Passpoint NCLEX

Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which statement the infant's mother indicates understanding of the disease and its management? Select all that apply.

"My baby cannot have milk-based formulas." "We have to follow a strict low-phenylalanine diet." "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow."

The nurse is discharging a newborn to home. Which discharge instructions will the nurse give to the newborn's parents? Select all that apply.

1. "Sponge bathe as needed until the umbilical cord comes off." 2. "Ensure that feedings occur every 3 to 4 hours." 3. "Place newborn in a rear-facing car seat."

A nurse is teaching a client about metformin therapy. The nurse warns the client that metformin commonly causes hypoglycemia when combined with which other medication?

ACE inhibitors

A client who is taking aspirin caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which action first?

Apply an icepack for 20 min

Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin?

nausea and vomiting; Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures are not findings in digoxin toxicity.

A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply.

1. taking small steps with feet shoulder length apart when walking on wet surfaces 2. removing clients from the area where a fire is reported 3. using tongs to place a dislodged radioactive device in a lead container

A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take?

Notify the physician immediately to have the physician determine client competency; Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.

A nurse is caring for a 16-year-old girl who isn't sexually active. The girl asks if she needs a Papanicolaou (Pap) test. How should the nurse respond?

"No, it isn't necessary because you aren't sexually active."

The nurse reviews a client's lab values and implements which intervention to help with maintenance of skin integrity?

Begin infusion of intravenous fluids; A client with an increased sodium level potentially has dehydration, which can impact skin integrity as a risk factor. Beginning rehydration through the infusion of intravenous fluids will help with restoring fluid volume, and preventing dry skin. The WBC count is still within normal limits, so monitoring the temperature is not indicated. While the potassium level is decreased and the client may need cardiac monitoring, this does not have an effect on skin integrity. Nutrition does have an effect, but there is no indication of the client being malnourished with a glucose level of 111 mg/dL.

The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first? You Selected:

Check the function of the suction equipment; When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the HCP should be called.

The client with gastroesophageal reflux disease (GERD) has a chronic cough. The nurse should further assess the client for which other possible problem?

aspiration of gastric contents.

A nurse obtains a fingerstick glucose level of 45 mg/dl (2.47 mmol/L) on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene?

obtain a repeat fingerstick glucose level; The nurse should recheck the fingerstick glucose level to verify the original result because the client isn't exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time.

The nurse is developing a care plan for a female child who is 12 years of age and receiving surgery to correct idiopathic scoliosis. Which postoperative problem is a priority?

pain control

The emergency room nurse is caring for a client who fell, breaking the tibia. The nurse determines that the client understands the risk of compartment syndrome when knowing to report which early symptom following treatment?

paresthesia; Compartment syndrome is the compression of the nerves, blood vessels, and muscle inside a closed space. Paresthesia is the earliest sign of compartment syndrome. Pain, heat, and swelling are also signs but occur after paresthesia. Skin pallor is not a sign of compartment syndrome.

A nurse completing management rotation in the intensive care unit (ICU) is working with an experienced ICU nurse. One client's work supervisor calls to "check up" on the client. The nurse offers to transfer the call to the client's family members. The experienced ICU nurse recognizes this action as

protection of the client's privacy.

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

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

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should

wash their hands after touching the client; To maintain enteric precautions, the nurse must wash their hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.

The nurse is preparing to administer medications to a client through a nasogastric (NG) tube. What interventions should the nurse include in the client's plan of care? Select all that apply.

1. Flush NG tube in between medications. 2. Position the client in a Fowler's position during feedings; Medications should be separated with 15 mL of NS or water in between. High Fowler's position prevents aspiration. Time-released medications should never be crushed. Medications should be given in separate syringes and residual contents should be returned.

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

1. Splint the incisional site. 2. Inhale through the nose. 3. Exhale through pursed lips. 4. Cough deeply from the lungs; The client must first splint the incision to avoid increased intolerable pain or he or she may not cooperate with the pulmonary ventilation. The next step is to inhale oxygen to expand the alveoli for a few seconds and then exhale carbon dioxide in successive steps 5 to 10 times. The client should try to cough on the end of the exhalation to remove retained secretions from the larger airways.

For which medication(s) will the nurse ask another nurse to witness the disposal of a partial dose in the phamaceutical waste container? Select all that apply.

alprazolam hydrocodone meperidine; Federal law requires two nurses to witness and document the waste of all controlled subsatnces in order to prevent diversion and misuse of these substances. Alprazolam, hydrocodone, and meperidine are controlled substances. These medications require the nurse to have another nurse witness the waste in a pharmaceutical waste container. Losartan and amlodipine are not controlled substances and do not require special procedures for the waste of a partial dose.

