and feelings about the assault before leaving the emergency room.

(1) valid goal that needs to be addressed but after the initial goal has been met (2) valid goal that needs to be addressed but after the initial goal has been met (3) valid goal that needs to be addressed but after the initial goal has been met (4) correct—is nurse's initial priority to encourage client to begin dealing with what happened by verbalizing her feelings and gaining some acceptance and perspective

A client comes to the clinic complaining of severe facial pain. To collect subjective data from the client, it is MOST important for the nurse to take which of the following actions? 1. Obtain the client's vital signs. 2. Interview the client. 3. Inspect the face for grimacing. 4. Administer pain medication.

(1) vital signs are objective data (2) correct—subjective data is collected in the health history or interview (3) objective data (4) implementation, complete assessment to determine the problem

Which observation indicates to the nurse that the client needs further teaching before self-administering insulin? 1. The client draws up the regular insulin first, then the NPH. 2. The client gently rotates the insulin bottle before withdrawing the dose. 3. The client rotates injection sites following the guide on the printed diagram. 4. The client administers the insulin while it is still cold from the refrigerator.

(1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH) (2) bottle of insulin should never be vigorously shaken, but rather gently mixed (3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption (4) correct—insulin should be administered at room temperature; temperature extremes should be avoided

The clinic physician diagnoses Graves' disease for a client. The nurse expects the client to exhibit which of the following symptoms? 1. Lethargy in the early morning. 2. Sensitivity to cold. 3. Weight loss of 10 lb in 3 weeks. 4. Reduced deep tendon reflexes.

(1) will be restless (2) will have heat intolerance due to increased metabolic rate (3) correct—increased metabolic rate causes weight loss even with increased appetite (4) reflexes will be hyperactive

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

(1) will cause bradycardia (2) usually causes constipation (3) correct—Calan is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure (4) not most important or frequent side effect

The nurse develops a comprehensive care plan for a young woman diagnosed with anorexia nervosa. The nurse refers the client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with which of the following? 1. Aggressive behaviors and angry feelings. 2. Self-identity and self-esteem. 3. Focusing on reality. 4. Family boundary intrusions.

(2) correct—clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do

During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." Which of the following responses by the nurse is BEST? 1. "You are nauseated because of the fatigue you are feeling." 2. "The nausea is due to an increase in the basal metabolic rate." 3. "The nausea is caused by an elevation in the hormones." 4. "If you eat different kinds of foods, you won't be nauseated."

(3) correct—during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system

Which of the following statements is both a correctly stated nursing diagnosis and a high priority for an older client immediately following a modified radical mastectomy and axillary dissection? 1. Anxiety related to the mastectomy. 2. Impaired skin integrity related to the mastectomy. 3. Pain related to surgical incision. 4. Self-care deficit related to dressing changes.

(3) correct—immediately after surgery the priority is optimizing the client's comfort

The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which of the following as the primary goal of this type of group activity? 1. Provides psychosocial educational opportunities for stress and coping. 2. Provides an avenue for physical exercise. 3. Provides an environment for social interaction and companionship. 4. Reorients and provides a reality test for confused clients.

(3) correct—primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members (4) groups that facilitate orientation to time, person, place, and current events are called reality orientation groups

The nurse assesses a client immediately after an exploratory laparotomy. Which of the following nursing observations indicates the complication of intestinal obstruction? 1. Protruding soft abdomen with frequent diarrhea. 2. Distended abdomen with ascites. 3. Minimal bowel sounds in all four quadrants. 4. Distended abdomen with complaints of pain.

(3) immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen (4) correct—if an obstruction is present, the abdomen will become distended and painful

Amniocentesis

"The test will show us if there is any problem in the spinal cord." 4. "Early problems with the baby's blood can be identified with this test."

An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter. An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.

(1) common complaint, moderate pain is frequently experienced as fluid is instilled during first few exchanges (2) common complaint due to inactivity, decreased nutrition, use of medications; high-fiber diet and stool softeners help prevent (3) correct—indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity (4) caused by subcutaneous bleeding, common during first few exchanges ...

A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOST appropriate nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications. 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing. 3. Restart the IV and continue the previous medication schedule. 4. Call the physician and recommend that the IV medications be changed to PO.

(1) continued IV medication may not be necessary based on the current assessment (2) physician should be notified if IV medications are not infusing as scheduled (3) client has improved breathing, so IV medications may not be indicated (4) correct—before a new IV is started on this client, physician should be called and PO medications recommended

The nurse cares for a client during an acute manic episode. The nurse identifies which client behavior is MOST characteristic of mania? 1. Agitation, grandiose delusions, euphoria, difficulty concentrating. 2. Difficulty in decision-making, preoccupation with self, distorted perceptions. 3. Paranoia, hallucinations, disturbed thought processes, hypervigilance. 4. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.

(1) correct—characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior (2) characteristic of depression (3) indicative of schizophrenia (4) consistent with personality disorders

The nurse knows which of the following observations is indicative of chronic cocaine use? 1. Nasal septum disruption. 2. Lack of coordination. 3. Constricted pupils. 4. Craving for sweets and carbohydrates.

(1) correct—chronic inhalation creates sores, burns, disruption of mucous membranes, and holes in the nasal septum (2) barbiturate abusers typically suffer from lack of coordination (3) narcotic abusers demonstrate constricted pupils (4) clients who abuse marijuana, hashish, and/or THC experience cravings for sweets and carbohydrates ...

The nurse receives a bedside report from another nurse. The nurse giving the report begins to talk about another client. Which action by the nurse receiving the report is MOST appropriate? 1. Ask the nurse to report on this client only. 2. Ask the nurse to lower his/her voice. 3. Ask the nurse to move to another part of the room. 4. Ask the nurse to clarify which client s/he is reporting on.

(1) correct—client confidentiality is being violated, nurse should intervene to protect client (2) does not provide for client confidentiality (3) does not provide for client confidentiality (4) does not provide for client confidentiality

The nurse prepares a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is MOST important for the nurse to ask? 1. "Did you have anything to eat or drink before you came in today?" 2. "Have you had any headaches since your last treatment?" 3. "Who came with you to the hospital today?" 4. "Have you had much memory loss since you began your treatments?"

(1) correct—client given general anesthesia for ECT; NPO after midnight (2) not relevant to ECT (3) not most important (4) memory loss is an expected outcome

The nurse plans care for a client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which of the following responses? 1. Cause the client to defend the idea. 2. Help the client clarify thoughts. 3. Facilitate better communication. 4. Lead to a breakdown of the defense.

(1) correct—contraindicated; encourages patient to engage in further distortion of reality (2) needs reality testing from nurse, not questioning (3) questioning is nontherapeutic; may cause patient to avoid nurse physically (4) needs defense; questioning will further distort reality or elaborate on delusion

The nurse prepares discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) test? 1. The initial specimen should be collected as close to discharge as possible but not after 7 days. 2. The infant can have water but should not have formula for 6 hours before the test. 3. The test will need to be repeated at 6 weeks and at the 3-month check-up. 4. Blood will be drawn at three 1-hour intervals; there is no specific preparatio

(1) correct—if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age (2) no restriction on formula intake (3) test may be repeated within 2 weeks to ensure accuracy (4) only one blood sample is needed

The nurse prepares a client for a liver biopsy. The nurse should position the client in which of the following positions? 1. Prone with the head turned to the side. 2. On the right side with the head slightly elevated. 3. Supine with arms raised above the head. 4. On the left side with the bed flat.

(1) incorrect positioning for procedure (2) positioned on right side with small pillow under puncture site for 3 hours after procedure (3) correct—elevates the ribs to allow access to the liver, needle is inserted between two of the lower ribs or below the right rib cage (4) incorrect positioning for procedure

A 2-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse. An appropriate nursing diagnosis is high risk for 1. impaired swallowing. 2. failure to thrive. 3. fluid volume deficit. 4. altered health maintenance.

(1) no information about swallowing provided with question (2) this is a medical diagnosis, not a nursing diagnosis (3) correct—may become dehydrated (4) not specific for problem described

The nurse monitors a client in active labor who is receiving oxytocin (Pitocin) 1 mU/min IV. The nurse should stop the infusion if which of the following is observed? 1. The contractions occur at 3-minute intervals and last more than 60 seconds. 2. The contractions occur at 2.5-minute intervals and last more than 90 seconds. 3. The contractions occur at 2-minute intervals and last more than 90 seconds. 4. The contractions occur at 2-minute intervals and last more than 60 seconds.

(1) normal frequency and duration (2) normal frequency and duration (3) correct—contractions should be less frequent (longer than 2-minute intervals) and should be of shorter duration (less than 90 seconds); allows for longer resting time between contractions (4) normal frequency and duration

The nurse knows which of the following is an important consideration in the care of a newborn with fetal alcohol syndrome? 1. Prevent iron deficiency anemia. 2. Decrease touch to prevent overstimulation. 3. Provide feedings via gavage to decrease energy expenditure. 4. Replace vitamins depleted as a result of poor maternal diet.

(1) not highest priority (2) infant needs to be held and cuddled due to a poorly developed CNS (3) usually unnecessary (4) correct—frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following? 1. Signs and symptoms of infection. 2. Fluid and electrolyte balance. 3. Seizure precautions. 4. Steroid replacement.

(1) not most important (2) not most important (3) not most important (4) correct—steroid replacement is the most important information the client needs to know ...

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

(1) present at 9 months of age (2) correct-6-month-old should sit with help (3) present at 1 year (4) fontanelle is closed by 2 to 3 months

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

(1) provides information regarding the fluid volume level, but is not the best action for evaluation (2) correct—daily weight is the best way to evaluate for fluid volume deficit (3) provides information regarding the fluid volume level, but is not the best action for evaluation (4) provides information regarding the fluid volume level but is not the best action

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which of the following? 1. Projection and displacement. 2. Sublimation and internalization. 3. Rationalization and intellectualization. 4. Reaction formation and symbolization.

(1)correct— -projection (attributing one's thoughts or impulses to another -displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object)

types of foods should the nurse encourage for a client diagnosed with hypoparathyroidism?

(2) correct—diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance

During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint? 1. An infant with septicemia. 2. A child with a tonsillectomy. 3. An infant with cleft lip repair. 4. A child with meningitis.

(3) correct—arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line

Under the supervision of the registered nurse, a student nurse changes the dressing of a client with a newly inserted peritoneal dialysis catheter. Which of the following activities, requires an intervention by the registered nurse? 1. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine. 2. The student nurse applies two sterile precut 4 × 4s to the catheter insertion site. 3. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site. 4. The student nurse securely tapes the edges of the sterile dressing with paper tape.

(3) correct—should clean from insertion site outward toward outer abdomen.

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse? 1. 11 months of age. 2. 14 months of age. 3. 17 months of age. 4. 20 months of age.

(3) not able to physiologically control sphincters until 18 months of age (4) correct—by 24 months may be able to achieve daytime bladder control

The nurse is aware that which of the following assessments indicates hypocalcemia? 1. Constipation. 2. Depressed reflexes. 3. Decreased muscle strength. 4. Positive Trousseau's sign.

(4) correct—positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia

A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. re-establishes a trusting relationship with his/her other parent. 3. verbalizes that he/she is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse.

.(1) continues the myth of "badness" and that he/she deserved the abuse and actively consented to it (2) outcome that would be positive but usually is not an initial result of treatment (3) correct—victim needs assistance to challenge "belief of victims," which includes "I am bad and deserve the abuse" (4) expected outcome ..

The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client that he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room.

...(1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eat at regular time; remain in the seclusion room for client's safety

A client with chronic pain due to cancer receives meperidine (Demerol) 100 mg PO q4h PRN for pain without much relief. Which of the following changes in narcotic pain management is the MOST valid suggestion for the nurse to make to the physician? 1. Decrease medication to twice a day. 2. Decrease medication to every 6 h PRN. 3. Administer medication every 4 h around the clock. 4. Administer medication every 2 h PRN.

1) decreases the amount of pain medication (2) decreases the amount of pain medication (3) correct—around-the-clock (ATC) administration of analgesics is more effective in maintaining blood levels to alleviate the pain associated with cancer (4) might be too frequent an interval to administer the medication

The clinic nurse performs diet teaching for an older client with acute gout. The nurse should teach the client to limit the intake of which of the following? 1. Red meat and shellfish. 2. Cottage cheese and ice cream. 3. Fruit juices and milk. 4. Fresh fruits and uncooked vegetables.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—should be on low-purine diet, should avoid red and organ meats, shellfish, oily fish with bones (2) calcium-rich foods are not limited with gout (3) no restriction with gout (4) high-roughage foods are not limited with gout ...

A client is scheduled for a left lower lobectomy. The physician orders diazepam (Valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure.

Strategy: Determine if the answer choice relates to Valium. (1) more indicative of preoperative complications, should be reported before medications are given (2) more indicative of preoperative complications, should be reported before medications are given (3) correct—observation most indicative for antianxiety drugs is restlessness and increase in heart rate due to circulating catecholamines (fight or flight) (4) hostility may be treated best by ventilating feelings ...

The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical. 2. The girl walks with a waddling gait. 3. The girl's lower legs are edematous. 4. The girl has a protruding sternum.

Strategy: Determine the significance of each answer choice and how it relates to scoliosis. (1) correct—thoracic area becomes noticeably distorted (2) seen with hip dislocation (3) seen with circulatory or inflammatory processes (4) seen with pigeon breast, or pectus carinatum

The nursing staff plans to use behavior modification techniques for an elderly woman who constantly screams. Which of the following nursing assessments is necessary to establish a successful program? 1. Monitor the client's ability to complete her activities of daily living (ADL). 2. Assess the client's levels of pain and correlate it with her response to analgesia. 3. Observe the client's behavior at regular intervals to obtain baseline information related to her screaming. 4. Ask the client why she is screaming and document it on her nursing assessment record.

Strategy: Determine what is being assessed in each answer choice and how it relates to screaming. (1) important because activities of daily living can contribute to the targeted behavior of screaming; assessing only the area of ADLs does not provide comprehensive data for developing a behavior management program (2) important because activities of pain can contribute to the targeted behavior of screaming; assessing only the area of pain does not provide comprehensive data for developing a behavior management program (3) correct—to design an effective behavior modification program, accurate baseline data must first be collected about the target behavior in relation to frequency, amount, time, and precipitating factors (4) client may be unable to state why she is screaming; asking "why" questions is nontherapeutic

The nurse cares for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST? 1. A client with cold symptoms has an oral temperature of 103°F (39.4°C). 2. A client with stage II decubitus ulcer reports that the dressing has come off. 3. A client is nauseated and has vomited 6 times in the previous 24 hours. 4. A client complains of leg pain after walking half a mile.

