PN Learning System Comprehensive Final Quiz

A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include? "Sit with your back supported." "Keep your knees at hip level." "Use an ergonomically designed computer keyboard." "Keep your elbows away from your body." "Adjust the monitor screen so that you have to tilt your head slightly to look at it."

Sit with your back supported, keep your knees at hip level, and use an ergonomically designed computer keyboard *Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain.

A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage the clients behavior? Confront the client for breaking the rules. Stand close to the client to offer comfort and support. Speak to the client with clear, calm, caring statements. Escort the client to the nurses' station.

Speak to the client with clear calm caring statements *To remain in control of the situation, the nurse should use clear, calm statements that are nonthreatening to the client. The nurse should also set limits for clients who exhibit potentially violent behavior.

A nurse is collecting data from a school age child who has celiac disease. Which of the following findings should the nurse expect? Elevated sweat chloride Steatorrhea Clubbing of the fingers Jaundice

Steatorrhea Foul, fatty, frothy stools, known as steatorrhea, are a manifestation of celiac disease, a malabsorption syndrome.

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A small, plastic doll with clothes and accessories Alphabet flash cards A handheld video game A 10-piece wooden puzzle

A 10 piece wooden puzzle *Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys allow for manipulation and exploration and meet the child's developmental and diversional activity needs.

A nurse on the pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A client who has bacterial pneumonia and a WBC count of 15,800/mm3 A client who has chronic kidney disease and a calcium level of 8.7 mg/dL A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL A client who has leukemia and a hematocrit of 32%

A Client in DKA and a blood glucose of 375 *The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage.

A nurse is reinforcing teaching with a client who is scheduled for LASIK surgery which of the following information should the nurse include? "Your procedure will only take 10 or 15 minutes for each eye." "You may drive home after the procedure." "This procedure is prescribed to treat farsightedness." "You will need to remain in the hospital overnight following the procedure."

Your procedure will only take 10 to 15 minutes per eye *LASIK is a type of refractive laser eye surgery performed to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. The procedure typically takes 10 to 15 min per eye.

A nurse is reinforcing teaching with the client who has come to the family planning clinic requesting an IUD. Which of the following information should the nurse reinforced with the client? "If you lose weight, you will need a refitting for your IUD." "An IUD provides protection from certain sexually transmitted infections." "Your risk for ectopic pregnancy increases with an IUD." "You shouldn't use an IUD if you want to have children later on."

Your risk for ectopic pregnancy increases with an IUD *An IUD is a family planning device the provider inserts through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in the uterus more difficult. Consequently, an IUD increases the risk for ectopic pregnancy.

A nurse in an urgent care center is collecting data from a group of clients who all have in odor Of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse report first to the charge nurse? A client who is difficult to arouse and is unable to respond to questions A client who has slurred speech and exhibits anger A client who reports nausea and vomiting A client who is uncooperative and uncoordinated

A client who is difficult to arouse and is unable to respond to questions *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore; the nurse should identify the client who is difficult to arouse and is unable to respond to questions as the priority to report to the charge nurse. These findings might indicate a decreased level of consciousness due to an alcohol intoxication level of 401-800 mg percent or traumatic brain injury. The greatest risk to this client is neurological sequelae of the head trauma or death due to severe alcohol intoxication.

A nurse in a long-term care facility is caring for a group of clients. One of the clients as walking in the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? Offer the client a nutritious snack. Accompany the client back to his room. Reorient the client to his surroundings. Administer a PRN antianxiety medication.

A companyto his room *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect the client from injury due to wandering.

A community health nurse is contributing to the plan of care for for high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for first? A 1-week-old newborn who needs another phenylketonuria screening test A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy A 10-day-old newborn who is small for gestational age and who requires daily weighing A 2-week-old newborn who was born at 35 weeks of gestation and weighed 2,268 g (5 lb) at discharge

A four day old newborn who has elevated Bilirubin level and requires photo therapy *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to the client's safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome. Phenylketonuria is an inborn error of phenylalanine metabolism. Without treatment with a phenylalanine-free diet, newborns who have this disorder can develop severe, irreversible developmental delays. Blood collection for this test prior to 24 hr after delivery can result in inconclusive results and the need for another specimen collection after at least 2 days of breast or formula feeding. The nurse should collect this specimen promptly; however, there is another client that is the priority.