While preparing to start a stat I.V. infusion, a nurse notices a broken ground wire on the infusion pump's plug. What would the nurse do first?

Obtain another pump from central supply.

A nurse notices that a severely depressed client is crying and asks what's wrong. The client responds, "Well, it looks like my suspicions are about to be confirmed." When asked what that means, the client refuses to talk about the matter. The nurse later notices a letter from the client's spouse lying on the floor near the bed. The client is in session with the psychiatrist and the nurse believes the contents of the letter could offer clues about the client's depression. What is the nurse's best course of action?

Pick up the letter and place it on the client's bedside table;

A postpartum client decides to bottle-feed her neonate. Which client statement indicates the need for further teaching about preventing engorgement?

Taking hot showers can help reduce engorgement" This client demonstrates a need for futher teaching when she states that hot showers can help reduce engorgement. Hot showers actually stimulate the breasts, triggering milk production and prolonging the discomfort of engorgement. The client is correct in stating that she shouldn't express milk manually because doing so can also trigger milk production. Antilactation drugs are no longer recommended because a rebound effect may occur after they're discontinued; also, they're expensive and may cause adverse effects. The proper brassiere does help prevent breast engorgement by providing support and acting as a barrier to breast stimulation.

A terminally ill client in hospice care is experiencing nausea and vomiting because of a partial bowel obstruction. To respect the client's wishes for palliative care, what can the nurse recommend that the client use?

a clear liquid diet; The use of diet modification is a conservative approach to treat the terminally ill or hospice clients who have nausea and vomiting related to bowel obstruction. Osmotic laxatives would be harder for the client to tolerate. An NG tube is more aggressive and invasive. IV antiemetics are also invasive. The hospice philosophy involves comfort and palliative care for the terminally ill.

Which client's care may a registered nurse (RN) safely delegate to the nursing assistant?

a client requiring assistance ambulating, who was admitted with a history of seizures; The RN may safely delegate assistance ambulating for the client with a history of seizures to a nursing assistant. The RN should provide direct care to the client who requires continuous pulse oximetry monitoring because pulse oximetry interpretation requires assessment skills. Care of the clients requiring suctioning and patient-controlled analgesia can be safely delegated to a licensed practical nurse.

A client is to start on enteral tube feedings. What intervention will the nurse implement to best promote the client's ability to adequately digest the feeding and reduce residual gastric volumes?

Begin with a slow, continuous rate of feeding and adjust based on client repsonse;

A public health nurse has been asked to teach the importance of hand washing to elderly clients. Which statement by a client indicates that the teaching has been effective?

Friction while washing hands decreases transmission of bacteria; Soap helps by reducing surface tension of water, but friction is necessary for the removal of microorganisms. The use of warm water still needs friction. Use of other products besides soap can reduce infection. Fifteen seconds is an insufficient length of time for hand washing.

A client who is allergic to penicillin has a prescription to receive cefazolin. What should the nurse do first?

Ask if the client has taken cefazolin before without an adverse response; A client who has an allergy to penicillin may have a cross-sensitivity to cefazolin, a first-generation cephalosporin, and the drug should be given with caution. The nurse should ask the client whether he has taken cefazolin before. The nurse should inform the pharmacy of the client's allergy after asking the client about prior use of cefazolin. The medication should not be administered until the nurse first inquires about the client's exposure to cefazolin and then consults the pharmacist or HCP. Observing the client for urticaria is appropriate but is not an initial response.

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. What should the nurse do next?

Document assessment findings in the client's medical record.

A client hospitalized for preterm labor tells the nurse that she's having occasional contractions. Which nursing intervention would be the most appropriate?

Encourage the client to empty her bladder, give I.V. fluids, and encourage oral fluids.

A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. The client's physician orders neomycin, 4 g by mouth daily in four divided doses. The client's partner asks how neomycin decreases the serum ammonia concentration. How should the nurse respond?

Neomycin decreases the amount of ammonia-producing bacteria in the GI tract; Neomycin lowers the blood ammonia level by reducing the quantity of ammonia-producing bacteria in the GI tract. The drug also exerts its antibacterial activity directly on the ribosomes of susceptible organisms, among them E. coli, by inhibiting protein synthesis via direct action on ribosomal subunits. When present, these bacteria convert urea to ammonia. Neomycin is bactericidal in high concentrations and bacteriostatic in low concentrations. Thus, it doesn't trap or bind with ammonia in the GI tract.

The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should most avoid?

Rock climbing; A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camps, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures.

An adult with diabetes insipidus is hospitalized for care. Which finding should the nurse report to the physician?