Strategy: Eliminate the two most stable clients. Use the ABCs to determine the most unstable client. (1) elevated temperature indicates infection; determine the underlying cause, encourage fluids (2) stable client (3) correct—assess amount, character, symptoms of fluid volume deficit (4) stable client, complaint indicates intermittent claudication

The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which of the following ages? 1. 5 months of age. 2. 6 months of age. 3. 9 months of age. 4. 12 months of age.

Strategy: Picture each infant. (1) unable to sit unsupported until 8 months (2) unable to sit unsupported until 8 months (3) correct—can pull self up and assume a sitting position at 8 months, can say few words (4) would be able to say three to five words in addition to dada and mama

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

Strategy: Remember therapeutic communication. (1) correct—states observation (2) doesn't help patient confront feelings (3) doesn't deal with avoidance behavior (4) nontherapeutic to ask why, causes patient to be defensive

The nurse in a psychiatric emergency room cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following? 1. Encourage the client to verbalize feelings. 2. Assess for physical trauma. 3. Provide privacy for the client during the interview. 4. Help the client identify and mobilize resources and support systems.

Strategy: Think "Maslow." (1) psychosocial, priority is physical injury (2) correct—physical, victim may have physical trauma and concealed injuries; assessment is of utmost importance so that the client's physiologic integrity is maintained (3) psychosocial, done concurrently as the nurse is assessing for physical injury (4) psychosocial, priority is physical injury

Which of the following is a correctly stated nursing diagnosis for a client with an abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding.

Strategy: Think about each answer choice. (1) inaccurate for the situation (2) incorrectly stated (3) incorrectly stated (4) correct—abruptio placentae is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients

When a nurse is using restraints for an agitated/aggressive patient, which of the following items should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.

Strategy: Think about each answer choice. (1) nurse should follow the policies of the institution (2) must get written permission from the patient for restraints; if patient has been judged incompetent, permission is obtained from the legal guardian (3) correct—the need for restraints is based on patient's behavioral status and condition, not the patient's voluntary/involuntary status (4) must first try less restrictive means to control patient before using restraints

After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.

Strategy: Think about how each answer choice relates to a head injury. (1) not priority (2) correct—indicates a rupture of meninges and presents a potential complication of meningitis (3) not priority (4) is not a change in assessment

A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST? 1. Amount of the drainage. 2. Character of the drainage. 3. Consistency of the drainage. 4. Amount of suction on the drainage system.

Strategy: Think about the significance of each assessment and how it relates to a wound abscess. (1) lower priority (2) correct—with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report (3) lower priority (4) unnecessary

CANDLELIGHTERS

Support group for families who have lost a child to cancer.

RESOLVE

Support group for infertile clients.

Lumbar disc injury

Symptoms - pain in the back or lower extremities, abnormal sensation and weakness, paresis and limited mobility.

Alcohol withdrawal

Symptoms show within 24-48 hours., , --psychomotor agitation, - tremor, -elevated Temp. -nocturnal leg cramps -pain complains -insomnia, -nausea, seizures, vomiting, -anxiety, hallucinations -delirium, potentially fatal - use long-acting Benzodiazepams to help with this.

MOST important for the rehabilitation nurse to assess during a new client's admission?

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

Rationalization

Attempt to make behavior appear to be the result of logical thinking.

Colostomy

Colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination.

Reason elderly adults have problems with constipation is

Elderly adults have less activity and decreased muscle tone.

Epinephrine

A catecholamine secreted by the adrenal medulla in response to stress preparing the body for "flight or fight" (trade name Adrenalin)

verapamil (Calan)

Antidysrhythmic class IV; antihypertensive: CA channel blocker -verapamil is indicated for the treatment of supraventricular tachycardias, so the client's heart rate should be checked prior to administration

Subcutaneous insulin injections after surgery, for a client controlled usually with oral meds

Being NPO inhibits normal blood sugar control.inability to control diabetes mellitus by diet and oral agents, coupled with surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids necessitates temporary control by insulin.

cataract post-op

Cautioned about not making sudden movements or bending over, to avoid pressure on the ocular suture line. -Sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line

The nurse cares for a patient receiving chlorpromazine hydrochloride (Thorazine). The nurse notes the patient is restless, unable to sit still, and complains of insomnia and fine tremors of the hands. The nurse identifies which of the following as the BEST explanation about why these symptoms are occurring? 1. A side effect of the medication that will disappear as time passes. 2. The reason the patient is receiving this medication. 3. Extrapyramidal side effects resulting from this medication. 4. An indication that the dosage of the medication needs to be increased.

Chlorpromazine hydrochloride (Thorazine) 3- Extrapyramidal side effects resulting from this medication. (1) untrue statement; dosage may need to be decreased because of side effect of medication; antiparkinsonian drug such as Cogentin may be ordered (2) not accurate; antipsychotic medication (3) correct—side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing) (4) dosage may be decreased; antiparkinsonian drug such as Cogentin may be ordered Conventional antipsychotic, schizophrenia drug; IV forms should be used only during surgery for severe hiccups; preg. category C; not advised for use in alcohol withdrawal;caution should be used with these conditions: subcortical brain damage, bone marrow depression, and Reye's syndrome; St. John's wort and kava increase the risk and severity of dystonia 3-correct—side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing)

Intellectualization

Excessive reasoning or logic used to avoid experiencing disturbing feelings.

A client undergoes peritoneal dialysis. The physician orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 mL. During the nurse's shift, the client drinks 700 mL of fluids and voids 400 mL. Record the client's intake in milliliters. Your Response: 2700 Correct Response: 900

Inflow and intake are recorded separately. The difference between inflow and outflow is considered intake.

Aggressive play

Is not play but a behavior

Ataxia

Lack of coordination -supervise ambulation

Hip fracture

Most common type of fracture; may cause shortening or external rotation of the leg (The leg appears to be shortened and is adducted and externally rotated.)

Cellilitis in drug addicts

Most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus.

naproxen sodium (Naprosyn)

NSAID (nonsteroidal anti-inflammatory drug) used as analgesic; side effects include headache, dizziness, gastrointestinal distress, pruritus, and rash.

Lead poisoning

Poisoning caused by an elevated level of lead in the human body that can result in damage to the -brain: (↑ICP, shift of fluids in brain, intellectual deficiencies, mental retardation, convulsions, death), - nervous system, -kidneys, and blood., -Microcytic Anemia(initial sign)

A client had a kidney transplant yesterday...

Visitors should perform a good hand washing,because is the most effective method of reducing infection; very important with immunosuppressed clients.

Pituitary dwarfism.

Condition of congenital hyposecretion of growth hormone slowing growth and causing short yet proportionate stature (not affecting intelligence), often treated during childhood with growth hormone; other forms of dwarfism are most often caused by gene defects. -Delicate features. -small size but normal body proportions -delayed sexual maturity -appear younger than chronological age -usually see fine, smooth skin

The parents of a 1-month-old boy bring their son to the clinic for evaluation of a possible developmental dysplasia of the right hip. The nurse should observe for which of the following? 1. Limited adduction of the right leg. 2. Uneven gluteal fold and thigh creases. 3. Increase in length of the right limb. 4. Internal rotation of the right leg.

(1) will see limited abduction (2) correct—folds and creases will be longer and deeper on affected side (3) will be decrease in limb length (4) may or may not see internal rotation

The nurse determines which of the following actions has HIGHEST priority when caring for the client diagnosed with hypoparathyroidism? 1. Develop a teaching plan. 2. Plan measures to deal with cardiac dysrhythmias. 3. Take measures to prevent a respiratory infection. 4. Assess laboratory results.

(2) correct—cardiac dysrhythmias related to low serum calcium would be the highest priority (3) potential for respiratory infection is not a major threat

Generativity versus stagnation.

45-64 years of age

Integrity versus despair and disgust.

65 y/o ↑

Preeclampsia

Abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria (loss of protein in urine), and edema

Dystonia

Abnormal muscle tone that causes the impairment of voluntary muscle movement

Artificial passive immunity

Antibodies from another person or animal that are injected into a human (tetanus).

Parathyroid hormone

Regulates phosphorus and calcium in the body and functions in neuromuscular excitation and blood clotting.

Client ordered to receive two units of packed cells .

Requires the assessment and teaching skills of the RN

Observations suggesting the client has developed an addisonian crisis?

Restlessness and rapid, weak pulse. -{Muscular weakness and fatigue, Dark pigmentation of the skin, Gastrointestinal disturbances and anorexia are signs and symptoms of Addison's disease, but do not indicate a crisis.}

Test to evaluate the baby's lungs."

determined with lecithin/sphingomyelin (L/S) ratio by an amniocentesis

Apraxia

Inability to perform purposeful movements or to use objects appropriately. Ex: common in elderly with ADL's difficulty.

Internalization

Incorporation of someone else's opinion as one's own.

Webber test

Tunning fork on midline of skull, pt idenities sound that is loudest, normal hearing sound is heard equally, sound louder in ear with hearing loss, softer in ear with sensorineural hearing loss.

18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB), early symptoms? 1. Kussmaul respirations and bradycardia. 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions. 4. Inspiratory stridor and restlessness.

Inspiratory stridor and restlessness. correct—this condition is characterized by edema and inflammation of upper airways

The nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis?

→Right upper abdominal pain. -N/V/ Flatulencia, dyspepsia indicates other GI problems

Reflect a client's emotional adjustment to being hospitalized.

"The client constantly calls for nurses and cries uncontrollably." correct—gives an objective description of the client's behavior and affect

Which of the following assessments is priority when documenting the nursing history of a 2-year-old child? 1. The child's rituals and routines at home. 2. The child's understanding of hospitalization. 3. The child's ability to be separated from the parents. 4. The parent's methods for dealing with the child's temper tantrums.

(1) correct—during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home (2) important, but not as critical to the planning of the child's hospital care (3) important, but not as critical to the planning of the child's hospital care (4) important, but not as critical to the planning of the child's hospital care

The nurse identifies the MOST reliable client measure to evaluate the desired response of diuretic therapy includes which of the following? 1. Obtain daily weights. 2. Obtain urinalysis. 3. Monitor Na+ and K+ levels. 4. Measure intake.

(1) correct—effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights

The nurse reviews client assignments on a medical/surgical unit. The nurse determines that the assignment is appropriate if the nursing assistant is caring for which of the following clients? 1. A client with AIDS dementia complex who requires a urine specimen. 2. A client complaining of postoperative pain after repair of a torn rotator cuff. 3. A client with GI bleeding due to a duodenal ulcer who is receiving packed cells. 4. A client with type 1 diabetes receiving prednisone for a herniated disk.

(1) correct—standard, unchanging procedure (2) assign to the RN (3) assign to the RN (4) assign to the RN

When assisting with a bone marrow aspiration, the nurse should take which of the following actions? 1. Drop additional sterile supplies onto a sterile tray. 2. Unwrap all sterile packs for the procedure in case they are needed. 3. Reach over the tray, and remove contaminated supplies. 4. Place the bottle of sterile liquid on the sterile field so that it does not splash.

(1) correct—sterile articles should be dropped at a reasonable distance from the edge of the sterile area (2) sterile packs should be opened only as needed (3) never reach an unsterile arm over a sterile field (4) outside of a bottle containing sterile liquid is not considered to be sterile ...

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

(1) correct—will see dyspnea, cough, edema, hemoptysis (2) will initially increase and then fall due to congestive heart failure, doesn't fluctuate (3) reflects body's general hydration status, mainly shows dramatic changes with dehydration (4) would indicate infectious, inflammatory process, skin temperature will fall with circulatory overload

The nurse knows that which of the following symptoms is supportive of a diagnosis of Guillain-Barré syndrome? 1. Hemiplegia, hypertension, tachycardia. 2. Respiratory failure, flaccid paralysis, urinary retention. 3. Peripheral edema, hypertension, pulmonary congestion. 4. Diminished reflexes, pain, paresthesia.

(1) relates to a CVA (2) correct—classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation (3) relates to pulmonary edema (4) relates to peripheral nerve problems

Hip fracture care

-Position pt to non operative side -Maintain abduction pillow between legs -ambulate pt the first post op day( pt transfer to a chair w / assistance and begings assisted ambulation) -Never flex the hip > 90 degrees -HOB no more than 60 degress

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

1) would be noted, but is not as high a priority (2) inappropriate (3) correct—suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies (4) inappropriate

The nurse cares for a newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics?

2. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. -usually small for gestational age -may have feeding difficulties and poor sucking ability -head circumference usually small, respiratory distress related to preterm birth, neurologic damage, small trachea, floppy epiglottis

Identity versus role diffusion.

appropriate for the adolescent

Parallel play

Describes play for a toddler

Solitary play

Describes play for an infant

Hemolytic transfusion reaction

Destruction of erythrocytes that occurs when a patient receives a transfusion of mismatched blood -hypotension, ↑PR, U/O, hematuria -chills -lower back pain, -fever, nausea, vomiting -flushing, -bleeding, shock, -hemoglobinuria (life threatening).

Cholesterol test

Determination of blood cholesterol levels following a 12-hour fast. Only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results.

Pacemaker

Device that delivers electrical impulses to the heart to regulate the heartbeat and main purpose is to ↑ CO

Indications of early pre-eclampsia?

Facial swelling and proteinuria.

Early signs of lithium toxicity?

Fine tremors, nausea, vomiting, diarrhea.

The nurse cares for a client with a tracheostomy. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to increased tracheobronchial secretions.

Encourage fluids for a toddler with lead poisoning.

Milk: milk provides a large amount of vitamin D; vitamin D optimizes deposition of lead in the long bones; purpose of the treatment is to remove lead from the blood and soft tissues.

BEST way for a nurse to assess the fluid balance of an elderly .

Monitor fluids intake and output -Turgoris not accurate r/t changes in skin elasticity.

Narcotics

Mood-altering drugs most often associated with an increased risk for HIV infection related to intravenous drug use

Expiratory wheezing and substernal retractions.

More often noted with respiratory distress of the newborn

Which of the following symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin? 1. Severe cravings, depression, fatigue, hypersomnia. 2. Depression, disturbed sleep, restlessness, disorientation. 3. Nausea and vomiting, tachycardia, coarse tremors, seizures. 4. Runny nose, yawning, fever, muscle and joint pain, diarrhea.

Strategy: Think about the cause of each symptom and how it relates to narcotic withdrawal. (1) describes cocaine withdrawal (2) describes amphetamine withdrawal (3) describes barbiturate withdrawal (4) correct—narcotic withdrawal is very much like the symptoms of the flu

ceftriaxone sodium (Rocephin) IV for infection

cephalosporin, long-term use of Rocephin can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended

Delusions of persecution.

Delusion is a strongly held belief that is not validated by reality; the idea that his brother is trying to steal his property is a belief not validated by reality.

adult client diagnosed with mental retardation for discharge and teaching them self medication administration

Determine the client's comprehension of the medication administration. -Encourage a return demonstration of medication self-administration might be done after evaluation of the comprehension level

Sublimation

Diversion of unacceptable drives into socially acceptable channels.

