NCLEX WK 2

A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?

"By discharge, the client correctly identifies three potassium-rich food sources." RATIONALES: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed.

A client exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the client's anxiety?

"Let's talk about what is bothering you." RATIONALES: Anxiety may result from feelings of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the client to express feelings. The nurse should be supportive and develop goals together with the client to give the client some control over an anxiety-inducing situation. Because the other options ignore the client's feelings and block communication, they wouldn't reduce anxiety.

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

"The client remains free of signs and symptoms of phlebitis." RATIONALES: "The client remains free of signs and symptoms of phlebitis" is an appropriate expected outcome for this client. Monitoring fluid intake and output is a nursing intervention. Edema and warmth are objective assessment findings. Option 4 is a nursing diagnosis.

The cardiologist prescribes digoxin (Lanoxin) 0.125 mg by mouth every morning for a client diagnosed with heart failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablets should the nurse administer in each dose?

0.5 RATIONALES: The following formula is used to calculate drug dosages: Dose on hand/Quantity on hand = Dose desired/X The nurse should use the following equations: 0.25 mg/1 tablet = 0.125mg/X tablet; 0.25X = 0.125; divide both sides by 0.25; X = 0.5 tablet.

The nurse is preparing to give an average-sized 9-year-old client a preoperative I.M. injection. Which size needle should the nurse use?

22G, 1" RATIONALES: The nurse should first evaluate the muscle mass and amount of subcutaneous fat and then select the correct size needle. Without more information, the nurse would select the 22G, 1" needle, appropriate for an average-sized school-age child. The 20G, 1" needle would be unnecessarily large. The 22G, 1½" needle would be too long. The 20G, 1½" needle would be both too long and unnecessarily large.

The nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate?

1. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. 2. Respect the client's cultural beliefs. 3. Ask the client if he has cultural or religious requirements that should be considered in his care. RATIONALES: Nonverbal cues may have different meanings in different cultures. In one culture, eye contact is a sign of disrespect; in another, eye contact shows respect and attentiveness. The nurse should always respect the client's cultural beliefs and ask if he has cultural requirements. This may include food choices or restrictions, body coverings, or time for prayer. The nurse should attempt to understand the client's culture; it is not the client's responsibility to understand the nurse's culture. The nurse should never impose her own beliefs on her clients. Culture influences a client's experience with pain. For example, in one culture pain may be openly expressed whereas in another culture it may be quietly endured.

While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped." How should the nurse respond?

1. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries 2. Assist the client in developing a safety plan for times of increased violence. 3. Provide the client with telephone numbers of local shelters and safe houses. RATIONALES: The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected to be victims of abuse should be counseled on a safety plan, which consists of recognizing escalating violence within the family and formulating a plan to exit quickly. The nurse shouldn't report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Nurses do, however, have a duty to report cases of actual or suspected abuse in children or elderly clients. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a nonthreatening manner that promotes trust, rather than ordering her to break off her relationship.

A nurse is working with the family of a client who has Alzheimer's disease. The nurse notes that the client's spouse is too exhausted to continue providing care all alone. The adult children live too far away to provide relief on a weekly basis. Which nursing interventions would be most helpful?

1. Recommending community resources for adult day care and respite care 2. Encouraging the spouse to talk about the difficulties involved in caring for a loved one with Alzheimer's disease 3. Asking whether friends or church members can help with errands or provide short periods of relief RATIONALES: Many community services exist for Alzheimer's clients and their families. Encouraging use of these resources may make it possible for the client to stay at home and to alleviate the spouse's exhaustion. The nurse can also support the caregiver by urging her to talk about the difficulties she's facing in caring for a spouse. Friends and church members may be able to help provide care to the client, allowing the caregiver time for rest, exercise, or an enjoyable activity. A family meeting to tell the children to participate more would probably be ineffective and may evoke anger or guilt. Counseling may be helpful, but it wouldn't alleviate the caregiver's physical exhaustion and wouldn't address the client's immediate needs. A long-term care facility is not an option until the family is ready to make that decision.