Urine specific gravity of 1.001; Diabetes insipidus is caused by a deficiency of antidiuretic hormone, which results in excretion of a large volume of dilute urine. Therefore, a urine specific gravity of less than 1.005 should be reported. Urine output should be 30 to 50 ml/hour; thus, 350 ml is a normal urinary output over 8 hours. The potassium level is normal. Weight loss, not weight gain, should be monitored as a sign of dehydration.

The nurse is assessing with a head injury a client for decerebrate posturing. Which position indicates the client has decerebrate posturing?

back arched, rigid extension of all four extremities; Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

After a third arrest for abusing a neighbor's cat, a client is admitted to the psychiatric unit for treatment of antisocial personality disorder. This client has a history of conduct disorder. Which action is most appropriate for the nurse assigned to this client?

examining personal feelings toward the client; When caring for a client with a personality disorder, a nurse must examine personal feelings toward the client. If the nurse has negative feelings about the client, the client will sense this and may "act out" the feelings. Also, conveying negative feelings could jeopardize the therapeutic relationship. Clients with antisocial personality disorder aren't motivated to problem-solve because they lack remorse and have no regard for the truth. Although the nurse must set strict limits on manipulative behavior, insisting that the client obey all unit rules and attend all unit activities would make the client feel increasingly threatened. Drug therapy is rarely effective in treating personality disorders, except in cases of extreme distress such as severe anxiety (which this client doesn't exhibit).

A client with idiopathic thrombocytopenic purpura (ITP) is being treated with prednisone and rituximab. The nurse prioritizes what aspect of care planning?

infection control measures;

A nurse can auscultate for heart sounds more easily if the client is

leaning forward; The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This position enables the nurse to listen for heart sounds without the sound of expiration interfering. Using the supine position to visually inspect the precordium allows the nurse to observe the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole

A nurse is planning staffing for a nursing unit in which the primary need of the clients is learning how to manage their health problems. Which combination is the ideal mix of staff for this unit?

three registered nurses (RNs); The ideal staffing for a nursing unit focused on client teaching and learning is to have three registered nurses. It is within the scope of practice for the RN to assess, plan, implement, coordinate, and evaluate client learning. It is not within the scope of practice for LPNs/VNs and UAP to provide client teaching.

A client with colon cancer had a left hemicolectomy 3 weeks ago. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. The nurse should recommend to the health care provider which nutritional support to maintain the nutritional needs of the client?

total parenteral nutrition through a central catheter; Total parenteral nutrition solutions supply the body with sufficient amounts of dextrose, amino acids, fats, vitamins, and minerals to meet metabolic needs. Clients who are unable to tolerate adequate quantities of foods and fluids and those who have had extensive bowel surgery may not be candidates for enteral feedings. The nurse would anticipate total parenteral nutrition via central catheter to promote wound healing. IV dextrose does not supply all the nutrients required to promote wound healing.

A 36-year-old client is admitted with a possible ruptured ectopic pregnancy. The nurse should prepare the client for which procedure?

ultrasound; Symptoms of ruptured ectopic pregnancy are not always obvious. If bleeding into the pelvic cavity is extensive, then vaginal examination causes intense pain. Ultrasound will detect the location of rupture and bleeding, thus confirming the diagnosis. Dilation and curettage is indicated for a missed or incomplete abortion, not for a ruptured ectopic pregnancy. The uterus is not evacuated because the pregnancy is located outside the uterus. Oophorectomy (removal of the ovaries) is usually not performed, although a salpingectomy (removal of the tube) or salpingostomy (removal of the conceptus) is often performed to prevent further bleeding.

The nurse is preparing to administer medications to the client. Which identifiers will the nurse use? Select all that apply.

wristband birthdate name

Which statement by the parent of an 18-month-old child <most>indicates to the nurse that the child needs laboratory testing for lead levels?

"My child does not always wash after playing in the dirt;" Eating with dirty hands, especially after playing outside, can cause lead poisoning because lead is often present in soil surrounding homes. Also, children who eat lead-containing paint chips commonly develop lead poisoning. Milk is a major source of calcium, and diets high in calcium help prevent lead poisoning. Temper tantrums are characteristic of 18-month-old children as they try to assert themselves. Determining whether the child is smaller than other children the same age requires measuring height and weight and plotting them on growth charts. In addition, inadequate growth could be a result of numerous causes, such as genetics, chronic illness, or chronic drug use (e.g., prednisone).

A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first?

Assist the client up to the toilet to attempt to void; Urinary retention is common following abdominal surgery. The nurse should first assist the client to an anatomically comfortable position to void prior to resorting to other strategies such as cauterization. If the client is unable to void, the nurse can use a bladder scanner to determine the volume of retained urine, and then, if necessary, use an intermittent urinary catheter. While increasing fluid intake is important, it will not help the client void now.