Client with hypothyroidism to avoid which of the following

Narcotic sedatives. —client is very sensitive to narcotics, barbiturates, and anesthetics

Cardiac catheterization

Procedure where a catheter is inserted into an artery and guided into the heart; may be used for diagnosis of blockages or treatment, -Thin, flexible tube is guided into the heart via a vein or an artery and after contrast material is introduced, blood pressure is measured, and x-rays taken to image patterns of blood flow. - check allergies for shellfish

Kwell shampoo for lices

Repeat shampoo in 7-10 days ( or5-7 days) -very hot water and a special detergent (RID) need to be used for cleansing clothing and personal belongings (3) correct—Kwell is an organic solvent, can be toxic, absorbed through scalp; may be repeated 5 to 7 days after first application -must be repeated after the eggs hatch; permethrin 1% crème rinse (Nix) kills both lice and nits after one application

Symbolization

Something represents something else; symbolization is involved in phobias

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

Strategy: "Further teaching" indicates incorrect information (1) taking with meals ensures consistent therapeutic effect (2) common side effect, usually subsides (3) correct—no change in stool color (4) side effect seen with medication

A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed? 1. Kussmaul respirations and diaphoresis. 2. Anorexia and lethargy. 3. Diaphoresis and trembling. 4. Headache and polyuria.

Strategy: "MOST concerned" indicates a complication. (1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia

The physician orders indomethacin (Indocin) 25 mg PO bid for a client. It is MOST important for the nurse to make which of the following statements? 1. "Take this medication with food." 2. "Take this medication one hour before meals." 3. "Take this medication one hour after meals." 4. "Take this medication with orange juice."

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) correct—reduces GI upset (2) risk of GI upset (3) should be given with food (4) risk of GI upset

A middle-aged adult is seen in the emergency department for complaints of severe right-flank pain. The client is 20 pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi 4 years ago. Which of the following actions, if performed by the nurse, is MOST important? 1. Ensure that the client has nothing to eat or drink. 2. Obtain a "clean-catch" urine specimen for analysis. 3. Provide warm packs to relieve discomfort. 4. Measure and strain the client's urine.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) should force fluids to 3,000 mL/day to assist client to pass stone (2) not most important, used to identify infection (3) not most important, analgesics given to reduce discomfort (4) correct—will document passage of stone and allow composition to be analyzed

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

Strategy: "MOST important" indicates priority. Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) correct—protein needed to slow down degeneration process of aging (2) necessary, but not most important (3) necessary, but not most important (4) should maintain oral intake

A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h."

Strategy: "Question which of the following orders" indicates an incorrect order. (1) H1 receptor blocker, used as an antiemetic (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers

The nurse supervises a student nurse teach the client about a newly prescribed medication. Which of the following actions, if observed by the nurse, requires an intervention? 1. The student nurse glances at the clock when instructing the client. 2. The student nurse uses culturally appropriate language and teaching materials. 3. The student nurse begins instructions to the client discussing information that concerns the client. 4. The student nurse chooses a time for teaching when there are no visitors.

Strategy: "Requires an intervention" indicates that you are looking for an incorrect behavior. (1) correct—lack of attending behaviors are always a barrier to learning (2) appropriate teaching strategy (3) appropriate teaching strategy (4) appropriate teaching strategy

The nurse in the outpatient clinic instructs a client diagnosed with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is effective? 1. The client advances the cane 18 inches in front of the foot with each step. 2. The client holds the cane in the left hand. 3. The client advances the right leg, then the left leg, and then the cane. 4. The client holds the cane with elbows flexed 60°.

Strategy: "Teaching is effective" indicates a correct behavior. (1) should advance cane 6-10 inches with body weight on both legs (2) correct—should hold cane on strong side, widens base of support, reduces stress on affected side (3) should advance cane, weaker leg, stronger leg (4) should flex no more than 30°

A client is scheduled for a cardiac catheterization and the nurse teaches the client about the procedure. Which of the following statements, if made by the client to the nurse, indicates an understanding of the teaching? 1. "I'm going to feel cold during the procedure." 2. "I can get up and walk to the bathroom immediately after the procedure." 3. "The nurse will be checking my foot pulses after the procedure." 4. "I won't be able to eat for 24 hours before the procedure."

Strategy: "Understands teaching" indicates that you are looking for a true statement. (1) may feel burning sensation when dye injected (2) on bedrest 8 to 12 h after procedure with pressure dressing applied over catheter insertion site (3) correct—peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4 h (4) NPO midnight before procedure

A client is admitted diagnosed with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness.

Strategy: All answers are assessments. Determine how each relates to increased intercranial pressure. (1) indicates brainstem damage (2) late sign of brainstem damage (3) late sign of increased intracranial pressure (4) correct—may be confused and stuporous

A woman at 38 weeks' gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding? 1. "I feel fine, but the bleeding scares me." 2. "I've been more nauseated during the past few weeks." 3. "The bleeding started after I carried four bags of groceries." 4. "I've been having severe abdominal cramps."

Strategy: All answers are assessments. Think about what each phrase is describing and how it relates to a placenta previa. (1) correct—placenta previa is characterized by painless vaginal bleeding (2) nausea not a symptom of placenta previa (3) bleeding is not necessarily related to activity (4) pain not characteristic of placenta previa

The physician orders ranitidine hydrochloride (Zantac) 150 mg PO daily for the client. The nurse should advise the client the BEST time to take the medication is which of the following? 1. Prior to breakfast. 2. With dinner. 3. With food. 4. At hour of sleep. After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contacts to identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?"

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) absorption is not affected by food (2) absorption is not affected by food (3) absorption is not affected by food (4) correct—best results when taking once a day ...

The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following? 1. Atropine sulfate (Atropine) IV. 2. Isoproterenol (Isuprel) IV. 3. Verapamil (Calan) IV. 4. Lidocaine hydrochloride (Xylocaine) IV.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antidysrhythmic, used for bradycardia (2) antidysrhythmic, used for heart block, ventricular dysrhythmias (3) antihypertensive, calcium-channel blocker (4) correct—lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia

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

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—promotes venous return and decreases venous pressure, relieving pain and edema (2) obstructs venous flow, increasing chance for thrombus formation (3) can cause pulmonary emboli, should be on bedrest 5 to 7 days (4) used to prevent deep vein thrombosis, should be on bedrest initially

An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following? 1. High-protein, low-residue diet. 2. Position client on unaffected side. 3. Exercise the client's arms and legs. 4. Encourage the client to cough and deep breathe.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) diet should be high residue to prevent constipation due to inactivity (2) may be positioned on affected side after incision heals (3) foot flexion exercises should be done every hour to prevent complications (4) correct—prevents respiratory complications due to immobility following surgery

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

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) diet should not be reduced (2) correct—dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia (3) peaks in 4 to 6 hours, would not prevent dawn phenomena (4) would adjust snack, not eliminate it...

The nurse prepares to perform peritoneal dialysis on an older patient. The patient states that he/she had pain the last time the procedure was done. It is MOST appropriate for the nurse to take which of the following actions? 1. Administer a warm drink to the patient. 2. Administer a warm bath to the patient. 3. Warm the bag of dialysate solution with a heating pad. 4. Warm the bag of dialysate solution in a microwave oven.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not affect pain with fluid infusion (2) does not affect pain with fluid infusion (3) correct—temperature can be regulated, warming reduces pain caused by cold solution (4) contraindicated because of unpredictable warming patterns

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

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not promote rest (2) does not promote rest (3) correct—elderly client who feels isolated and unable to obtain help if needed cannot rest properly (4) elderly client will rest better if s/he understands what is going on with his/her health care

Which of the following nursing actions is the priority for an infant admitted with a positive stool culture for Salmonella? 1. Change diet to clear liquids. 2. Initiate intravenous fluids. 3. Maintain contact precautions. 4. Apply cloth diapers.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may be appropriate, but is not a priority over answer choice 3, which will prevent transmission (2) may be appropriate, but is not a priority over answer choice 3, which will prevent transmission (3) correct—prevents transmission of this bacterium to other individuals (4) may be appropriate, but is not a priority over answer choice 3, which will prevent transmission

The nurse cares for a client with a long history of alcohol and drug dependence. It is MOST important for the nurse to include which of the following as part of the discharge planning? 1. Refer to a social service agency for assistance with housing. 2. Refer to an aftercare center in the community. 3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor. 4. Ask the client to obtain a prescription for an antidepressant medication.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may be of some help, but will not directly provide support necessary to maintain sobriety (2) may be of some help, but will not directly provide support necessary to maintain sobriety (3) correct—self-help groups have greatest success rate as a sustained support system in the community (4) is information to indicate client depressed

An adult client has regular insulin ordered before breakfast. The nurse notes that the client's blood glucose level is 68 mg/dL and the client is nauseated. Which of the following actions should the nurse take? 1. Immediately give the client orange juice to drink. 2. Administer the insulin on time. 3. Withhold the insulin, and notify the physician. 4. Return the breakfast tray to the kitchen.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may cause vomiting (2) correct—take insulin or oral agent as ordered, check blood glucose or urine ketones every 3 to 4 hours, sip 8 to 12 oz liquid per hour, substitute easily digested soft foods, liquids if solids not tolerated (3) blood glucose increases during illness; even though client can't eat, administer insulin (4) does not address the client's problem

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

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) mononucleosis is spread by direct contact (2) no reason to be isolated (3) correct—symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months (4) clients with mononucleosis are not isolated

The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 1. Notify the physician. 2. Inform surgery. 3. Contact the father to obtain consent. 4. Continue the child's preoperative preparation.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to notify the physician (2) no reason to call the OR (3) consent from either divorced parent is sufficient (4) correct—parent or legal guardian required to give informed consent prior to surgical procedure

A child comes to the school nurse with a honey-colored crusted lesion below the right nostril. Which of the following actions should the nurse take FIRST? 1. Remove the scab. 2. Apply a wet cloth to the lesion. 3. Notify the child's parents. 4. Contact the health department.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) notify parents first; loosen scab with Burrow's solution compress; gently remove, topical ointment (2) notify parents first; treated with systemic antibiotics, antibacterial soap (3) correct—describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician (4) unnecessary to report impetigo to the health department

The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. The client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of treatment. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for 6 to 9 months.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) on airborne precautions during hospitalization; can send home with family because they are already exposed (2) not required (3) important, but not as important as taking medication (4) correct—necessary to take medication for 6 to 9 months

At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. Which of the following responses by the nurse is MOST appropriate? 1. Leave approximately three or four lines for the day nurse to enter the day information and sign the chart. 2. Review with the client the activities after 1 PM and enter what are determined to be the activities after 1 PM. 3. Begin charting on the next line below the last entry and make a note for the day nurse to make a late entry to complete the chart. 4. Do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) blank lines should never be left in the nurses' notes (2) nurse should chart only the care that s/he has administered (3) correct—day nurse can make a "late entry" to add any additional information (4) unnecessary

A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client should recline for 30 minutes after eating (2) fluids should be given between meals (3) intake of carbohydrates should be reduced along with highly spiced foods (4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates

The nurse cares for a client diagnosed with Cushing's syndrome. Which of the following nursing actions is the priority? 1. Implement measures to prevent skin breakdown. 2. Plan measures to prevent infections. 3. Teach the client signs and symptoms of hyperglycemia. 4. Instigate measures to prevent fluid overload.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clients are susceptible to skin breakdown and infections (2) clients are susceptible to skin breakdown and infections (3) impaired glucose tolerance often leads to hyperglycemia, but is not highest priority (4) correct—respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention

The nurse supervises the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—contact precautions required for diapered or incontinent clients (2) do not remove toys from room, possibly contaminated (3) diet should be high in carbohydrates and protein and low in fat (4) contact precautions required in addition to standard precautions

The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? 1. Talk with the client about how the client is feeling. 2. Instruct the nursing assistant to sit with the client while the client eats. 3. Contacts the physician to obtain an order for an antacid. 4. Evaluate the most recent vital signs recorded in the chart.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) more important to assess what is happening now

The nurse cares for a client with type 1 diabetes. The client receives nasal oxygen at 4 L/min. The student nurse reports that the client has pulled out the nasogastric tube and is picking at the bed covers. The client's BP is 150/90 and pulse is 90. Which of the following actions by the nurse is MOST appropriate? 1. Obtain a pulse oximetry reading. 2. Apply soft wrist restraints. 3. Reorient the client to person and place. 4. Determine the client's blood glucose level.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment; symptoms indicate reduced oxygen levels (2) implementation; must assess first to determine problem; all other interventions must be tried before using restraints (3) implementation; must determine the cause of the behavior before implementing (4) assessment; symptoms indicate decreased oxygen levels

The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST? 1. "That must have been a real shock to you." 2. "You should be tested for hepatitis B." 3. "You'll receive the hepatitis B immune globulin (HBIG)." 4. "Have you had unprotected sex with your boyfriend?"

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) nurse is interjecting own feelings (2) will require testing; not best response initially (3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine (4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implement

The physician orders meperidine (Demerol) 50 mg IM every 3-4 h PRN for pain for a client. The client asks the nurse for the medication at bedtime. Before administering the pain medication, the nurse should take which of the following actions? 1. Determine if the pain is psychological. 2. Read the client's chart to see if the client has a history of addiction. 3. Try several other comfort and pain relief measures. 4. Ask the client about the location, character, and intensity of the pain.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) should assess patient first (2) not highest priority, should assess patient first (3) need to assess before implementing action (4) correct—assessment first step in nursing process

The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action? 1. Remove reading material to decrease eyestrain. 2. Ask the client if he is nauseated. 3. Assess color of drainage from the affected eye. 4. Maintain sterility during q3h saline eye irrigations.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Think about what the assessments mean. (1) implementation; would be ineffective (2) correct—assessment; is important to prevent nausea and vomiting, would increase intraocular pressure, could cause damage to area repaired (3) assessment; refers to an eye infection, would be important after initial operative day (4) implementation; eye irrigations are not commonly done following this procedure ...

The nurse makes rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should take which of the following actions? 1. Put the infant to the woman's breast. 2. Encourage the woman to drink warm oral fluids. 3. Check the woman's pulse and respirations. 4. Continue to monitor the firmness of the uterus.

Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. (1) correct—implementation, causes natural surge of oxytocin that results in contraction of uterus (2) implementation, has no effect on contraction of uterus (3) assessment, not best action, situation does not suggest that patient is in shock (4) assessment, needs manual massage or release of natural oxytocin to contract uterus

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

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate 1 hour before surgery? No. Determine the outcome of each implementation. (1) should be done earlier than 1 hour before surgery (2) correct—surgical consent should be rechecked before going to surgery (3) should be done earlier than 1 hour before surgery (4) assessment; should be done earlier than 1 hour before surgery

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

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? Yes. (1) will not provide the data that a physical assessment would; may be a medical emergency requiring an immediate intervention (2) correct—best way to identify possible physical complications of alcohol dependence is through a complete physical assessment (3) should be done after the physical assessment is completed (4) inaccurate because the symptoms are most likely caused by physical and not psychological stressors

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

Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) does not need to be NPO (2) correct—prevents puncture of bladder (3) bowel preparation unnecessary (4) would make it more difficult to drain fluid; patient should be positioned sitting upright at side of bed with feet supported

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

Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) semi-Fowler's; too high, puts pressure on abdominal area (2) Trendelenburg position; impedes respiratory excursion (3) correct—low Fowler's; reduces stress on suture line, may be placed supine with hips and knees bent (4) high Fowler's; too high, puts pressure on abdominal area

An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should take which of the following actions? 1. Warm the irrigating solution to 110.0ºF (43.3ºC). 2. Establish a sterile field that includes the irrigating equipment. 3. Direct the irrigating solution at the outer edges of the wound, then the center of the wound. 4. Aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.

Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) too warm, should be room temperature or 90-95°F (32.2-35.0°C) (2) correct—requires strict aseptic technique (3) may cause new microorganisms to be flushed into wound (4) fluid should drain by gravity

A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions? 1. "Report an increase in blurred vision." 2. "Eat soft, warm foods." 3. "Change positions slowly." 4. "Chew food on the affected side."

Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary, does not occur with this condition (2) correct—intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain (3) intervention for Ménière's disease (4) chewing food on unaffected side less likely to trigger an attack

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

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee (2) exercise would not prevent future external rotation of the leg (3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required (4) leg will externally rotate unless propped in proper alignment

The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply."

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—most effective way of deep breathing and coughing, dilates airway and expands lung surface area (2) should splint incision before coughing to reduce discomfort and increase efficiency (3) partial answer, should take three deep breaths before coughing (4) implies coughing routine is adequate, incision needs to be splinted

The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care? 1. Standard precautions. 2. Testing for HIV. 3. Transfer to an acute care nursery facility. 4. Request AZT from the pharmacy.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—provides immediate protective care for the staff members (2) might be employed, safety is the priority (3) might be employed, is not a priority (4) this medication is not used in infancy ...

In planning anticipatory guidance for parents of a beginning school-aged child, it is MOST important for the nurse to include which of the following? 1. Teach the child to read and write. 2. Teach the child sex education at home. 3. Give the child responsibility around the house. 4. Expect stormy behavior.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may require some assistance from the parents, but children this age learn at their own rate (2) unnecessary at this early age (3) correct—giving children responsibilities allows them to develop feelings of competence and self-esteem through their industry (4) does not occur until about age 11

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. Administer oxygen. 2. Turn her to the right side. 3. Provide adequate hydration. 4. Start antibiotics.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not a priority (2) not a priority (3) correct—adequate hydration is a priority for any client with sickle cell crisis (4) not a priority

The nurse cares for an elderly client diagnosed with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unrealistic (2) correct—irreversible disease that leads to permanent physical limitations (3) unnecessary; disease usually is not terminal (4) unrealistic; disease is progressive, cannot be arrested

The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse considers the assignments appropriate if the nursing assistant is assigned to care for which of the following clients? 1. A client diagnosed with Alzheimer's requiring assistance with feeding. 2. A client diagnosed with osteoporosis complaining of burning on urination. 3. A client diagnosed with scleroderma receiving a tube feeding. 4. A client diagnosed with cancer who has Cheyne-Stokes respirations.

Strategy: Assign to nursing assistants clients with standard, unchanging procedures. (1) correct—standard, unchanging procedure (2) requires assessment; should assign to an RN (3) stable patient with expected outcome; should assign to an LPN/LVN (4) unstable patient, requires assessment and nursing judgment; should assign to an RN

Prior to a caesarean section delivery, a client is treated for abruptio placenta. The nurse cares for the woman during the postpartum period. Which of the following symptoms is suggestive of disseminated intravascular coagulation (DIC)? 1. The client's vital signs are: BP 90/58, temperature 101.0°F (38.3°C), pulse 112/min, respirations 18/min. 2. The client's laboratory results are Hgb 13 g/dL, HCT 40%, WBC 7,000/ mm3. 3. The client is nauseated, lethargic, and has vomited three times. 4. There is oozing blood from the venipuncture site and abdominal incision.

Strategy: Determine how each answer choice relates to DIC. (1) may indicate hemorrhage or sepsis (2) results normal, DIC would be reflected in clotting studies (PT, PTT) (3) nonspecific, could be related to anesthesia or pain medication (4) correct—DIC is an acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom

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

Strategy: Determine how each answer choice relates to an appendectomy. (1) doesn't indicate understanding that drainage may be normal after this surgery (2) first dressing usually changed by physician (3) doesn't indicate understanding that drainage may be normal after this surgery (4) correct—drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced

If a client develops cor pulmonale (right-sided heart failure), the nurse expects to observe which of the following? 1. Increased respiration with exertion. 2. Cough producing large amount of thick, yellow mucus. 3. Peripheral edema and anorexia. 4. Twitching of extremities.

Strategy: Determine how each answer choice relates to cor pulmonale. (1) common assessment finding of the patient with chronic lung disease (2) describes a complication of pneumonia (3) correct—right-sided heart failure is manifested by congestion of the venous system, resulting in peripheral edema; also, there is congestion of the gastric veins, resulting in anorexia and eventual development of ascites (4) is not seen with this client...

A nurse cares for a client diagnosed with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0 g/dL. 4. The patient's hemoglobin is 8.5 g/dL.

Strategy: Determine how each answer choice relates to nutritional status. (1) appetite is not the best indicator (2) weight gain may be fluid retention (ascites) (3) correct—albumin levels are best indicators of long-term nutritional status (4) low levels are caused by chemotherapy or cancer, not a good indicator because it takes long time to increase levels

A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says that she feels pressure against her diaphragm when the baby moves.

Strategy: Determine how each answer choice relates to pregnancy. (1) correct—abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency (2) not unusual, caused by pressure of enlarging uterus on veins returning blood from lower extremities (3) common near term with increased vascularity of vagina and perineum, only abnormal if bloody, foul-smelling, or abnormally colored (4) not unusual, due to pressure of enlarging uterus

The nurse identifies which of the following clients as being at HIGHEST risk of developing pulmonary embolus? 1. A 19-year-old 4 days' postpartum diagnosed with a placenta previa at 28 weeks' gestation. 2. A 22-year-old client diagnosed with leukemia with a platelet count of 120,000/mm3, hemoglobin 9.0 g/dL. 3. A 40-year-old man who is obese and diagnosed with multiple pelvic fractures due to a motor vehicle accident 2 days ago. 4. A 65-year-old woman who had a fractured hip repaired 10 days ago and is currently receiving daily physical therapy.

Strategy: Determine how each answer choice relates to pulmonary embolism. (1) not at risk for pulmonary embolism (2) at high risk for bleeding (3) correct—obesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli (4) client does not have a high risk for pulmonary emboli

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

Strategy: Determine how each answer choice relates to schizophrenia. (1) not indicative of schizophrenia (2) correct—inappropriate affect, expression of feelings bizarre for situation (3) describes depression (4) appropriate response

The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique? 1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes. 2. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing. 3. The nurse packs wet gauze into the incision without overlapping it onto the skin. 4. The old dressing is saturated with sterile saline before it is removed.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should clean from the center of wound to the outside using sterile equipment (2) dressings should be soaked before application (3) correct—if wet dressing touches skin, it could cause skin breakdown (4) should be removed dry so that wound debris and necrotic tissue are removed with old dressing

Prochlorperazine maleate (Compazine) 10 mg IM is ordered for a client. The client is also to receive butorphanol (Stadol) 2 mg IM. Before administering these medications, the nurse should take which of the following actions? 1. Obtain respirations and temperature. 2. Dilute with 9 ml of NS. 3. Draw the medications in separate syringes. 4. Verify the route of administration.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and temperature are not as high a priority (2) inappropriate (3) correct—Compazine should be considered incompatible in a syringe with all other medications (4) unnecessary

The nurse prepares to administer an injection of haloperidol decanoate (Haldol D) to a client. Which of the following actions by the nurse is MOST appropriate? 1. Massage the injection site. 2. Give deep IM in a large muscle mass. 3. Use a 2 inch 25 gauge needle. 4. Administer the medication in divided doses.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should not be done because medication is very irritating to subcutaneous tissue (2) correct—medication is very irritating to subcutaneous tissue (3) should use a 2 inch 21 gauge needle (4) should administer in single dose; patient should lie in recumbent position for one-half hour after administration of IM haloperidol decanoate

The nurse assists a patient from the bed to the chair for the first time after a right total hip replacement. It is MOST important for the nurse to take which of the following actions? 1. Assist the patient to stand on the right leg and pivot to a low soft chair, keeping her hips straight. 2. Assist the patient to stand on the left leg and pivot to a straight-backed chair, flexing her hips slightly. 3. Ask the patient to bear weight equally on both legs, bend at the waist, and sit in a low soft chair. 4. Assist the patient to stand on both legs and take a few steps to a straight-backed chair.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should not bear weight on affected side, dislocation may occur (2) correct—prevents dislocation (3) no weightbearing on affected leg, dislocation may occur (4) no weightbearing on affected leg, dislocation may occur

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1. Wash the burn with an antiseptic soap and water. 2. Remove clothing, and wrap the victim in a clean sheet. 3. Leave the blisters intact and apply an ointment. 4. Take no action until the victim arrives in a burn unit.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) soaps and ointments should not be applied to second-degree burns in an emergency situation (2) correct—after fire is out, remove clothing and cover victim with a clean sheet (3) soaps and ointments should not be applied to second-degree burns in an emergency situation (4) does not prevent infection

A young adult patient constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate? 1. Encourage the patient to establish trust with one staff person with whom therapeutic interventions should occur. 2. Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors. 3. Ignore the patient when the patient exhibits attention-seeking behavior. 4. Rotate the staff so that the patient will learn to relate to more than one nurse.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) staff should use a consistent undivided approach (2) correct—reward non-attention-seeking behaviors by giving the patient unsolicited attention (3) remain nonjudgmental, carry out limit-setting (4) staff should use a consistent undivided approach

The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 × 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions? 1. Remove the dressing, and replace it with a more absorbent dressing. 2. Collect a culture and sensitivity specimen of the drainage. 3. Observe the wound for dehiscence. 4. Reinforce the dressing with an 8 × 10 dressing

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each implementation. (1) correct—expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry (2) drainage described is bile, which is expected; no indication of infection (3) doesn't usually occur (4) reinforcing dressing might cause infection; change dressing to keep site clean and dry

The nurse is assigned to work with the parents of a child diagnosed with mental retardation. Which of the following should the nurse include in the care plan for the parents? 1. Interpret the grieving process for the parents. 2. Discuss the reality of institutional placement. 3. Assist the parents in making decisions and long-term plans for the child. 4. Perform a family assessment to assist in the planning of intervention.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) inappropriate before the assessment; action can be taken only when the circumstances are known (2) inappropriate before the assessment; action can be taken only when the circumstances are known (3) inappropriate before the assessment; action can be taken only when the circumstances are known (4) correct—assessment; this will help the nurse to know where the family is in regard to grieving, coping, etc.

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

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) maternal morbidity and mortality are increased with SLE (2) correct—should be in remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis before conceiving

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

Strategy: Determine how each answer choice relates to the lab values (1) will increase due to decreased oxygenation caused by anemia; normal RBC male: 4.3-5.9 million/mm3; female: 3.5-5.5 million/mm3; decreased with anemia, causes heart rate and respirations to increase; normal WBC 4,500-11,000/mm3; decreased (leukopenia) causes susceptibility to infection; normal Hgb: male 13.5-17.5 g/dL, female 12-16 g/dL; decreased with anemia (2) no change in temperature (3) correct—due to low platelet count, normal platelets 150,000-400,000/ mm3, decrease causes problems with blood clotting (4) no information about airway problems

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

Strategy: Determine how each statement relates to pyloric stenosis. (1) not expected with pyloric stenosis, suggestive of blood in stool (2) sucking problems not expected with pyloric stenosis (3) correct—becomes lethargic, dehydrated, and malnourished (4) would expect emesis to contain milk or formula, should not be bile-colored

A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5°C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.

Strategy: Determine if each answer relates to increased ICP. (1) normal for the first year of life (2) correct—high-pitched cry is one of the first signs of an increase in the intracranial pressure in infants (3) fontanelle should be closed by the third month (4) with increased pressure, the pupil may respond to light slowly, rather than with the usual brisk response

The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical. 2. The girl walks with a waddling gait. 3. The girl's lower legs are edematous. 4. The girl has a protruding sternum.

Strategy: Determine the cause of each answer choice and how it relates to Pronestyl. (1) procainamide is given to treat premature ventricular contractions or atrial tachycardia (2) correct—severe hypotension or bradycardia are signs of an adverse reaction to this medication (3) procainamide is given to treat premature ventricular contractions or atrial tachycardia (4) lab value is within normal limits

The home care nurse visits a client with newly diagnosed type 1 diabetes. The physician orders include 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the client perform a blood sugar analysis. The result is 50 mg/dL. The nurse should observe for which of the following? 1. Confusion; cold, clammy skin; and an elevated pulse. 2. Lethargy; hot, dry skin; rapid deep respirations. 3. Alert and cooperative, blood pressure and pulse within normal limits. 4. Shortness of breath, distended neck veins, and a bounding pulse of 96.

Strategy: Determine the cause of each answer choice. (1) correct—symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (2) symptoms of hyperglycemia, blood sugar above 110 mg/dL (3) normal appearance and vital signs (4) symptoms of fluid overload caused by heart failure, rapid infusion of IV fluids

The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST? 1. A client with chronic renal failure complaining of swollen fingers and ankle edema. 2. A client 1 day postoperative after abdominal surgery with dried blood on the abdominal dressing. 3. A client diagnosed with type 1 diabetes mellitus who states, "I have this quivering feeling in my abdomen." 4. A client on high doses of antibiotics for a resistant infection complaining of diarrhea.

Strategy: Determine the least stable client. (1) indicates peripheral edema, treatment includes fluid and sodium restrictions (2) stable client (3) correct—indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk (4) common sequelae of antibiotic therapy, monitor fluid and electrolytes, check for skin breakdown

Which of the following guidelines is appropriate for the nurse to give a mother concerning the developmental stage of her 7-year-old daughter? 1. The child's periods of shyness are to be expected. 2. Nightmares are not characteristic of this age and should be investigated. 3. The child should be encouraged to care for her younger sister. 4. Punishment may be necessary for acts of independence.

