Nclex review-5

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

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 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

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 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

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

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)

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 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 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 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

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 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

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

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 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

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

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 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 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

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

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

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

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

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

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

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

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

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

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 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

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 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

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

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

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 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

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 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

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 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 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 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 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

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

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

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

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 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

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

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.

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

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 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.

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 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

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

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

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 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

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

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

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

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

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 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 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 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 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

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

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

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 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

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

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

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

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

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 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

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

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

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

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

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

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

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 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

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 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

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

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

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 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 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

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

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

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

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 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 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

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 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

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

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

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

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 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

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

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

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 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

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

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

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

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 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

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

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

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

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

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

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

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

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

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 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 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 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 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

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

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 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.