The health care provider prescribes raloxifene hydrochloride for a 60-year-old woman. The drug is effective if the client does not develop:

Osteoporosis; Raloxifene hydrochloride, an estrogen receptor modulator, increases bone mineral density without stimulating the endometrium. The drug is useful in preventing osteoporosis in postmenopausal women. This drug is contraindicated for women who smoke cigarettes or who have a history of venous thrombosis. Raloxifene does not prevent hot flashes or hyperglycemia. One of its adverse effects is increased headaches.

Which of the following situations does the nurse recognize as having the greatest risk for the fetus?

a fundal height of 27 cm at 32 weeks gestation; Optimal fetal growth and development during pregnancy are assessed with fundal height measurement. Fundal height, measured in centimeters, should equal gestational weeks throughout the pregnancy (e.g., fundal height of 27 cm should occur at 27 weeks gestation). A fundal height of 27 cm at 32 weeks gestation is a very ominous finding that requires immediate attention and investigation. The fetal heart rate (FHR) range is 110-160 bpm but may fluctuate with fetal movement. It is considered tachycardia and at risk only if a FHR is greater than 160 bpm for at least 10 minutes. A breech lie may result in a cesarean section, which carries increased risk after childbirth. There is a possibility that the fetus will change the lie naturally prior to birth or an external cephalic version may be performed. A gestation of 37 completed weeks is considered term.

A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure?

nephrotoxic injury secondary to use of contrast media; Intrinsic renal failure results from damage to the kidney, such as from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or bacterial toxins. Poor perfusion to the kidneys may result in prerenal failure. Damage to the epithelial cells of the renal tubules results from nephrotoxic injury, not damage to the adrenal cortex. Obstruction of the urinary collecting system may cause postrenal failure.

Two days following abdominal surgery, a client is refusing to take a narcotic pain medication, even though the pain rating is an 8 on a 0 to 10 scale. The client tells the nurse, "I don't want to get dependent on that stuff." Which response from the nurse is the most appropriate?

"You will recover more quickly and more effectively if you take pain medication now;" Common client misconceptions regarding pain and pain medication administration include a concern that taking pain medication regularly will lead to addiction. However, this misconception overstates the risk of addiction and greatly understates the risk of immobility due to poor pain control, including atelectasis, decubitus formation, and delayed healing. The nurse should assist the client to understand the importance of adequate pain medication to support and promote client mobilization following surgery and client/family satisfaction with care. There is a potential for dependence and addiction with all narcotic drugs, although this is not likely during the postoperative period.

The obstetrical triage nurse assesses a client with a term pregnancy. There has not been any change in the cervix for the past 2 hours despite irregular contractions. When discharging the client to her home, the nurse should tell the client to return to the hospital when which conditions occur? Select all that apply.

1. Contractions become more intense and closer together. 2. She notices vaginal bleeding. 3. She thinks the membranes have ruptured. 4. She notices an absence of fetal movement. 5. She feels the urge to push; Because there have been no cervical changes, the client is not in labor. The client should understand to return to the hospital if the contractions become more intense and regular, if she has vaginal bleeding, if she thinks her membranes rupture, if the baby is not moving, or if she has an urge to push. Three contractions an hour would be too infrequent to indicate active labor.

An older adult is being discharged following a repair of an inguinal hernia. The client is independent and lives alone, but the client's family lives 60 miles from the client's house. When at home, the client is to cleanse and inspect the incision for signs of infection. The client and family are able to read and understand written instructions. When giving discharge instructions, what should the nurse do? Select all that apply.

1. Explain the instructions to the client. 2. Ask the client to demonstrate the procedure. 3. Provide written instructions for the client. The nurse should explain and demonstrate the discharge instructions and then ask the client to give a return demonstration. The Joint Commission and Health Canada require that discharge instructions be written for the postoperative client. Clients need to be given discharge instructions orally and in written form because of stress, medications, and the volume of material to be learned. Explaining all the instructions to family members and giving them a link to a video is important but does not replace the need for written instructions. Since the family does not live nearby, the nurse must be certain the client can manage the instructions alone.

A laboring client provides the nurse with the birth plan that she wishes to follow. The birth plan expresses that the client wishes for her partner to do the coaching through her contractions. What is the best way for the nurse to meet this family's needs during labor and birth?