Strategy: Remember growth and development. (1) correct—normal for developmental stage, beginning to show independence from parents (2) nightmares are frequently experienced at this age (3) should be encouraged to be independent, not responsible for sibling, inappropriate for this age group (4) should allow child to be increasingly independent without punishment

The client had an aortic aneurysm resection 2 days ago. A complete blood count reveals a decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the following? 1. Fatigue, pallor, and exertional dyspnea. 2. Nausea, vomiting, and diarrhea. 3. Vertigo, dizziness, and shortness of breath. 4. Malaise, flushing, and tachycardia.

Strategy: Remember the "comma, comma, and" rule. Each part of the answer choice must be correct for the answer to be correct. (1) correct—characteristic of most types of anemia; result of tissue hypoxia secondary to inadequate red blood cells (2) indicates GI problems (3) vertigo not an indication of anemia (4) flushing not an indication of anemia

A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions? 1. Head of bed elevated 30-45°. 2. Head of bed elevated 60-90°. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side.

Strategy: Remember the positioning strategy. (1) head of bed not elevated enough (2) correct—facilitates swallowing and movement of tube through gastrointestinal tract (3) not the best position (4) not the best position

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

Strategy: Think about each answer choice. (1) correct—important to prevent the complication of pulmonary embolism in clients at high risk (2) relates to arterial disease (3) surgery is not anticipated for this client (4) preventing embolism is the first priority

The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST? 1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift. 2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week. 3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab. 4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy.

Strategy: Determine the least stable situation (1) important issue that needs to be addressed after tending to the client who is bleeding (2) patients take priority over personnel issues (3) can be delegated to another staff member (4) correct—should assess client to determine amount and cause of bleeding

A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST? 1. Restart the IV above the level of the graft. 2. Take blood pressures on the right arm. 3. Elevate the left arm above the level of the heart. 4. Check the radial pulse on the left arm q4h.

Strategy: Determine the outcome of each answer choice. (1) IVs should not be started in the grafted arm (2) correct—BP should always be taken on the opposite arm from the graft (3) unnecessary (4) important to assess circulation in extremity; priority is to prevent complication

The nurse cares for clients in the antepartal clinic. A client at 34 weeks' gestation comes to the clinic for treatment of a sprained ankle. The nurse should question which of the following orders? 1. ASA (aspirin) 650 mg PO q4h prn for pain. 2. Return to the clinic in 2 weeks. 3. Apply ice to sprain for 20 minutes qh for 24 hours. 4. Teach client three-gait crutch walking.

Strategy: Determine the outcome of each answer choice. Is it desired? (1)correct—aspirin can cause fetal hemorrhage; do not use during pregnancy (2) routine follow-up (3) treat sprain with rest and elevation of affected part; intermittent ice compresses for 24 hours (4) appropriate gait if client unable to bear weight

An older woman comes to the outpatient clinic because she has not been feeling well for several days. During the admission interview, the nurse learns that the client has a history of heart failure (HF), is on a low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg PO daily for 6 months. Diagnostic tests indicate sodium 127 mEq/L, potassium 3.8 mEq/L, glucose 110 mg/dL, and normal chest x-ray. It is MOST important for the nurse to assess for which of the following? 1. Sticky mucous membranes; decreased urinary output; and firm, rubbery tissues. 2. Cool, moist skin; fine hand tremors; and mental confusion. 3. Headache, apprehension, and lethargy. 4. Shortness of breath, chest pain, and anxiety.

Strategy: Determine the significance of each answer choice. (1) symptoms of hypernatremia, along with restlessness, weakness, coma, tachycardia, flushed skin, oliguria, fever (2) symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (3) correct—symptoms of hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprinting of skin (4) symptoms of CHF, chest x-ray clear, no other information provided

The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.

Strategy: Identify the least stable client. (1) no indication of hemorrhage, will require a tetanus shot (2) correct—disoriented, requires immediate assessment to determine underlying cause (3) splint; cover wound with sterile dressing; check temperature, color, sensation; give narcotic (4) hyperglycemic, give IV fluid, regular insulin ...

A client takes gemfibrozil (Lopid) 600 mg PO bid. It is MOST important for the nurse to monitor which of the following? 1. Serum creatine. 2. Erythrocyte sedimentation rate (ESR). 3. Aspartate aminotransferase (AST) (or formerly SGOT). 4. Arterial blood gases (ABG).

Strategy: Recall what each lab function is measuring and determine how it relates to gemfibrozil (Lopid). (1) indicates renal function, normal 0.6 to 1.2 mg/dL (2) indicates inflammation, normal 0 to 20 mm/h (3) correct—indicates liver function, normal 8-20 units/L; lipid-lowering agent used with patients with high serum triglyceride levels, side effects include abdominal pain, cholelithiasis; take 30 minutes before breakfast and supper (4) indicates acid/base balance...

A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following? 1. The nurse's opinion regarding the mental and emotional status of the client. 2. Data addressing the client's emotional state. 3. Data addressing a biopsychosocial approach, including a family system assessment. 4. Specific data detailing the client's mental status.

Strategy: Think about each answer choice. (1) depends on opinions that are not based on a complete assessment (2) limits the degree of information that is obtained from the client (3) correct—complete nursing history includes biopsychosocial data; client's psychosocial and physical status are evaluated along with an assessment of the client's family system and social support network; evaluation of the client's cognitive ability is important during the physiological status assessment (4) is necessary information about mental status but is also an incomplete assessment

The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a patient. The nurse should observe for which of the following side effects?

2. Hypotension and respiratory depression. (2) correct—narcotic analgesic used for moderate to severe pain, monitor vital signs frequently

Cortisol

An adrenal-cortex hormone (trade names Hydrocortone or Cortef) that is active in carbohydrate and protein metabolism. -Responsible for converting proteins and fat into glucose. -is also an anti-inflammatory agent

Quinidine

Class 1A Na blocker • Use: ventricular arrhythmias, recurrent atrial arrhythmias. -Prevents premature ventricular contractions (PVCs).

clomiphene citrate (Clomid)

Clomiphene citrate (Clomid) induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum.

Visual changes in DM I

The client's decreased vision is caused by gradual destruction and degeneration of the retina. destruction of the vessels, as well as edema, occurs.

the admitting nurse attaches an internal fetal monitor. The nurse knows which of the following is the MOST important reason for the fetal monitor?

To monitor the oxygen status of the fetus during labor.

A 2-month-old with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is related to the immunization. The nurse's response should be based on which of the following? 1. If a fever does occur in a child after a DPaT, it usually occurs within the first 2 hours. 2. An elevated temperature is very rarely seen in a child after a DPaT immunization. 3. If there is a fever after a DPaT, it is usually low-grade and appears within the first 48 hours. 4. The child's high fever is a direct response to the DPaT immunization and should be treated.

Strategy: Think about each answer choice. (1) inaccurate; low-grade fever is expected within 24 to 48 hours (2) inaccurate; low-grade fever is expected within 24 to 48 hours (3) correct—low-grade fever and irritability frequent response to immunization (4) symptoms should be reported to physician, antipyretic usually prescribed

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

Strategy: Think about each answer choice. (1) not a function of this catheter, and does not reflect hemodynamic monitoring (2) correct—CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle (3) not a function of this catheter, and does not reflect hemodynamic monitoring (4) not a function of this catheter, and does not reflect hemodynamic monitoring

After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), the nurse notes a decrease in muscle tone. The nurse determines which of the following nursing diagnoses is priority? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes.

Strategy: Think about each answer choice. (1) not a priority (2) correct—leading cause of skin breakdown is a decrease in tissue perfusion (3) not a priority (4) would be more relevant to right-sided hemiparesis ...

A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery? 1. "I have been helping my family deal with their feelings about the surgery." 2. "I have been having difficulty coping with the surgery and cry frequently." 3. "I have been unable to leave the house or talk to my friends about the surgery." 4. "I am doing just great since the surgery and have gone back to work at my job."

Strategy: Think about each answer choice. Does it describe an expected response to a crisis situation? (1) will not be able to help others this soon after surgery (2) correct—normal reaction 1 month later (3) excessive, abnormal reaction (4) indicates integration, too early for this stage

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

Strategy: Think about each answer. (1) correct—colon should not have remaining soft stool (2) anything eaten after midnight would not appear as stool by the next morning (3) not expected; need to clean gastrointestinal tract for surgery (4) assumption; not substantiated

An elderly client recently immobilized is ordered to begin passive range-of-motion (ROM) exercises. What should the nurse understand about ROM before initiating this order? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort. 4. A sufficient ROM assists the elderly to carry out activities of daily living (ADLs).

Strategy: Think about each answer. (1) inaccurate statement (2) ROM may be limited (3) should not be done to point of discomfort (4) correct—full ROM may not be needed or accomplished without discomfort for an elderly client; emphasis should be on ROMs that support ADLs

The nurse cares for clients in outpatient surgery. The mother of a 4-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST? 1. "Draw a picture of the eye to explain what will happen." 2. "Tell your daughter that the procedure will take 1 hour." 3. "Use dolls or puppets to explain how to get ready for surgery." 4. "Read an age-appropriate illustrated book about eye surgery to your daughter."

Strategy: Think about growth and development. (1) appropriate for school-aged child (2) preschooler can't relate to the concept of 1 hour (3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel (4) appropriate for school-aged child

A client begins doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client's therapy if which of the following occurs? 1. The client refuses to speak and sits quietly in the room. 2. The client becomes excitable and develops tremors. 3. The client refuses to eat breakfast. 4. The client sleeps 18 hours a day.

Strategy: Think about the cause of each assessment and how it relates to Sinequan. (1) not relevant to this medication (2) correct—doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors (3) not relevant to this medication (4) not relevant to this medication

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

Strategy: Think about the cause of each symptom and how it relates to pregnancy. (1) correct—is usually indicative of an impending convulsion (2) expected observation (3) expected observation (4) is important to address, but is not as high a priority as answer choice 1

The nurse identifies which of the following is MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment? 1. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups. 2. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking. 3. Tell the family that it is not their fault that the client behaves inappropriately. 4. Involve the family in the assessment of the client when he/she is first admitted to the hospital.

1) correct—this group provides ongoing support and educational information; people who attend have common needs and goals focused on managing the clients' behavior at home (2) would be helpful but will not have the ongoing impact of the support group (3) would be helpful but will not have the ongoing impact of the support group (4) would be helpful but will not have the ongoing impact of the support group

For an elderly client diagnosed with type 1 diabetes, the nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which of the following? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person.

1. The renal threshold for glucose is elevated in the elderly.(1) correct—the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels (2) more expensive procedure (3) provides false-negative readings; may be negative from 0 to 180 mg/dL (4) results are expressed as a percentage according to color change

Normal adjustment to terminal illness

1rst stage: Denial and isolation 2nd stage: Anger 3rd: Bargaining (negociation) 4rd: Depression 5th: Acceptance

The lung has re-expanded if which of the following is observed in the client who has a chest tube connected to a three-chamber water-seal drainage system (Pleur-evac)?

The fluid in the water-seal chamber does not fluctuate with respirations, which indicates no more air leaking into pleural space.

mannitol (Osmitrol)

Therapeutic class/Mechanism: Osmotic diuretic Primary use: Increased intracranial pressure, to promote diuresis in renal failure, increased intraocular pressure (narrow-angle glaucoma), to promote excretion of renal toxins

Blood transfusion allergic reaction

Type I hypersensitivity reaction against plasma proteins in transfused blood -Mild: urticaria, pruritus, facial flushing -Anaphylaxis: -hypotension, dyspnea, wheezing, -↓O Sat -fever -flushing -epiglottal edema -TX: with antihistamines

A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are BUN 25 and K+ 4.0 mEq/L. The nurse should restrict which of the following in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium.

(1) correct—decreased production of urea nitrogen can be achieved by restricting protein; metabolic wastes cannot be excreted by the kidneys (2) decreases the nonprotein nitrogen production; these foods are encouraged (3) decreases the nonprotein nitrogen production; these foods are encouraged (4) should not be restricted ...

The nurse observes a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which of the following positions? 1. Posterior and anterior base of right side. 2. Right anterior chest between the fourth and sixth intercostals. 3. Left of the sternum, midclavicular, at right fifth intercostal. 4. Posterior chest wall, midaxillary, right side.

(1) cannot auscultate the RML from the posterior (2) correct—RML is found in the right anterior chest between the fourth and sixth intercostal spaces (3) point of maximum impulse or apical pulse (4) cannot auscultate the RML from the posterior

The nurse cares for an 8-lb, 8-oz newborn. The infant's history indicates the mother was given magnesium sulfate IV 4 g in 250 mL D5W several hours before delivery. The nurse is MOST concerned if which of the following was observed? 1. Temperature 97.6°F (36.5°C). 2. Apical pulse 140 bpm. 3. Respirations 18/min. 4. BP 80/50.Strategy:

"MOST concerned" indicates a complication. (1) normal temperature 98.6°F (37.0°C), magnesium sulfate does not affect temperature (2) normal pulse 120-140 bpm, magnesium sulfate does not affect cardiac system of infant (3) correct—magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min (4) normal BP 60/40-80/50, magnesium sulfate does not affect BP

At 32 weeks' gestation, a client has an order for an ultrasound. The nurse determines the client understands the procedure if the client states which of the following? 1. "The results will inform us of the gestational age." 2. "This test will evaluate the baby's lungs." 3. "The test will show us if there is any problem in the spinal cord." 4. "Early problems with the baby's blood can be identified with this test."

"The results will inform us of the gestational age." Strategy: Think about each answer. (1) correct—ultrasound detects the gestational age (2) determined with lecithin/sphingomyelin (L/S) ratio by an amniocentesis (3) determined with an amniocentesis (4) determined with an amniocentesis

A client comes to the clinic for the results of a glycosylated hemoglobin (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of the procedure? 1. "This test is performed by sticking my finger and measuring the results." 2. "This test needs to be performed in the morning before I eat breakfast." 3. "This test indicates how well my blood sugar has been controlled the past 6 to 8 weeks." 4. "I must follow my diet carefully for several days before the test."

(1) 3 to 5 ml of blood is needed (2) timing of test is not important (3) correct—when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5 to 6% (4) current blood sugar doesn't affect test

The nurse observes care given to a client experiencing severe to panic levels of anxiety. The nurse should intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.

(1) appropriate nursing action for this level of anxiety (2) appropriate nursing action for this level of anxiety (3) correct—at this level of anxiety, client is unable to process thoughts and feelings for problem solving (4) appropriate nursing action for this level of anxiety ...

A patient is returned to the room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy setup. 4. Suction equipment.

(1) correct—hypokalemia is not expected after this surgery (2) used to treat tetany resulting from possible damage to parathyroid glands (3) essential equipment to provide for airway (4) needed to maintain a patent airway ...