A nurse On the pediatric unit is assisting with the plan of care for a preschooler who will have a surgical procedure in the morning. The child has been crying despite his parents presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan because it offers which of the following benefits? Decreases the child's fear of the dark Allows the child to manipulate toy medical equipment Provides an opportunity to analyze the child's emotions Encourages parents to engage with their child

Allows the child to manipulate toy medical equipment A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express his fear of the unfamiliar medical equipment in the hospital. The nurse encourages the child to touch the equipment to decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.

A nurse delegates newly Licensed nurse to provide one on one observation for a client who requires suicide precautions. Which of the following actions by the newly licensed nurse indicates the need for further reinforcement of teaching? Accompanies the client to physical and occupational therapy. Ambulates the client's roommate while the client sleeps. Asks the nurse at lunch time to assign another newly licensed nurse to perform this task. Remains with the client while family members are visiting.

Ambulates the client's roommate while the client sleeps *One-on-one observation requires constant supervision of the client. The client might wake up and engage in self-injurious behavior while the newly licensed nurse is caring for the other client.

A nurse in an urgent care center is reviewing laboratory results for several clients who have benefit stations of influenza. Which of the following clients should the nurse report to the provider in mediately? A school-age child whose urine specific gravity is 1.035 A toddler whose BUN is 25 mg/dL and whose creatinine is 0.5 mg/dL An infant whose WBC count is 24,000/mm3 An adolescent whose beta human chorionic gonadotropin is positive

An infant who is wbc count is 24,000 *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. This WBC count is high and indicates infection and possibly sepsis, which poses the greatest risk to the client. The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy.

A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose A raised, circumscribed lesion on the face that contains yellow-white purulent material An irregularly shaped brown lesion with light blue areas on the neck

And irregularly shaped brown lesion with light blue areas on the neck *Malignant melanoma, the leading cause of death from skin cancer, is a neoplasm of dermal or epidermal cells. Exposure to sunlight increases the risk, with fair-skinned people at the greatest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck, and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion, with irregular borders in hues of tan, black, or blue.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? Administer aspirin. Tilt the child's head back and apply pressure. Instruct the child to lie down and rest. Apply continuous pressure to the lower part of the child's nose.

Apply continuous pressure to the lower part of the child's nose *With the child sitting up and breathing through his mouth, the nurse should apply continuous pressure with her thumb and forefinger to the soft lower area of the nose for 10 min. Most bleeding from the nose stops within that period.

A nurse in an acute care clinic is talking with the client reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss nonpharmacological approaches that will relieve her pain. Which of the following interventions should the nurse suggest? Applying warm compresses to sore joints Decrease the daily intake of dietary protein. Keeping joints in extension during rest periods Limit sleep to 6 to 7 hr per night.

Apply warm compresses to sore joints *Warm packs or warm soaks, such as in a bath or hot tub, are often effective for relieving arthritic pain. The nurse should encourage the client to avoid temperatures hot enough to cause burns. She should plan for a temperature just a little warmer than body temperature for optimal comfort.

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding? Bruising of both knees with sutures on one Arm cast for a spiral fracture of the forearm Consistent bedwetting at nap time Frequent, vague reports of a stomach ache or a headache

Arm cast for a spiral fracture of the forearm *Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury.

A nurse is assisting with developing a plan of care for a client who has GERD. The nurses should suggest monitoring the client for which of the following complications? Aspiration Infection Anemia Weight loss

Aspiration *Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled regurgitation, whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which is an indication of aspiration.

A nurse is observing a client who has schizophrenia and is in the day room when another client asks him if two items of clothing match. He replies a match. I like matches. They are the givers of light, the light of the world. God will light the world. Let your light shine on. The nurse should identify these statements as which of the following speech alterations? Clang association Echolalia Word salad Associative looseness

Associative looseness *The nurse should identify that this client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts that lead from one to another.