Enter the birthing room as few times as possible to do the required assessments; The birth plan is a vehicle for communicating to the healthcare providers the family's desires regarding the birth attendant; birth setting; support person; and activities during labor, birth, and the postpartum period. The nurse should collaborate with the couple to respect their plans and privacy while achieving the goals of safe childbirth. It is incorrect to contact the physician; the plan should be discussed directly with the couple to ensure understanding of their desires. It is critical that the nurse does enter the room to perform the required assessments, and not only when requested, to ensure safety of both mother and baby.

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply.

cooked dry beans peanut butter yogurt

The nurse is assigning a room for a client admitted with hepatitis A. Which diagnosis would be an appropriate roommate for this client?

Congestive heart failure

The nurse instructs a group of parents about emergency treatment for accidental poisoning and injury. The nurse would need to do further teaching if a participant makes which statement?

"I should call the poison control center if there are any symptoms;" Many poisons require immediate attention but do not cause immediate symptoms. Therefore, parents who believe that a child has ingested or otherwise been exposed to a poisonous substance should immediately call the Poison Control Center. Eyes should be flushed for 15 to 20 minutes with saline or room temperature tap water. Emesis should be saved for analysis, especially if the type or amount of poison ingested is not clear. Vomiting caustic substances may lead to esophageal or airway damage; therefore, vomiting should only be induced if directed by the Poison Control Center.

A client is scheduled for cardiac catheterization. The client reports being nervous because there have been incidents of people dying during this procedure. How would the nurse respond?

"Would you like to go over the details of the procedure with me now?"

A client is experiencing intertrigo caused by friction between the inner thighs. Which action should the nurse take to help this client?

Apply lubricating lotion over the affected areas; Friction between the inner thighs can be reduced by applying a lubricant over the affected areas. An antihistamine would be used for an allergic reaction. Because there is no evidence that the affected area was caused by a fungus, an antifungal agent would not be appropriate. Warm soaks may cause further irritation to the affected skin areas and should not be used

A nurse is caring for a client who has returned to their room after a carotid endarterectomy. Which action should the nurse take first?

Ask the client if they have trouble breathing; The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.

A client in the emergency department reported vomiting and diarrhea for the previous 24 hours. The client's blood pressure is 90/60 mm Hg, respiration is 20 breaths per minute, heart rate is 92 beats per minute, and temperature is 37.5° C (99.5° F). Which intervention will the nurse perform first?

Assess for dehydration; The priority for this client is assessing the problem. Then the nurse should treat the fluid volume deficit, then the temperature. This client has hypotension, and the nurse would raise the legs, not the head, of the bed first to improve perfusion to the brain, as it is the least restrictive intervention.

The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time?

Attend the funeral; It is appropriate for the nurse who took care of a client for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up personal or phone call to the client's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. Flowers may not be desired by the family. The nurse needs to do more than just remove the client's name from the care list.

A 12-year-old client needs lifesaving emergency surgery, but the relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response?

Call the family for a consent over the telephone, and have another nurse listen as a witness; While laws in states and provinces may vary, generally, when the client cannot sign the operative consent and it is a true life-saving emergency, consent may be obtained over the telephone from the client's next-of-kin or guardian. The surgeon must obtain the telephone consent, but if it is a true life-saving emergency the surgeon often is already in surgery, so the nurse makes the telephone call and another nurse witnesses the call. Some institutions have a special consent form for emergency surgery. Consent can be waived in situations in which no family is available; however, if the family can be reached by telephone before surgery, verbal consent is legally required.

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which best defines this type of charting?

Charting by exeption

The nurse is caring for a client who entered the hospital with a diagnosis of dehydration. The client's serum potassium is 5.2 mmol/L this morning and the healthcare provider orders the primary I.V. fluid as D5 1/2 NSS with 20 mEq/KCL (mmol/L). What will the nurse do? Select all that apply.

Hold the I.V. fluid; Clarify the order with the healthcare provider; Review the lab results.

When planning care for a client with schizophrenia, who lacks motivation to shower and dress, which outcome should the nurse expect the client to achieve by the end of 4 days?

Perform showering and dressing for herself; By the end of 4 days, the client should be able to perform showering and dressing for herself. The client with schizophrenia commonly appears to be apathetic and lack initiative. Therefore, demonstrating the ability to complete the tasks indicates improvement. Although the client may be able to recognize, verbalize, or explain the need to shower and dress herself, she may be unable to do so because of the ambivalence associated with schizophrenia that impedes the client's ability to initiate and complete self-care. Therefore, evidence of improvement would be lacking.

The nurse is caring for a client admitted with Addisonian crisis. Which outcome is the priority?

Preventing irreversible shock; A client in Addisonian crisis has an uncontrolled loss of sodium in the urine, and impaired mineralocorticoid function, which results in a loss of extracellular fluid, low blood volume, and possible irreversible shock. Preventing infection isn't an appropriate goal in this life-threatening situation. Relieving anxiety is appropriate after the client is stabilized. The client in Addisonian crisis is hypotensive, and blood pressure should be raised not lowered.