While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority? 1. The medication should be taken once a day for 6 weeks. 2. The medication should be taken with orange juice. 3. The medication should be taken in the morning and at bedtime. 4. The medication should be taken with meals.

(1) is taken twice a day for 2 to 3 weeks (2) unnecessary (3) will cause GI upset unless taken with meals (4) correct—will decrease GI upset

EDTA

-Best substance to remove lead from blood chelation therapy, -Anticoagulant in lavender top tubes

A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements? 1. The catheter can be removed during the day. 2. External catheters are uncomfortable. 3. The catheter would drain into a bag at the bedside or on the wheelchair. 4. The external condom catheter is easy to apply.

.(1) correct—being free from any drain bags during the day would appeal to a 13-year-old (2) is negative (3) would be embarrassing to a 13-year-old (4) it would be impossible for a teen with muscular weakness to put on an external catheter ..

A nonstress test is scheduled for a client at 34 weeks' gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1. Start an intravenous line for an oxytocin infusion. 2. Obtain a signed consent prior to the procedure. 3. Instruct client to push a button when she feels fetal movement. 4. Attach a spiral electrode to the fetal head.

.(1) would be appropriate for an oxytocin (stress) test (2) is incorrect because this is noninvasive (3) correct—nonstress test is a noninvasive test to evaluate the response of the fetal heart rate to the stress of fetal movement; response will be reflected on the fetal monitor (4) prepares for internal fetal monitoring ..

A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication 5 minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture.

...(1) should be taken immediately when pain is felt (2) presence or absence of a stinging sensation is not indicative of the effect of the drug (3) should be taken when pain is experienced (4) correct—nitroglycerin can cause hypotension; client should avoid changing positions quickly to decrease the chances of falling

An elderly client returns from surgery after a hysterectomy due to cancer, and there is an order for antiembolism stockings. Which of the following should the nurse include when instructing the client about wearing the support stockings? 1. "Wear the stockings when your legs cramp." 2. "Wear the stockings during your hospitalization." 3. "Put the stockings on prior to going to bed." 4. "Put the stockings on after you get out of bed in the morning."

...Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antiembolism stockings should be worn to prevent any discomfort and to increase the blood flow (2) correct—stockings should be worn the entire time that client is in the hospital; should be removed for baths and replaced after the skin is dry, and before the client gets out of bed (3) stockings should be worn during the day and when client is nonambulatory (4) stockings should be applied before getting out of bed

Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as "My breathing is much improved now." 2. Notes objective findings, such as decreased respiratory rate and pulse. 3. Consults with the respiratory therapist to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds.

1) subjective data and not as conclusive (2) correct but not as effective (3) not appropriate (4) correct—to assess the effectiveness of suctioning, auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions

Glycosides

Cardiac drug derived from plant sources such as the Digitalis plant and Foxglove Digoxin Improves cardiac contractility and reduces energy and oxygen demand VERY narrow therapeutic window. ↑the force of myocardial contraccion

Norepinephrine

A catecholamine precursor of epinephrine that is secreted by the adrenal medulla and also released at synapses. -Enhancing musculoskeletal activity.

An intravenous pyelogram (IVP) is ordered for a client scheduled to have the left kidney removed due to renal disease and hypertension. Which of the following nursing actions has the highest priority the evening before the IVP? 1. Administer a cathartic enema to cleanse the bowel. 2. Obtain information about client allergies. 3. Instruct the client to be NPO after midnight. 4. Teach the client that x-rays will be taken at multiple intervals.

An intravenous pyelogram (IVP) is ordered for a client scheduled to have the left kidney removed due to renal disease and hypertension. Which of the following nursing actions has the highest priority the evening before the IVP? 1. Administer a cathartic enema to cleanse the bowel. 2. Obtain information about client allergies. 3. Instruct the client to be NPO after midnight. 4. Teach the client that x-rays will be taken at multiple intervals.

Hallucinations

Are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone.

Delusions of reference

Delusions of reference are a false belief that public events or people are directly related to the individual.

Dyskinesia

Distortion or impairment of voluntary movement such as in a tic or spasm

TB symptoms

Flulike symptoms, night sweats, elevated temperature, decreased deep tendon reflexes.

IVP- Intravenous pyelogram

IV dye is injected & diagnostic x-rays of entire urinary tract taken. performed to: -detect kidney tumors -identify blockages or obstructions of normal urine flow -detect kidney or bladder stones -establish is prostate gland is enlarged -detect injuries to urinary tract

Nephrotic syndrome diet

Low sodium, High protein -( if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted)

3-month-old infant scheduled for a barium swallow in the morning.

Make the infant NPO for 3 hours prior procedure

akathisia

Motor restlessness such as fidgeting, rocking, or pacing due to the neuromuscular or neurologic adverse effects associated with the use of antipsychotics

Adduction

Movement towards the midline

The physician writes an order for a stat dose of Demerol 50 mg IM for pain. Three hours later the client again complains of pain, and the nurse administers a second injection of Demerol. Which of the following describes the nurse's liability?

Order for a stat dose does not state PRN; nurse had an order for only the first injection, not the second one.

Natural active immunity

Production of one's own antibodies or T cells as a result of infection or natural exposure to antigen following a disease.

When we should start giving a baby solid foods.

Rice cereal is usually the first solid food and is started around 4 to 5 months.

SHARE

SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage.

SIDS

SIDS will provide you with this opportunity

The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary? 1. "The poison control center number is stored on all the phones in our house." 2. "I should induce vomiting if my child swallows lighter fluid." 3. "If I carry medication in my purse, it should be in a child-proof container." 4. "Proper storage is the key to poison prevention in the home."

Strategy: "Further teaching is necessary" indicates an incorrect statement. (1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions (2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration (3) 'poison-proofs' the medication (4) store in locked cabinets

A school-aged child injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. The child's right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy is diagnosed with hemophilia A. The nurse identifies which of the following medications is BEST for this patient? 1. Oxycodone terephthalate (Percodan). 2. Ibuprofen (Motrin). 3. Enteric-coated aspirin. 4. Codeine phosphate (Paveral).

Strategy: Think about the action of each medication. (1) contains aspirin, contraindicated for persons with bleeding disorders (2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (4) correct—analgesic used for moderate to severe pain

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

Strategy: Think about the action of the medications. (1) decreased dosage of narcotics are used (2) dosages of sedatives and hypnotics will be similar (3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant (4) dosages of narcotics are reduced

Natural passive immunity

The passage of antibodies from the mother to the baby for about the first 6 months of the baby's life. Rich source of antibodies.

The nurse supervises a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the procedure? 1. The Levin tube remains unclamped for 30 min after the feeding. 2. Sterile equipment is used to administer the feeding. 3. The amount of the feeding is varied according to the patient's tolerance. 4. The tube feeding is given at room temperature.

The nurse supervises a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the procedure? 1. The Levin tube remains unclamped for 30 min after the feeding. 2. Sterile equipment is used to administer the feeding. 3. The amount of the feeding is varied according to the patient's tolerance. 4. The tube feeding is given at room temperature.

Rinne test

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

Associative play

This is the play that characterizes 4-year-olds

Intimacy versus isolation.

Young adult

Kussmaul respirations

are associated with diabetic ketoacidosis

Enema position

positions the patient left side-lying (Sim's) with knee flexed. -tube inserted no more that 4 inches

Which of the following statements indicates that the nurse has an understanding of the verbally abuse patient's behavior?

Abusive language is one of the behaviors symptomatic of the patient's illness.

Which of the following assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and decreased serum potassium. 4. Tachycardia with complaints of night sweats.

(1) BP increases and client gains weight (2) correct—clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising (3) no correlation with urinary output; potassium decreases (4) no correlation with Cushing's syndrome

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

(1) client has been medicated with benzodiazepines and did not experience untoward reactions (2) correct—client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations (3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations (4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementia

The nurse cares for a client diagnosed with Ménière's syndrome. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips. 2. The client does not have to turn her head to see the nurse. 3. The nurse will have the client's undivided attention. 4. There is a decrease in client's peripheral visual field.

(1) client is not hard of hearing (2) correct—by decreasing movement of client's head, vertigo attacks may be decreased (3) there is no problem with visual fields (4) there is no problem with visual fields

A client is seen in the clinic for treatment of chronic back pain. The client mentions to the clinic nurse that at home he applies an ointment prepared from several different herbs that relieves his lower back pain. He asks the nurse, "Should I continue using it?" Which of the following responses by the nurse would be BEST? 1. "No. It might do you more harm than good." 2. "Yes. Continue using it, but I don't see how it could help your condition." 3. "You may think it works, but I don't believe home remedies work." 4. "Pain can be relieved in several ways. Consult your physician regarding this home remedy."

(1) closed statement (2) closed statement; casts doubt on efficiency of alternative therapy (3) focus should be on client, not on nurse's beliefs (4) correct—herbal medication can interact with other medication ...

The daughter of a patient diagnosed with cancer asks the nurse, "Do you believe in euthanasia?" Which of the following responses by the nurse is BEST? 1. "I think that each person has to decide this issue for herself." 2. "My religion is opposed to euthanasia." 3. "What are your thoughts about euthanasia?" 4. "Did you see the TV program about euthanasia last night?"

(1) closed statement, focus is on the nurse and not the client (2) focus is on the nurse and not the client (3) correct—open-ended question, allows client to verbalize (4) yes/no question

The nurse conducts a physical examination of a client suspected to have bulimia. Which of the following observations by the nurse MOST likely indicates bulimia? 1. The client has edema of the lower extremities. 2. Physical exam of the client reveals the presence of lanugo. 3. The client has ulcerated mucous membranes of the mouth. 4. The client has dry, yellowish color of the skin.

(1) common with anorexia (2) seen with anorexia (3) correct—due to frequent vomiting (4) bulimics are normal in appearance

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

(1) consistency is important to maintain joint mobility (2) active exercises are better than passive or active-assistive exercises (3) correct—should reduce repetitions when patient experiences more pain (4) should do exercises that have been prescribed for patient

The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a 5-year-old boy? 1. The boy plays with a large truck with another child. 2. The boy talks on a toy telephone and imitates his father. 3. The boy works on a puzzle with several other children. 4. The boy holds and cuddles a large stuffed animal.

(1) cooperative play occurs in school-aged children (2) correct—imitative behavior seen at this age (3) too advanced for this age (4) too regressed for this age

A patient has a Levin tube connected to intermittent low suction. At 7 A.M., the nurse charts that there is 235 ml of greenish drainage in the suction container. At 3 P.M., the nurse notes that there is 445 ml of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 ml of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift? 1. 150 ml. 2. 210 ml. 3. 295 ml. 4. 385 ml.

(1) correct-445 − 235 = 210 − 60 = 150 (2) does not subtract 60 ml of fluid used to irrigate Levin tube (3) does not take into account solution added to container during day shift; does not subtract for fluids used to irrigate Levin tube (4) does not subtract 235 ml that was in container from night shift

The mother of a 7-year-old child is dying. The nurse anticipates the child will have which of the following concepts of death? 1. Death is punishment for his/her actions. 2. Death is inevitable and irreversible. 3. Death is temporary and gradual. 4. Death as a concept based on past experience.

(1) correct-7-year-olds see death as a punishment (2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible (3) is a preschool child's concept of death (4) is an adolescent's concept of death

A 3-month-old infant is placed in traction for developmental dysplasia of the hips. Which of the following toys is appropriate for the nurse to offer the infant during hospitalization? 1. A rattle. 2. A stuffed animal. 3. Colorful blocks. 4. A tape playing nursery rhymes.

(1) correct—3-month-old infant can grasp a rattle (2) not as good as answer choice (1) (3) designed for an older child (4) not as good as answer choice (1)

The nurse is caring for an elderly client diagnosed with type 1 diabetes. The client is scheduled for cataract surgery under general anesthesia at 9 AM. The client usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse expects to take which of the following actions? 1. Hold the morning dose of NPH and regular insulin and monitor the blood glucose. 2. Give half the morning dose of NPH insulin together with the regular insulin and monitor the blood glucose when the client returns from surgery. 3. Give the full dose of NPH and regular insulin and monitor the blood glucose every 2-4 hours. 4. Give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.

(1) correct—usually use sliding scale with regular insulin based on blood glucose readings (2) may cause hypoglycemia because client will be NPO when NPH peaks, NPH intermediate-acting insulin, onset 1-2 hours, peaks 6-12 hours, duration 18-26 hours; regular insulin short-acting, onset 0.5-1 hour, peaks 2-4 hours, duration 6-8 hours (3) client may become hypoglycemic because NPH will peak when client is NPO (4) may cause hypoglycemia during surgery

The nurse observes late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. Which of the following actions should the nurse take FIRST? 1. Discontinue the infusion. 2. Turn client to the left side. 3. Change the fluids to Ringers lactate. 4. Increase the IV flow rate.

(1) correct—will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration (2) may help the deceleration, but is not a priority (3) will have no influence on the fetal heart rate (4) will have no influence on the fetal heart rate

A college student has a Mantoux test performed at the college health clinic and the result is positive. The clinic nurse should take which of the following actions? 1. Refer the student to an appropriate center for further testing. 2. Restrict the student's activity until his parents can be notified. 3. Notify the local Public Health Department. 4. Place the student in an isolation room in the college infirmary.

(1) correct—will perform chest x-ray (2) premature action, insufficient information (3) true if active disease confirmed, premature action (4) premature action, insufficient information

A patient complains of pain after an appendectomy. After administering an analgesic, the nurse should take which of the following actions? 1. Elevate the head of the bed 30-45°. 2. Place a pillow behind the patient's knees. 3. Elevate the knee gatch on the bed 30°. 4. Position the client supine with a small pillow under the head.

(1) correct—would reduce stress on suture line and provide for comfort (2) would put pressure on popliteal space, would restrict circulation and increase risk of thrombophlebitis (3) would put pressure on popliteal space, would restrict circulation and increase risk of thrombophlebitis (4) does not reduce stress on suture line

When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse identifies which of the following instructions is BEST? 1. After pursed lip breathing, cough into a container. 2. Upon awakening, cough deeply and expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.

(1) coughing into a container is indicated, but not pursed-lip breathing (2) correct—specimens should be obtained in the early morning because secretions develop during the night (3) appropriate for acid-fast stain for TB (4) earliest specimen is most desirable

The nurse observes the following patients in the emergency department (ED). Which of the following patients should the nurse see FIRST? 1. 8-month-old infant crying loudly with facial ecchymosis. 2. 12-year-old boy with a possible fractured ankle. 3. 34-year-old man with a distended abdomen and splenomegaly. 4. 44-year-old woman with possible whiplash from an automobile accident.