The physician prescribes cefoxitin (Mefoxin), 1 g in 100 ml of 5% dextrose in water, to be administered I.V. The nurse determines that the recommended infusion time is 15 to 30 minutes. The available infusion set has a calibration of 10 drops/ml. To infuse cefoxitin over 30 minutes, which drip rate should the nurse use?

33 drops/minute RATIONALES: To calculate an I.V. flow rate, the nurse multiplies the number of milliliters to be infused (100 in this case) by the drop factor (10 drops/ml), and then divides by the number of minutes over which the solution is to be infused — 30 minutes. (100 × 10) ÷ 30 = 33 drops/minute

After undergoing small-bowel resection, a client is prescribed metronidazole (Flagyl) 500 mg I.V. The mixed I.V. solution contains 100 ml. The nurse is to run the drug over 30 minutes. The drip factor of the available I.V. tubing is 15 gtt/ml. What is the drip rate?

50 RATIONALES: Use the following equation: 100 ml/30 minutes × 15 gtt/1 ml = 49.9 gtt/minute (50 gtt/minute)

A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff?

A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. RATIONALES: The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants. A staff nurse isn't licensed to fill prescriptions.

The nurse is teaching a client how to administer subcutaneous (S.C.) insulin injections. Which injection site would be appropriate for the client to use?

Anterior aspect of the thigh RATIONALES: S.C. injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites.

After a client receives an I.M. injection, he complains of burning pain at the injection site. Which nursing action would be the best to take at this time?

Apply a warm compress to dilate the blood vessels. RATIONALES: Applying heat increases blood flow to the area, which, in turn, increases the absorption of the medication. Cold decreases the pain but allows the medication to stay in the muscle longer. Massage is a good intervention, but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues.

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which of the following meals as high in protein?

Baked beans, hamburger, and milk RATIONALES: Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection.

The physician orders chest physiotherapy for a client with pulmonary congestion. When should the nurse plan to perform chest physiotherapy?

Before meals RATIONALES: Chest physiotherapy is best performed before meals to avoid tiring the client or inducing vomiting. Scheduling chest physiotherapy around client or nurse convenience is inappropriate.

The physician orders an I.M. injection for a client. Which factor may affect the drug absorption rate from an I.M. injection site?

Blood flow to the injection site RATIONALES: Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and strength have no effect on drug absorption. The amount of body fat at the injection site may help determine the size of needle and the technique used to localize the site; however, it doesn't affect drug absorption (unless the nurse inadvertently injects the medication into the subcutaneous tissue instead of the muscle).

To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this?

By swabbing the labia minora from front to back RATIONALES: The client should swab the labia minora from front to back, using one swab for each wipe, because this technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front because this increases the risk of contamination. The labia majora should be cleaned with soap and water from front to back — not back to front. Before swabbing the labia minora with an antiseptic, the client should wash the perineal area with soap and water.

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?

Carotid RATIONALES: During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) no longer are palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

When assessing a client's I.V. insertion site, the nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?

Check the tubing for kinks and reposition the client's wrist and elbow. RATIONALES: The nurse should check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge clots, if present. Elevating the I.V. fluid bag may help if no kinks are found and if repositioning doesn't resolve the problem.

Which action by the nurse is essential when cleaning the area around a Jackson-Pratt wound drain?

Cleaning from the center outward in a circular motion RATIONALES: The nurse should always move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and has no lasting effect on bacteria because it evaporates. The nurse should wear sterile gloves to prevent contamination, but a mask isn't necessary.

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

Demonstrating the procedure and having the client return the demonstration RATIONALES: Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

Elisabeth Kubler-Ross identifies five stages of death and dying. Loss, grief, and intense sadness are symptoms of which stage?

Depression RATIONALES: According to Kubler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance. Loss, grief, and intense sadness indicate depression.

What is the best way for the nurse to improve client compliance with the prescribed medication schedule?