What are important nursing care measures for a client with diabetes who is admitted with end-stage renal failure?

Restrict sodium and potassium and restrict fluids as ordered; In renal failure, there is retention of sodium and potassium, so these are restricted. Important care measures will also include fluid restrictions. The client will require permanent dialysis, not temporary as with acute renal failure. The diet will be restricted in protein to decrease waste products. Hypertension is associated with chronic renal failure.

A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. What finding should the nurse immediately report to the health care provider?

Sudden, sharp chest pain; Pneumothorax signs and symptoms include sudden, sharp chest pain, tachypnea, and tachycardia. The nurse should report these to the health care provider (HCP). Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Hemoptysis and cyanosis are not typically present with a pneumothorax.

Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children?

Teach parents to promote adequate fluid intake; Urinary stasis is a major cause of UTIs, and can be partially prevented by increasing fluid intake. Baths and hand hygiene are less significant factors in the development of UTIs. Urinary tract infections are increased in uncircumcised male infants under 1 year of age, but unaffected thereafter.

The third stage of labor ends

after the delivery of the placenta; The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth.

A client recently had a right total hip replacement. As a result of intraoperative blood loss, postoperative serum hemoglobin levels and hematocrit are low. The physician orders two units of packed red blood cells. During the infusion of the first unit of blood, the client develops a transfusion reaction and experiences urticaria, itching, and bronchospasm. The nurse discontinues the transfusion and notifies the physician. Which antihistamine does the nurse anticipate administering to treat this type I hypersensitivity reaction?

chlorpheniramine maleate; The parenteral form of chlorpheniramine maleate is used to relieve symptoms of anaphylaxis and allergic reactions to blood or plasma. Tripelennamine citrate, astemizole, and cyclizine aren't used to treat blood transfusion reactions.

What is the most common cause of medication errors among noninstitutionalized elderly clients?

deficient knowledge; Deficient knowledge is the most common cause of medication errors among noninstitutionalized elderly clients. Poor vision, dementia, and confusion can contribute to medication errors in this group, but they're less common causes of medication errors.

The nurse is receiving a change of shift report on a group of clients. Which client should the nurse see first?

heart failure who has a PaO2 of 75 and an oxygen saturation is 90% on a nonrebreather mask; The nurse should first see the client with heart failure who is on a nonrebreather mask and only has an oxygen saturation of 90% and a PaO2 of 75. This client is not responding appropriately to oxygen therapy and warrants further assessment. This client is most likely experiencing an exacerbation of heart failure, and gas exchange is not occurring at the capillary-membrane level in the lungs. The client with wheezing has an oxygen saturation of 90% on room with a PaO2 of 79 indicating that gas exchange is impaired but not severely. The client with COPD can have PaO2 of 65 if damage to the lungs is underway. A client with COPD can be considered adequately oxygenated with oxygen saturation of 91% on 2L nasal cannula. The client who is 30 minutes post-op from cardiac surgery and has a PaO2 of 80, which is within the normal range, and an oxygen saturation of 93% is considered normal. This client is not experiencing poor oxygenation because of the surgery.

An extremely agitated client is brought to the psychiatric unit by the client's partner. The partner reports that the client has been hospitalized several times for treatment of bipolar disorder and has spent thousands of dollars in the past week. The psychiatrist admits the client to the unit for exacerbation of the manic phase of bipolar disorder. Which approach by the nurse promotes a therapeutic relationship with this client?

maintaining a firm but nonthreatening manner; The nurse must maintain a firm but nonthreatening approach to avoid provoking anger in this agitated client. Because the client is having difficulty controlling behavior, confrontation would be pointless. Confrontation would also jeopardize rapport and detract from a therapeutic nurse-client relationship. The client's agitated state makes successful communication difficult. Instead of using reflection and open-ended questions to try to develop a therapeutic relationship, the nurse should provide emotional support and maintain a calm environment. Reflective communication and open-ended questions may anger the client, who has been hospitalized before and is accustomed to "therapeutic talk." This client is too agitated to gain insight into behavior.

Which factors can place adolescent girls at risk for iron deficiency anemia? Select all that apply.

menses; vegetarian diet; weight-loss diets; poverty

A client with jaundice has poor appetite, nausea, and two episodes of emesis in the past 2 hours. The client reports having spasms in the stomach area. The client does not have pruritus. The nurse should develop a care plan for which symptom first?

nausea

A nurse is assessing a client who is being abused. The nurse should assess the client for which characteristic(s)? Select all that apply.

self-blame alcohol abuse suicidal thoughts guilt

After teaching the client about lochia, the nurse determines that the client understands the instructions when she says that on the 10th or 11th postpartum day, the lochia should be which color?