A nurse is assisting with the admission of a client who has a urinary tract infection and a history of Myelomeningocele. After the admission history is complete, which of the following actions should the nurse recommend? Attach a latex allergy alert identification band. Initiate contact precautions. Post signs in the client's bathroom to strain the client's urine. Administer folic acid with meals.

Attach a latex allergy alert identification band *Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.

A nurse is reinforcing discharge teaching with a client who had a TIA. The nurse should instruct the client to monitor which of the following parameters at home? Blood glucose Blood pressure Daily weight Sensation in the feet

Blood pressure *A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should track his BP regularly to promote hypertension management and reduce the risk of cerebrovascular accident.

A nurse in a prenatal clinic is collecting data from several clients. which of the following client reports should the nurse identify as an expected physiologic adaptation to pregnancy? Spotting with urination Breast tenderness Thick, white vaginal discharge Facial swelling

Breast tenderness *Breast tenderness is common during the first and third trimesters of pregnancy. The nurse should explain to the client that this is expected and that she should wear a well-fitting, supportive bra to help alleviate the tenderness.

A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client? Tell the client that the nurse will talk to him at his request. Allow the client to skip group activities if he chooses. Leave the client alone for frequent rest periods throughout the day. Build trust with the client by sitting quietly with him.

Build trust with the client by sitting quietly with him *The nurse should build trust with the client to convey interest in the client's concerns. Offering self by sitting with the client and the use of silence are actions that promote trust which encourages the client to speak more openly about issues and concerns.

A nurse is beginning her shift and reviewing the medication administration records for her clients. She notes a dosage of medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? Call the nurse to verify that he gave the client that dosage. Give the medication in a safe dosage. Give the dose the provider prescribed. Call the provider to clarify the dosage.

Call the provider to clarify the dosage *After collecting data from the client to check for adverse effects of the medication, the nurse should notify the provider of her observations to determine the next action.

A nurse response to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following data should the nurse collect first? Measure the client's vital signs. Perform a neurological examination. Check airway patency. Check the client for injuries.

Check airway patency *The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is, therefore, the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The priority data the nurse should collect is to check the client's airway patency. The nurse should establish and maintain the client's airway to prevent respiratory arrest and hypoxia.

A nurse is reinforcing teaching with a client who has hypothyroidism and is taking levothyroxine. the nurse should instruct the client to report which of the following manifestations to the provider? Weight gain Constipation Chest pain Fatigue

Chest pain *Chest pain can result if a client takes too much levothyroxine. It is important to increase the dosage gradually to prevent rapid changes in cardiac output that can cause tachycardia and angina, especially for clients who have longstanding hypothyroidism or cardiovascular disorders.

A nurse is reinforcing teaching with an assistive personnel about dietary restrictions for a client who is taking phenelzine to treat depression. The APs selection of which of the following foods for the clients lunch indicates an understanding of the instructions? Bologna on wheat bread Chicken salad Cheddar cheese and crackers Pizza with pepperoni

Chicken salad *Phenelzine is an MAOI. Clients taking MAOIs must avoid foods that contain tyramine due to a dangerous food-drug interaction. Foods high in tyramine include those that are processed and aged, such as luncheon meats and cheeses. This menu selection does not contain food high in tyramine; therefore, it is the best choice.

A nurse is caring for a client during Her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on the list of calcium sources for this client? Collard greens Cottage cheese Orange juice Broccoli

Collard greens Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. They also contain folic acid, which is a nutrient women should consume during pregnancy to prevent birth defects.

The healthcare facilities leadership team is implementing a new computerized charting system. Before the implementation date, which of the following actions should the charge nurse take first? Discuss with the team leaders their responsibility in implementing the change. Post a sign-up sheet for in-service training sessions about the new system. Ask informal leaders to participate in the early implementation process. Collect the staff's input about planning and implementing the change.