Devise the simplest medication schedule possible. RATIONALES: To improve client compliance, nurses should simplify the medication schedule. Compliance drops sharply when more than three medications are prescribed; geriatric clients tend to use more than one medication concurrently. It's too costly and impractical to hire a visiting nurse in most instances. Although instructions may need to be repeated, giving all instructions at least three times doesn't necessarily ensure compliance. Moreover, a physician, not the nurse, must decide how often a medication should be given.

When bandaging a client's ankle, the nurse should use which technique?

Figure-eight RATIONALES: The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.

After a stroke, a client develops aphasia. Which assessment finding is most typical in aphasia?

Inability to speak clearly RATIONALES: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a stroke, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

Level of consciousness (LOC) RATIONALES: After bronchoscopy, LOC is the most important assessment because changes in the client's LOC may alert the nurse to serious neurologic problems. The other options are important but don't take precedence at this time.

A pediatric nurse is asked to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The nurse has never worked in ICU and has no critical care experience. Which action is most appropriate for this nurse?

Notify the nursing supervisor that she feels unqualified and untrained for the assignment. RATIONALES: The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained. The nursing supervisor can guide the pediatric nurse as to the tasks the pediatric nurse is qualified to perform in the ICU without jeopardizing the nurse's nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable manner for managing resources. Option 4 puts the decision and responsibility for performance on ICU nurses. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never take responsibility for a total client care assignment if the nurse doesn't have the skills to plan and deliver that care.

When providing oral hygiene for an unconscious client, the nurse must take which essential action?

Placing the client in a side-lying position RATIONALES: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning the tongue with gloved fingers wouldn't be effective in removing oral secretions or debris in an unconscious client. Placing the client in semi-Fowler's position would increase the risk of aspiration.

The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release RATIONALES: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. The other options aren't used to elicit rebound tenderness.

Which of the following factors would have the most influence on the outcome of a crisis situation?

Previous coping skills RATIONALES: Coping is the process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Age could have either a positive or negative effect during crisis, depending on previous experiences. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, option 2 is the best answer. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome.

Which safeguard should the nurse take to ensure accuracy with a telephone order?

Repeat the order to the prescriber. RATIONALES: When taking a telephone order, the nurse should repeat the order to the prescriber to ensure that it is clearly understood; it isn't necessary to repeat the order to a nursing supervisor. The drug may be administered before the physician signs the order, but the order must be cosigned within the time period established by facility policy. Although it's a good idea to have a second nurse monitor the call, it doesn't have to be the nursing supervisor.

When percussing a client's chest, the nurse should identify which sound as a normal finding?

Resonance RATIONALES: Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in emphysema. The nurse may assess tympany when percussing over the abdomen, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus.

The nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

Shifting dullness over the abdomen RATIONALES: Shifting dullness over the abdomen indicates ascites, an abnormal finding. The other options are normal abdominal findings.

A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, neck vein distention, and tachycardia. What should the nurse do first?

Slow the infusion and notify the physician. RATIONALES: Because this client has fluid overload, the nurse first should slow the infusion to prevent additional fluid overload, and then notify the physician and obtain further orders. Notifying the physician without slowing the infusion would put the client at risk for pulmonary complications or respiratory failure. Discontinuing the infusion is inappropriate because vascular access still may be needed to administer I.V. fluids (at a decreased rate) or additional I.V. medications. Administering a diuretic without changing the I.V. infusion rate wouldn't prevent fluid overload from recurring.

A client who was involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?

Temporal RATIONALES: The temporal lobe controls hearing, language comprehension, and the storage and recall of memories. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The occipital lobe functions primarily in interpreting visual stimuli. The parietal lobe interprets and integrates sensations, including pain, temperature, and touch.

A nurse is caring for a client with a diagnosis of Impaired gas exchange. Which outcome is most appropriate based upon this nursing diagnosis?

The client has normal breath sounds in all lung fields. RATIONALES: If the interventions are effective, breath sounds should return to normal. The client should be able to cough effectively and should be encouraged to increase activity, as tolerated. Fluid intake should thin secretions.