White; About the 10th day after childbirth, the discharge becomes thin, scanty, and almost without color (white). At this time, it is called lochia alba. The vaginal discharge from approximately day 4 through day 9 becomes more serous and watery, pink to pinkish or brown in color. At this time, it is called lochia serosa. The vaginal discharge that normally occurs for 2 to 3 days after childbirth, lochia rubra, contains mostly blood and is dark red in color. A brown vaginal discharge is commonly associated with lochia serosa, the vaginal discharge from approximately day 4 through day 9.

The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess?

amenorrhea and quickening; Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective, but nonconclusive indicators — for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators, such as fetal outline on ultrasound confirm pregnancy.

A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for complications?

gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl; Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may experience more complications such as poor wound healing and inability to tolerate activity. An intact incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8° F (37.7° C) after a vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.

A nurse is monitoring a client following the administration of sotalol. Which finding would be of greatest concern to the nurse?

bilateral inspiratory wheezing upon auscultation; Nonselective beta-blocking drugs may cause bradycardia, hypotension, heart block, heart failure, bronchoconstriction, and/or increased airway resistance. Any preexisting respiratory condition such as asthma might be worsened by the concurrent use of these medications. A weight gain of more than 3 lbs (1.36 kg) in 2 days or 5 lbs (2.26 kg) in a week should be reported.

A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which signs and symptoms? Select all that apply.

bleeding that is concealed or apparent, abdominal rigidity, painful abdomen

Which findings should lead the nurse to suspect that a client who had a cesarean birth 8 hours earlier is developing disseminated intravascular coagulation (DIC) and report to the health care provider (HCP)? Select all that apply.

petechiae on the arm where the blood pressure was taken; heart rate of 126 bpm; abdominal incision dressing with bright red drainage; platelet count of 80,000/mm3 (80 X 109/L)

A pregnant client presents to the emergency department with complaints of back pain. This is the second visit in a month. She is accompanied by her spouse, who refuses to let the client speak for herself. When inspecting the painful area, the nurse notes bruising on the client's lower back. The client's spouse states that the client is clumsy and falls down the front steps of the house often. What should the nurse do first in this situation?

Separate the pregnant client from her partner; The possibility of violence should be considered when there are injuries to the client and a reported history that is not consistent with the actual presenting problems. If abuse is suspected, immediately isolate the woman from the possible abuser. The client and the fetus are assessed for safety. The fetal heart rate should be monitored, and the nurse should assess for bleeding and contractions. The nurse should ask the woman if she feels safe going home with her partner, whether she has an escape plan if she feels in danger, and if she has an immediate need for a place of safety. A list of community resources should be provided to the client whether they are needed at this time or for the future.

A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about:

left end-diastolic pressure; When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area, and is considered a more accurate reflection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.

Which moral principle is a nurse applying when the nurse decides what is best for a client and acting without consulting the individual?

paternalism; Nurses and other healthcare workers employ paternalism when a client's loss of consciousness or other circumstances compel them to decide what is best for the client and to act without consulting the individual. Beneficence means that nurses should act in the client's interests always. Fidelity requires the nurse to be faithful and truthful and to keep promises to clients, families, coworkers, and employers. Autonomy refers to every individual's right to make rational decisions about their life. The nurse's belief in autonomy leads to a respect for the client's decisions.

To prevent the spread of infection in the home healthcare environment, the nurse should follow appropriate technique by

placing equipment back on a liner when setting it down in the client's home; To prevent the spread of infection, nurses should use appropriate technique when handling their equipment bags by performing hand hygiene before reaching into the bag for supplies, cleaning any equipment removed from the bag before returning it to the bag, and placing the bag on a liner when setting it down in the client's home. Donning gloves, a mask, or gown when greeting the client or family members is not necessary and will interfere with the greeting process.

The nurse is assessing a client's data with primary glomerular disease. Which assessment data will the nurse expect to verify progression to nephrotic syndrome? Select all that apply.

proteinuria diffuse edema hypoalbuminemia

A child has been admitted to the hospital following a severe concussion. Which nursing interventions are important while caring for this child? Select all that apply.

1. Implement seizure precautions. 2. Frequently assess vital and neurological signs. 3. Keep the head of the bed slightly elevated; Seizure precautions are an important safety measure. Frequent assessment of vital and neurological signs are important to detect any deterioration in condition. Bed rest with the head slightly elevated will minimize headache and reduce ICP. Heavy sedation is contraindicated as this may mask signs of deterioration in condition. There is no indication for NPO status.