Collect the staff input about planning and implementing the change *The charge nurses should apply the nursing process priority-setting framework. The nurses can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, he must first collect adequate data. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the charge nurses should collect data about the situation by gathering the staff's input, and collaborate about implementing the change smoothly and efficiently.

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record to the clients bedside and perform which of the following verification procedures? Check the client's name and medical record number on the MAR against the room and bed number. Call the client by name and check the name on her identification band against the MAR. Compare the medical record number and name on the MAR with the client's identification band. Ask the client's visitor to identify the client by name and to state the client's birth date.

Compare the medical record number and name on the medication administration record with the clients identification band *The Joint Commission requires the use of two client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band.

A nurse is caring for a client who has a new diagnosis of acute systemic lupus erythematosus And is to begin medication therapy. Which of the following types of medications should the nurse expect to administer? Corticosteroids Antihistamines Antivirals Opioids

Corticosteroids Corticosteroids, such as prednisone, are the treatment of choice for acute systemic manifestations of SLE because of their rapid anti-inflammatory action.

A nurse is assisting with the admission of a client to the medical unit and ask him if he has advanced directives. The client states I have a document with me the name of someone who can make healthcare decisions for me I am not able to. Should identify that the client is referring to which of the following documents? Informed consent form Living will document Do-not-resuscitate directive Durable power of attorney document

DPA *A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so.

A nurse is collecting data from a client who has aids and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider? Nausea and vomiting Decreased hemoglobin Decreased appetite Anxiety

Decreased hemoglobin *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the priority finding for the nurse to report to the provider is a decreased hemoglobin level. Zidovudine can cause severe anemia and neutropenia from bone marrow suppression resulting in hematologic toxicity.

A nurse is reinforcing teaching for a client who has coronary artery disease about the difference between angina pectoris and myocardial infarction. Which of the following manifestations should the nurse identify as indications Of a myocardial infarction? Nausea and vomiting Diaphoresis and dizziness Chest and left arm pain that subsides with rest Anxiety and feelings of doom Bounding pulse and bradypnea

Diaphoresis, dizziness, anxiety, impending doom, nausea, and vomiting *Nausea and vomiting is correct. Nausea, vomiting, and epigastric distress are common manifestations of MI. Diaphoresis and dizziness is correct. Diaphoresis (sweating), dizziness, fatigue, and anxiety are common manifestations of MI. Chest and left arm pain that subsides with rest is incorrect. Chest and left arm pain that subsides with rest is a manifestation of angina, not MI. Anxiety and feelings of doom is correct. Anxiety and feelings of doom and fear are common manifestations of MI. A diminished or absent pulse and bradypnea is incorrect. A diminished or absent pulse is a manifestation of an MI due to decreased cardiac output. Tachypnea is an indication of an MI due to anxiety and pain.

A nurse is reinforcing teaching with the parents of an infant who has a cleft palette. The parents asked the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6 to 12 months to prevent which of the following outcomes? Repeated ear infections Nutritional deficits Immune system deficits Difficulty with language acquisition

Difficulty with language acquisition *Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With the cleft in the palate, these infants could develop poor speech habits.

A nurse is caring for a client who has MRSA infection. A dietary assistant asks the nurse what precautions are necessary for entering the clients room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant? Don a gown before entering the room and remove it before exiting. Wear a mask while in the client's room. Don gloves when entering the room and use hand sanitizer when exiting. Take no special precautions unless you have direct contact with the client.

Don gloves when entering the room and use hand sanitizer when exiting *Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require that any staff who will have contact with the client's environment don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client, and a mask and goggles if secretions from the infected area could spray into the worker's face. Delivering the tray would require contact with the environment; therefore, the dietary assistant must wear gloves.

A nurse is contributing to the plan of care for a client who had a stroke and is to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend to take prior to initiating each feeding? Warm the feeding in a microwave oven. Elevate the head of the bed. Flush the tube with 0.9% sodium chloride for irrigation. Verify that the gastric pH is above 4.

Elevate the head of the bed *Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should take actions to prevent aspiration, such as elevating the head of the bed, prior to initiating the feeding.