The nurse inadvertently gives a client a double dose of a prescribed medication. After discovering the error, whom should the nurse notify?

The prescriber RATIONALES: After discovering a medication error, the nurse immediately should notify only those persons who can do something to rectify the error, such as the prescriber, the nursing supervisor, and the pharmacist.

A child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary?

To compensate for the effects of activity on the heart rate RATIONALES: Tachycardia may be a sign of heart failure. Mild tachycardia is more easily detected during sleep than during the day, when activity can cause an increase in heart rate. Medications given for rheumatic fever and rheumatic heart disease, such as digoxin (Lanoxin), exert their influence both day and night. Chorea, a symptom of rheumatic fever, is the loss of voluntary muscle control. However, it doesn't affect pulse because the child would be sitting quietly and not involved in purposeful movement. A 10-year-old child is unlikely to be able to consciously raise or lower his heart rate.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which of the following actions can the nurse institute independently?

Using a normal saline solution to clean the ulcer and applying a protective dressing as necessary RATIONALES: Washing the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash and an antibiotic cream require a physician's order. Massaging with an astringent can further damage the skin.

The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure?

Wrapping the cuff around the limb, with the uninflated bladder covering about three-quarters of the limb circumference RATIONALES: When measuring blood pressure, the nurse should wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-quarters (not one-fourth) of the limb circumference. Bladder size is chosen according to the size of the extremity.

The nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?

Yellow, purulent drainage RATIONALES: Yellow, purulent drainage suggests infection; the nurse must report this finding to the physician immediately and obtain a culture as ordered. The other options represent normal findings for a wound.

A client, age 75, is admitted to the facility. Because of the client's age, the nurse should modify the assessment by:

allowing extra time for the assessment. RATIONALES: When assessing an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, should address the client respectfully rather than by the first name, and should give simple instructions. Talking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

A client is receiving furosemide (Lasix), 40 mg by mouth twice a day. In the care plan, the nurse should emphasize teaching the client about the importance of consuming:

bananas and oranges. RATIONALES: Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the client to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; milk; and creamed corn aren't good sources of potassium.

An emergency department nurse is caring for a child diagnosed with croup. The nebulizer treatment of choice for a child with croup is:

racemic epinephrine (Racepinephrine). RATIONALES: Racemic epinephrine is an adrenergic used to reduce inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta2-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma.

A geriatric client who experiences several adverse drug reactions may benefit from:

reduced drug dosages. RATIONALES: Older clients frequently have diminished hepatic and renal function that reduces drug metabolism and excretion. Adverse reactions frequently are related to blood level; therefore, the client may benefit from reduced drug dosages. Adverse drug reactions aren't a cause for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the drug reacts in the client's body.

A client in her first postpartum month has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication being used by the nurse is:

self-disclosure. RATIONALES: Using self-disclosure as a therapeutic communication technique encourages an open and authentic relationship between the nurse and her client. Self-disclosure involves the nurse revealing personal information. Clarification involves the nurse asking the client for more information. Reflection is reviewing the client's ideas. Restating is the nurse's repetition of the client's main message.

A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This means they're:

touching the uvula. RATIONALES: Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are given a 4+ rating.

A nurse is assisting a physician with the insertion of a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. The appropriate response from the nurse should be to:

turn the client on his left side and place the bed in Trendelenburg's position. RATIONALES: When an air embolism is suspected, place the client on his left side and in Trendelenburg's position. This allows the air to collect in the right atrium rather than enter the pulmonary system. The other positions are therapeutic for other situations but not for air embolism.

For a client who takes over-the-counter drugs regularly, the nurse should ascertain:

whether the client knows the drug dosages and administration schedules. RATIONALES: The nurse should determine whether the client knows dosages and administration schedules for any over-the-counter drugs taken regularly. The nurse also should determine whether the client knows the correct reason for using the drug and its proper route of administration. Neither the drug's cost nor its generic classification are as important unless a problem arises with either of these two factors. Availability of drugs in the hospital isn't a high-priority item unless the client wants to purchase them from an outpatient pharmacy to save time.