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L (2.5 mmol/L), serum sodium level 140 mEq/L 140 mmol/L), and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, the client's total urine output has been 50 ml. Which physician order should the nurse question?

Change the second I.V. solution to dextrose 5% in water; The nurse should question the physician's order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. site until the client's blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and their specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias.

An Asian-American client with hyperglycemia is admitted to the healthcare facility. After the client is stable, the nurse discovers that the client has not had the prescribed medicines. The client believes that eating saffron will keep blood glucose level under control. The nurse determines that saffron is not known to influence blood glucose levels. What is the most appropriate response by the nurse?

"Why don't you take the medicines, too, and benefit from both?" Although the nurse may disagree with the client's beliefs concerning the cause of health or illness, respect for these beliefs helps the client to achieve healthcare goals. Asking the client to consider the benefits of medicine is appropriate, because the nurse, without disrespecting the client's beliefs, persuades the client to have medicines also. The nurse saying that saffron does not have any effect on blood glucose level is inappropriate because it disregards the client's beliefs. The nurse's agreeing with the client may provide encouragement and indicate low faith in the present treatment. It is inappropriate to call the doctor and complain about the client.

When caring for an oncology client receiving cisplatin and experiencing nausea and mouth sores, which nursing interventions are best to improve the client's diet? Select all that apply.

1. Schedule high-nutrient shakes between meals. 2. Offer small, frequent, light meals 5-6 times daily. 3. Administer oral anesthetic 15 minutes prior to meals. 4. Offer cool drinks and foods as tolerated; Optimal nutrition includes a balance of protein, carbohydrate, and only a small amount of fat. A client on cisplantin commonly has additional side effects of nausea and oral sores. Changes in the plan of care include high-nutrient shakes to compensate for low oral intake. Eating smaller, light meals commonly cooler in temperature as opposed to hot meals are better tolerated. Offering an oral anesthetic prior to meals decreases discomfort in the eating process. Large meals that are spicy and high in fat are discouraged.

A charge nurse is making client care assignments for the day. Which client would be most appropriate to assign a licensed practical nurse (LPN)?

6-year-old child 2-day post-op appendectomy with a surgical drain; The 6-year-old child who is post-appendectomy would be the most stable child to assign to the LVN/LPN. The skill set of an LVN/LPN includes care of surgical drains. A 6-month-old infant with pneumonia requiring oxygen might be the next choice, depending on the infant's vital signs. Being that the child is very young, the condition could change rapidly. This infant will require frequent respiratory assessments. The infant with a respiratory rate of 60 is not stable and is in respiratory distress. The child with nephrotic syndrome and 4+ protein is very ill and needs many nursing interventions and assessments best done by the registered nurse.

An adolescent is brought to the emergency department (ED) after accidentally taking an overdose of heroin. The adolescent is semiconscious, unable to respond appropriately to questions, slurs words, and has constricted pupils; the client's vital signs are blood pressure 60/50 mm Hg, pulse 50 beats/min, and respirations 8 breaths/min. Naloxone is administered to temporarily reverse the effects of the heroin. Which finding would first indicate that the naloxone administration has been effective?

The client's respirations improve to 12/min; Decreased respirations and coma are the two most dangerous effects of heroin overdose, so an increase in respirations after administration of the naloxone demonstrates initial effectiveness of the medication. Changes in cognition and psychomotor activity will take more time to become apparent. The client's blood opioid level may not drop to a nontoxic level for a few days.

Parents bring a child to the clinic who has not been eating or drinking well for the last few days. What action should the nurse take first to assess the child's overall hydration status?

Weigh the child; When implementing nursing care, the nurse should complete any noninvasive procedures before invasive ones. Therfore, the first step the nurse should take is to weigh the child. A decrease in body weight gives the most accurate information about the infant's hydration status. Monitoring vital signs would be the next step in the assessment process. The blood pressure reading would yield information about hypotension. A urinalysis would provide information about urine osmolality and specific gravity of the urine, which indicates dehydration. Obtaining electrolytes would provide information about electrolyte disturbances, not strictly about hydration.

An 8-year-old has a body mass index (BMI) for age at the 90th percentile but has no other risk factors. What should the nurse do?

Refer the family to a dietician; Children aged 2 to 20 years with a BMI-for-age at the 90th percentile are considered overweight. If no other risk factors are present, the family should receive dietary counseling to slow the child's weight gain until an appropriate height for weight is attained. Without intervention, the child may become obese. An HCP who specializes in pediatric weight loss should be considered when the child is obese and has complicating factors. Commercial diet programs alone do not include the necessary monitoring for children, thus are rarely appropriate.