(1) crying demonstrates adequate airway, not life-threatening (2) not life-threatening (3) correct—possibility of internal bleeding, life-threatening situation (4) not life-threatening

Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood? 1. "Client states, 'I see snakes climbing on the walls at all times of the day.'" 2. "Unable to sustain a train of thought for long periods of time during history-taking." 3. "Clenches her fists and shouts in an angry tone of voice when asked about family problems." 4. "Is unaware of where she is, what day and year it is, or what time it is."

(1) describes hallucinations (2) describes altered thought processes (3) correct—gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood (4) describes disorientation

The nurse reviews procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements? 1. "It is my responsibility to ensure that the consent form has been signed and is attached to the patient's chart." 2. "It is my responsibility to witness the signature of the patient before surgery is performed." 3. "It is my responsibility to explain the surgery and ask the patient to sign the consent form." 4. "It is my responsibility to answer questions that the patient may have before surgery."

(1) describes the nurse's responsibility in obtaining consent (2) signature indicates that the nurse saw the patient sign the form (3) correct—physician should provide explanation and obtain patient's signature (4) the nurse should answer questions after the physician has obtained consent

A preschooler is brought to the emergency department after ingesting a bottle of baby aspirin. The nurse should observe the preschooler for which of the following signs and symptoms? 1. Nausea and vertigo. 2. Epistaxis and paralysis. 3. Dysrhythmia and hypoventilation. 4. Tinnitus and gastric distress.

(1) dizziness not seen with aspirin overdose (2) nosebleed may occur, but not paralysis (3) may see hyperventilation with use of aspirin, does not affect heart rhythm (4) correct—symptoms of overdose

The nurse cares for an elderly adult client with multi-infarct dementia. Which of the following actions, if taken by the nurse, is BEST? 1. Place the client in soft hand restraints or chair restraints. 2. Monitor wandering behaviors during a 7-day period. 3. Keep the lounge's television volume on a low level. 4. Encourage a diet high in protein, iron, and vitamins.

(1) do not restrain unless all other options have been exhausted (2) correct—appropriate assessment to determine if client wanders during specific times of the day; assess before implementing (3) need to prevent sensory overload; should assess first (4) offer well-balanced diet

An adult client with newly diagnosed type 1 diabetes is being seen by the home health nurse. The physician has placed the client on an 1,800-calorie ADA diet, ordered the client to self-administer 15 units of NPH insulin each day before breakfast, and check his blood sugar qid. When the nurse visits the client at 5 PM, the nurse discovers that the client has not eaten since noon and has just returned from jogging. The client's vital signs are: BP 110/80, pulse 120/min, respirations 18/min, and temperature 98.2°F (36.8°C). The nurse anticipates the client's blood sugar to be which of the following? 1. 250 mg/dL. 2. 160 mg/dL. 3. 90 mg/dL. 4. 50 mg/dL.

(1) hyperglycemia symptoms are hot dry skin, rapid, deep respirations (Kussmaul), lethargic, polyuria, polydipsia, polyphagia, glycosuria, nausea, and vomiting (2) NPH insulin is intermediate-acting, onset 3-4 hours, peak 8-16 hours, duration 18-26 hours (3) normal blood sugar 70-110 mg/dL (4) correct—hypoglycemia symptoms are cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, headache, slurred speech, coma

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

(1) if both mother and baby are Rh-negative, there is no problem (2) correct—RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test (3) medication is not given if the mother has been sensitized by a previous pregnancy (4) there is no incompatibility here, but the mother needs to be evaluated regarding sensitization in the incomplete pregnancy

A young adult asks the nurse in the AIDS clinic what to do for the multiple small, painless purplish-brown spots on the right leg and ankle. The nurse should instruct the client to take which of the following actions? 1. Clean the spots carefully with soap and warm water twice a week, and cover them with a sterile dressing. 2. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air. 3. Shower daily using a mild soap from a pump dispenser, and pat the skin dry. 4. Soak in a warm tub three times a day, and rub the spots with a washcloth.

(1) if lesions are open and draining, they must be cleaned and dressed daily to prevent secondary infection (2) treatment for herpes simplex virus abscess, not Kaposi's sarcoma (3) correct—important to keep the skin clean and prevent secondary skin infection (4) increases risk of secondary skin infection ...

A client receives total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 ml/h.

(1) if the pulse rate increases, may indicate fluid overload (2) if the diastolic blood pressure decreases, it might indicate shock or lack of blood volume (3) temperature should remain within normal limits (4) correct—if the client is being properly hydrated with hypertonic IV such as TPN, urine output needs to be at least 30 ml/h; other nursing action includes assessment of blood glucose levels ...

The nurse cares for a child who is in Buck's traction. During the neurovascular assessment, the nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse should take which of the following actions? 1. Record the observation. 2. Encourage the child to move the foot. 3. Cover the colder foot with a sock. 4. Notify the physician.

(1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct—assessment indicates that Ace bandage is too tight and needs readjusting

The nurse cares for a child several hours after the application of a hip spica cast. The patient turns on the call light and complains of pain in the left foot. Which of the following actions should the nurse take FIRST? 1. Elevate the left leg on two pillows. 2. Palpate the cast for warmth and wetness. 3. Administer pain medication as ordered. 4. Check the blanching sign on both feet.

(1) implementation; done to prevent swelling and venous congestion, not helpful to reduce pain due to circulatory impairment (2) assessment; not helpful to reduce pain due to circulatory impairment, should not palpate wet cast, would result in depressions causing pressure (3) implementation; pain important diagnostic symptom, should not be suppressed or masked (4) correct—assessment; pain main symptom of circulatory impairment from cast; pressing nail of great toe indicates circulatory function, compare speed with which color returns with result on the opposite side; sluggish return indicates circulatory impairment, too rapid return indicates venous congestion ...

The nurse cares for a postoperative patient. Four hours after surgery, the patient voids 200 mL of urine with a specific gravity of 1.019. The nurse should take which of the following actions? 1. Palpate the patient's lower abdomen for distention. 2. Encourage an increased intake of oral fluids. 3. Record the time and the amount of urine. 4. Encourage the patient to void again in 2 hours.

(1) implies bladder distention and urinary retention, 200 mL divided by 6 hours = more than 30 mL/h (2) doesn't recognize amount and specific gravity as normal in this situation (3) correct—amount and specific gravity normal (1.010-1.030) (4) doesn't recognize amount and specific gravity as normal in this situation

The MOST appropriate nursing action before administering captopril (Capoten) is to check the client's 1. apical pulse for 60 seconds. 2. blood pressure. 3. urine output. 4. temperature.

(1) important, but not a priority (2) correct—Capoten is an antihypertensive that necessitates assessment of BP before administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication

An elderly man is admitted to an inpatient psychiatric unit with an initial diagnosis of psychotic depression. The INITIAL nursing priority includes which of the following? 1. Clarify perceptual distortions. 2. Establish reality orientation. 3. Ensure client and milieu safety. 4. Increase self-esteem.

(1) important, but secondary to safety issues (2) important, but secondary to safety issues (3) correct—initial nursing priority for all psychiatric patients is to ensure their safety and the safety of all members of the milieu (4) important, but secondary to safety issues

The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends." The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends."

(1) involves forced expiration; would not cause problems with asthma (2) correct—main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves (3) school activities should be encouraged to help development (4) walking is good exercise; running could be a problem if he has exercise-induced asthma

A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client, diagnosed with a spinal cord injury at the level of C4, is tearful, constantly complains of discomfort, and requests to be suctioned. The nurse understands that the client's attention-seeking behaviors may be due to which of the following? 1. Anger and frustration. 2. Awareness of vulnerability. 3. Increased social isolation. 4. Increased sensory stimulation.

(1) is not accurate for situation (2) correct—is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs (3) is not accurate for situation (4) is not accurate for situation

A client receives morphine sulfate after admission to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. Which of the following should the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure. 2. Decrease in anxiety. 3. Depression of the sympathetic nervous system. 4. Enhanced ventilation and decreased cyanosis.

(1) is not affected by morphine sulfate (2) correct—morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema (3) is not the action of the medication (4) medication does not improve ventilation

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

(1) is not the best way to evaluate for peripheral edema (2) correct—severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) (3) not as objective (4) is used for evaluating hydration

Promethazine hydrochloride (Phenergan) 25 mg IV push is ordered for a patient. Prior to administering this medication to the patient, the nurse should check which of the following? 1. The color of the medication solution. 2. The patient's pulse and temperature. 3. The time of the last analgesic dose the patient received. 4. The patency of the patient's vein.

(1) is true, but not as high a priority as answer choice (4) (2) no relevance to the question asked (3) Phenergan is used as an adjunct to analgesics but has no analgesic activity itself (4) correct—is very important to determine absolute patency of the vein; extravasation will cause necrosis

A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which of the following is the INITIAL priority nursing action? 1. Provide adequate hygiene and nutrition. 2. Decrease environmental stimuli. 3. Slowly involve the client in unit activities. 4. Administer and monitor sedative and mood-stabilizing medications.

(1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct—is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents

On a home health visit, an elderly client tells the nurse, "This neighborhood has really gone down. I feel like a prisoner in my own home with all the trouble out there." Which of the following nursing responses by the nurse is BEST? 1. "Have you and your neighbors formed a Neighborhood Watch?" 2. "It must be very difficult for you to live in this neighborhood." 3. "I see a lot of police cars, so you should be pretty safe." 4. "Tell me what has happened to make you feel that you are not safe."

(1) jumps ahead to solutions without adequately defining the problem (2) empathetic response, but does not obtain more information from the client or encourage the client to continue (3) false reassurance (4) correct—assessing the basis for client's fears and encouraging client to talk about them is the first positive step

When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse? 1. Short-term memory is more efficient than long-term memory. 2. The stress of an unfamiliar environment may cause confusion. 3. A decline in mental status is a normal part of aging. 4. Learning ability is reduced during hospitalization of the elderly client.

(1) just the opposite is true; long-term memory is more efficient than short-term memory (2) correct—stress of an unfamiliar situation or environment may lead to confusion in elderly clients (3) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things (4) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things

A client is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse identifies which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares." 2. "I have a headache, and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am, and I don't know where I live."

(1) posttraumatic stress disorder (PTSD) is characterized by anxiety and stress symptoms that occur after an intense traumatic event; characteristic symptoms are hypervigilance, insomnia, and recurring nightmares (2) somatoform disorder (or hypochondria) is concerned with physical and emotional health, accompanied by various bodily complaints for which there is no physical basis (3) reflects the compulsive checking behavior of the anxiety associated with obsessive-compulsive disorder (4) correct—dissociative disorders characterized by either a sudden or a gradual disruption in the integrative functions of identity, memory, or consciousness; disruption may be transient or may become a well-established pattern; development of these disorders is often associated with exposure to a traumatic event

The nurse knows that the client diagnosed with drug-induced Cushing's syndrome should FIRST be instructed about which of the following? 1. Compression fractures from increased calcium excretion. 2. Decreased resistance to stress. 3. The schedule for gradual withdrawal of the drug. 4. Changes in secondary sex characteristics.

(1) problems associated with Cushing's syndrome but are not the first priority (2) problems associated with Cushing's syndrome but are not the first priority (3) correct—if steroids are withdrawn suddenly, the client may die of acute adrenal insufficiency (4) not seen with this medication ...

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

(1) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated beverages (2) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon (3) excessive amounts of milk promote alkaline urine (4) promotes alkaline urine; should also avoid citrus juices, excessive amounts of milk, and carbonated beverages (5) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon (6) correct—promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon

Which of the following activities documented by the recreational therapist following a community reorientation outing for a client with paraplegia indicates to the nurse the client's readiness for discharge? 1. The client states that he enjoyed being outside the hospital environment. 2. The client participated in a structured team sport by keeping score. 3. The client independently ordered his meal and fed himself. 4. The client is independent in transfers and wheelchair mobility.

(1) psychosocial, speaks to his psychosocial status, but is not an indication for discharge (2) psychosocial, addresses social skills, but is not an indication for discharge (3) physical, not pertinent for a paraplegic (4) correct—physical, these skills are requisite for discharge

The client exhibits symptoms of myxedema. The nursing assessment should reveal which of the following? 1. Increased pulse rate. 2. Decreased temperature. 3. Fine tremors. 4. Increased radioactive iodine uptake level.

(1) pulse will decrease (2) correct—with myxedema there is a slowing of all body functions (3) associated with hyperthyroidism (4) associated with hyperthyroidism ...

A patient with type 1 diabetes asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST? 1. "Human insulin is less likely to cause you to have a localized allergic reaction to the injection." 2. "Human insulin will cause you to experience fewer problems with hypoglycemia or hyperglycemia." 3. "Human insulin prevents the development of long-term damage to the eyes and kidneys." 4. "Human insulin does not cause the formation of antibodies because the protein structure is identical to your own."

(1) reactions caused by preservatives in insulin, which is same for all types of insulin (2) no change in incidence of hypoglycemia or hyperglycemia (3) complications are caused by blood vessel damage from sugar and fat deposits, not type of insulin used (4) correct—protein molecules are identical to human insulin

A client at the health clinic asks the nurse if he should get a flu shot. Which of the following factors, if learned by the nurse in the history, would NOT be a reason for the client to receive the flu vaccine? 1. The client is 69 years old. 2. The client had bronchitis twice last year. 3. The client volunteers at a preschool. 4. The client lives with two large dogs.

(1) recommended for people over 65 (2) recommended for people with chronic respiratory or cardiovascular disease (3) recommended for people who come in contact with young children (4) correct—not at risk for getting the flu from a dog ...

The nurse cares for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why the client has the CBI. Which of the following responses by the nurse is BEST? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."

(1) refers to a possible preoperative complication of infection due to the enlarged prostate (2) not the reason for the CBI (3) correct—continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client (4) medication is not routinely administered via a CBI in a first-day postop TURP

A client asks what the difference is between a gastric ulcer and a duodenal ulcer. The nurse's response should be based on which of the following statements? 1. "Gastric ulcers have an increased association with clients who experience increased psychological pressures." 2. "The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals." 3. "Clients with gastric ulcers often gain weight, as food alleviates the pain." 4. "Antacids such as Maalox are seldom prescribed for clients with duodenal ulcers."

(1) refers to duodenal ulcers (2) correct—clients with duodenal ulcers experience pain after meals, e.g., midmorning and midafternoon (3) clients with gastric ulcer may be malnourished because food may cause nausea or vomiting (4) antacids are given to duodenal ulcer clients

A client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses the client, the client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride (Narcan), 0.4 mg IV is ordered stat. In planning care for this client, it is IMPORTANT for the nurse to consider which of the following? 1. The BP and respirations will need to increase before a second dose of Narcan can be given. 2. Narcan should not be given to the man because of his DNR status. 3. A dose of Narcan may need to be repeated in 2 to 3 minutes. 4. Narcan is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.

(1) will not change without Narcan, respirations increase within 2 min (2) DNR indicates no resuscitation should be done if heart stops; does not preclude administration of drugs to correct iatrogenic problems (3) correct—half-life of Narcan is short; may go back into respiratory depression; may need to be repeated (4) used for respiratory depression of opiates, not used with barbiturates or sedatives

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

(1) would be very difficult to prepare a 5-year-old child for a totally foreign procedure with only words (2) may be frightening without additional preparation (3) correct—excellent method to use with a child because it incorporates actually "feeling" many aspects of the procedure as they are explained (4) child probably doesn't know enough to ask many questions

Which of the following nursing interventions is MOST important for a client diagnosed with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position the client on the abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist the client with heat application and ROM exercises.

(1) would result in contractures due to the strength of flexor muscles (2) should encourage range of motion in all joints, not just hip flexors (3) massaging inflamed joints will add to inflammation and pain (4) correct—reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility ...

A client is scheduled for a myelogram at the outpatient clinic. The physician's office nurse reinforces the physician's explanation of the procedure. Which of the following statements, if made by the nurse, correctly describes a myelogram? 1. "The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown." 2. "The test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk." 3. "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 4. "The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."

(1) x-ray examination cannot determine the extent of myelin breakdown (2) no such procedure (3) correct—contrast medium or air is injected into spinal subarachnoid space through a spinal puncture; identifies tumors, cysts, herniated vertebral discs (4) no such procedure

An elderly female client is frantically yelling for the nurse to come into the room. The nurse enters the room as the client states, "See it? It's the devil!" Which of the following responses by the nurse is BEST? 1. "The devil is here?" 2. "Show me where the devil appeared to you." 3. "I don't see the devil, but I understand that he is real to you." 4. "The devil is not here; your mind is playing tricks on you."

(1) yes/no question, attempt to reason or argue with the client will only entrench her more firmly into this distortion (2) attempt to reason or argue with the client will only entrench her more firmly into this distortion (3) correct—nurse should not reinforce client's hallucinatory experiences; direct challenge to client's belief about sensory-perceptual intake will only increase mistrust and conflict between nurse and client (4) argumentative, attempt to reason or argue with the client will only entrench her more firmly into this distortion

The nurse recognizes which of the following nursing interventions is MOST important when caring for a client just placed in physical restraints? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints. 4. Monitor the client's needs for hydration and nutrition while restrained.

(2) correct—assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained

A client is admitted to the outpatient unit in the cancer center for chemotherapy. The client is lethargic, weak, and pale. During chemotherapy, which of the following nursing interventions is MOST important? 1. Establish emotional support. 2. Position for physical comfort. 3. Maintain droplet precautions. 4. Perform hand washing prior to care.

.(1) appropriate but not a priority (2) appropriate but not a priority (3) unnecessary during chemotherapy (4) correct—chemotherapy can lead to immunosuppression, which predisposes client to infection; hand washing is one of most effective means of decreasing infection transmission ..

breast-feeding mother should increase her daily caloric intake by how many calories?

500 calories more at day in order to obtain milk production.

Foot drop

Permanent dysfunctional position caused by shortening of the calf muscles and lengthening of the opposing muscles on the anterior leg. - The foot falls down at the ankle; permanent plantar flexion

The nurse's INITIAL priority when managing a physically assaultive client is which of the following? 1. Restrict the client to the room. 2. Place the client under one-to-one supervision. 3. Restore the client's self-control and prevent further loss of control. 4. Clear the immediate area of other clients to prevent harm.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) time out or room restriction might be a useful strategy before the client becomes assaultive; once client is assaultive, he/she may continue this behavior in his/her room without any redirection and support (2) may not stop assaultive behavior (3) correct—most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client's self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client (4) is helpful but may not be realistic if the situation escalates quickly

After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) tube would be irrigated with normal saline after the position of the tube was evaluated (2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4 (3) does not assess status of nasogastric tube (4) does not assess status of nasogastric tube

When caring for an elderly client with a depressed affect, which of the following nursing actions is MOST appropriate to help the client to complete activities of daily living? 1. Medicate the client before the activities begin. 2. Develop a written schedule of activities, allowing extra time. 3. Assist the client with grooming activities so it doesn't take as long. 4. Provide frequent forceful direction to keep the client focused.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not increase the client's independence and may interfere with the client's self-esteem (2) correct—written schedule with built-in extra time will allow client to understand what is expected and will allow client to participate at a slower pace (3) will not increase the client's independence; allow extra time for care (4) will not increase the client's independence and may interfere with the client's self-esteem

An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive range-of-motion exercises before walking. 2. Encourage partial weight bearing while ambulating. 3. Immobilize the extremity between activities. 4. Restrict the amount of time and the distance the man walks. An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive range-of-motion exercises before walking. 2. Encourage partial weight bearing while ambulating. 3. Immobilize the extremity between activities. 4. Restrict the amount of time and the distance the man walks.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would aggravate pain (2) correct—would relieve weight, pressure, and stress on affected leg, may use walker (3) would increase stiffness (4) immobility would aggravate pain and inflammation

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

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) yearly doses are given for flu shots, not for hepatitis B vaccine (2) correct—hepatitis B vaccine is repeated at 1 and 6 months (3) schedule for infant immunizations for IPV and DPT (4) inaccurate

A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following? 1. Prepare to administer IV Pitocin to the client. 2. A reduction in the amount of pain medication administered. 3. Check the client's blood pressure every 5 minutes. 4. Prepare an isolette for the infant.

Strategy: Answers are a mix of assessments and implementations. Does the assessment make sense? No. Determine the outcome of each intervention. (1) uterine contractions not affected by MS (2) correct—less pain medication is required because of overall decrease in pain perception due to MS (3) no reason to assess this frequently (4) baby's outcome not affected by MS ...

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

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each answer choice. (1) release of weights would change pull of traction, weight should never be released (2) pulling on traction weights would alter proper pull on fracture (3) correct—permits patient to reposition self and re-establish pull of traction weights (4) would not re-establish proper pull of traction

Which of the following strategies is MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems? 1. Observe family communication patterns at a "monitored mealtime." 2. Distract the client at mealtime. 3. Assign the client a food/thought/feelings/actions journal. 4. Assign the client to write a "lifeline" in relation to eating behaviors.

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. (1) assessment, should be done after a food/thought/feelings/actions journal (2) implementation, should be done after a food/thought/feelings/actions journal (3) correct—implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a "lifeline" in relation to eating behaviors will further benefit the client (4) implementation, should be done after a food/thought/feelings/actions journal

A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side.

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations. (1) correct—implementation; fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid (2) implementation; clients are not placed in the prone position (3) implementation; bed rest is maintained for several hours after the test (4) assessment; an extremity was not used for injection of the dye

An older client has an order for digoxin (Lanoxin) 0.25 mg PO daily. The nurse reviews the following information: apical pulse 68/min, respirations 16/min, plasma digoxin level 2 ng/mL. Which of the following actions by the nurse is BEST? 1. Give the medication on time. 2. Withhold the medication; notify the physician. 3. Administer epinephrine 1:1,000 stat. 4. Check the client's blood pressure.

Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of the implementations. (1) medication should be withheld (2) correct—therapeutic plasma level of digoxin is 0.5-2.0 ng/mL (3) not a correct action (4) assessment, does not address the issue of the elevated blood level of digoxin

Which of the following nursing actions is important for safe administration of oxytocin? 1. Assess respirations and urine output. 2. Administer oxytocin parenterally as the primary IV. 3. Have calcium gluconate available as an antidote. 4. Palpate the uterus frequently.

Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? Yes. (1) assessment; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (2) implementation; oxytocin is always given via an infusion pump and is never allowed to be the primary IV (3) implementation; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (4) correct—assessment; oxytocin stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus

The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil? 1. Reassess in 5 minutes. 2. Check the client's visual acuity. 3. Lower the head of the client's bed. 4. Contact the physician.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment or validation? No. Determine the outcome of the implementations. (1) assessment; situation does not require validation (2) assessment; has symptoms of increased intracranial pressure (ICP) (3) implementation; would increase the ICP (4) correct—implementation; fixed and dilated pupil represents a neurological emergency

An extremely agitated client receives haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. It is MOST important for the nurse to take which of the following actions? 1. Monitor blood pressure every 30 minutes. 2. Remain at the client's side to provide reassurance. 3. Tell the client the name of the medication and its effects. 4. Assess for anticholinergic effects of the medication.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment; monitoring vital signs is of utmost importance to ensure client safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension (2) implementation; should be done but is not highest priority (3) implementation; should be done but is not highest priority (4) assessment; circulatory system takes priority ...

The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST? 1. Withhold the medication. 2. Decrease the dose by half. 3. Administer the medication. 4. Wait 15 minutes, and then recheck the rate.

Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? No. Determine the outcome of each answer choice. (1) correct—maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure (2) should never change a prescribed dosage of medication (3) should not be given with a high pulse rate (4) assessment; maternal tachycardia is a side effect of Brethine; medication should be withheld

The mother of an 8-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse? 1. "Trust your doctors. They are excellent pediatricians and will know what to look for." 2. "There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor." 3. "It is an unlikely possibility, but if your child doesn't develop normally, your pediatrician will help you with any problems." 4. "You feel guilty about your son's illness, and that's understandable. You will feel better after you get home."

Strategy: Remember therapeutic communication. (1) nontherapeutic, diminishes person's concerns and feelings (2) nontherapeutic to discuss statistics with patients, wrong emphasis for discussion (3) correct—if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects); therapeutic response (4) nontherapeutic, interprets person's feelings

The nurse talks to a mother in the emergency department (ED) immediately after her son's death from sudden infant death syndrome (SIDS). Which of the following actions by the nurse is BEST? 1. Ask the mother if she has other children at home. 2. Explain the cause of SIDS. 3. Allow the mother to cry and talk about her son. 4. Determine how the infant was positioned in bed.

Strategy: The question is unstated. Read the answers to determine the topic of the question. Answers contain both assessments and implementations. Is assessment required at this time? No. Determine the outcome of each implementation. (1) assessment, does not help with current loss (2) implementation, too soon, should allow to vent feelings and experience grief (3) correct—implementation, needs to go through the grieving process (4) assessment, may make her feel guiltier, inappropriate at this time

A client diagnosed with AIDS is seen in the emergency room with complaints of mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the physician to order which of the following? 1. Metronidazole (Flagyl) 7.5 mg/kg q6h. 2. Ketoconazole (Nizoral) 200 mg daily. 3. Trimethoprim-sulfamethoxazole (Bactrim) 800 mg PO q12h. 4. Rifampin (Rifadin) PO 10 mg/kg daily.

Strategy: The topic of the question is unstated. (1) anti-infective, used in treatment of intestinal amebiasis, trichomoniasis, inflammatory bowel disease (2) correct—drug of choice for treatment of candidiasis (3) treatment for PCP; symptoms of dyspnea, tachypnea, persistent dry cough, fever, fatigue (4) treatment for tuberculosis; symptoms of fever, chills, night sweats, weight loss, anorexia

The nurse plans care for a client returning from surgery after a bowel resection with an IV of 0.9 % NaCl infusing at 100 mL/h into the left wrist. Which of the following actions, if performed by the nurse, is BEST? 1. Change the IV tubing each time a new IV solution is hung. 2. Cleanse the IV site with an alcohol swab using long strokes. 3. Limit manipulation of the cannula at the IV insertion site. 4. Adjust the drop rate to keep the total volume of IV fluids on schedule.

Strategy: The topic of the question is unstated. Read the answer choices to determine the topic. "BEST" indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary, changed every 48 to 72 h (2) should move swab in a circular motion outward (3) correct—will prevent dislodgment of needle (4) should give IV at rate ordered by physician, don't play "catch-up" with fluids

A 4-month-old child is admitted with a tentative diagnosis of meningitis. To confirm the diagnosis, a lumbar puncture (LP) is ordered. While assisting the physician with the procedure, it is MOST important for the nurse to take which of the following actions? 1. Appropriately restrain the child. 2. Instruct the parents about the procedure. 3. Provide support to the child. 4. Elevate the head of the bed.

Strategy: Think "Maslow." (1) correct—primary objective is to prevent trauma to child during the procedure; child must be restrained (2) not as high a priority as preventing injury to the child (3) should be done before and/or after the procedure (4) elevating the head of the bed for a 4-month-old will not expose the spinal column ...

The nurse cares for prenatal client at 8 weeks' gestation with a positive VDRL. When the nurse prepares the teaching plan, it is MOST important for the nurse to include which of the following? 1. Advise the client to not take any over-the-counter medications. 2. Instruct the client on the importance of taking the penicillin for the prescribed time. 3. Inform the client to refrain from sexual activity. 4. Maintain the confidentiality of sexual partners or contacts.

Strategy: Think "Maslow." (1) physical, should not take medication over the counter unless prescribed by a doctor, but not highest priority (2) correct—physical, vitally important to complete all the penicillin (3) physical, more important to be treated for disease (4) psychosocial, communicable diseases are reportable; partners or contacts need to be found and notified so that they may be treated

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

Strategy: Think "Maslow." (1) psychosocial, not highest priority (2) physical, use standard precautions (3) correct—safety is a priority for the client who is at high risk for infection (4) psychosocial, important for an adolescent but is not highest priority ...

A client takes perphenazine (Trilafon) by mouth for 2 days and now displays the following: head turned to the side, neck arched at an angle, and stiffness and muscle spasms in neck. The nurse expects to give which of the following as a PRN medication? 1. Promazine (Sparine). 2. Biperiden (Akineton). 3. Thiothixene (Navane). 4. Haloperidol (Haldol).

Strategy: Think about each answer choice. (1) antipsychotic medication, would not relieve the side effects (2) correct—antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing (3) antipsychotic medication, would not relieve the side effects (4) antipsychotic medication, would not relieve the side effects

To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube? 1. Suction equipment. 2. Blood pressure cuff. 3. Levine tube. 4. Emesis basin.

Strategy: Think about each answer choice. (1) correct—Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration (2) not a high priority (3) not a high priority (4) not a high priority

Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge? 1. The client shaves and brushes his teeth. 2. The client transfers himself into and out of his wheelchair. 3. The client maneuvers the wheelchair without difficulty. 4. The client prepares well-balanced meals. Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge? 1. The client shaves and brushes his teeth. 2. The client transfers himself into and out of his wheelchair. 3. The client maneuvers the wheelchair without difficulty. 4. The client prepares well-balanced meals.

Strategy: Think about the outcome of each answer. (1) paraplegic has full use of his upper body, so this activity presents no problem (2) correct—essential if client is to perform ADLs (3) done with the arms and presents no real problem (4) is a necessary requisite for living alone and performing ADLs but is not directly hindered by paraplegia