A nurse is collecting data from a client who is taking varenicline for smoking cessation . Which of the following findings is nurses priority? Erratic behavior Nausea Altered sense of taste Skin rash

Erratic Behavior *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk to the client is the development of neuropsychiatric effects that can progress to depression and suicide. Therefore, the highest priority finding is erratic behavior.

A nurse is discussing the fire safety with newly hired nurses. Which of the following identify as the priority if a fire occurs in the health care facility? Close the fire doors on the unit. Use a fire extinguisher on the fire. Pull the nearest fire alarm. Evacuate clients from the unit.

Evacuate clients from the unit *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk during a fire is injury to clients; therefore, the nurse's priority action is to evacuate clients from the unit. The nurse should follow the RACE protocol when responding to a fire - Rescue, Activate, Confine, and Extinguish.

A nurse is talking with a group of clients at a senior center about the risk factors for osteoporosis. Which of the following statements should the nurse include? "Extended periods of immobility increase your risk for osteoporosis." "Prolonged periods of sun exposure increase your risk for osteoporosis." "Eating a diet high in protein can reduce your risk for osteoporosis." "Corticosteroid therapy will reduce your risk for osteoporosis."

Extended periods of immobility increase your risk for osteoporosis *Osteoporosis is a disorder of weakened bones due to a loss of bone mass and a change in bone structure. Immobility can result in osteoporosis; therefore, weight-bearing exercise, such as walking, is one way for the client to help prevent osteoporosis.

A nurse participating in the community health fair is providing information to a client who has a blood pressure of 150/90 during a blood pressure screening. Which of the following actions should the nurse take? Give the client a written record of his BP to bring to his provider. Encourage the client to go to the nearest emergency department. Instruct the client to follow up with a provider within 6 months. Explain to the client that he is not at risk unless he has manifestations of hypertension.

Give the client a written record of his blood pressure to bring to his provider *When a client has an elevated reading at a hypertension screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider.

A nurse is caring for a client who has dehydration. Which of the following laboratory values should the nurse expect for this client? BUN 18 mg/dL Capillary refill 1.5 seconds Hct 55% Urine specific gravity 1.001

Hematocrit 55% *An elevated hematocrit indicates dehydration. Other manifestations of dehydration are a weak pulse, tachycardia, hypotension, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.

A nurse is reinforcing teaching with a client about how to use an albuterol MDI. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?

Hold the mouthpiece 1 to 2 inches in front of your mouth, tilt your head back slightly and open your mouth wide, depress the canister while taking a slow deep breath, and hold your breath for 10 seconds

A nurse is reviewing the laboratory report for a client who has CDK. The nurse finds the following laboratory test results: potassium 6.8, calcium 7.4, hemoglobin 10.2, and phosphate 4.8. Which of the following findings is the priority for the nurse to report to the provider? Hypocalcemia Hyperkalemia Anemia Hyperphosphatemia

Hyperkalemia *The nurse should apply the urgent versus nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority need because they pose more of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. Therefore, hyperkalemia which can cause life-threatening cardiac dysrhythmias is the priority for the nurse to report to the provider.

A nurse in the providers office is talking with an older adult client reports having trouble sleeping. Which of the following statements should the nurse identify as a possible causes for the patients sleeping difficulties? "I take a warm shower when getting ready to go to bed." "I often have a cup of coffee with my dessert before going to bed." "I usually read a chapter in a book before I go to bed." "I make sure I do my exercises in the morning."

I often have a cup of coffee with my dessert before going to bed *The client should avoid beverages that contain caffeine in the late afternoon and evening because caffeine stimulates the CNS and can result in sleep disturbances. Caffeine is also a diuretic and can cause nighttime awakenings for urination.

A female client who has we currency Cystitis asked the nurse about preventing future episodes. Which of the following statements should the nurse provide for the reinforcement of teaching? "I drink at least 2 liters of fluid per day." "I prefer tub baths to showering." "I urinate after sexual relations." "I wipe from front to back after urinating."

I prefer tub baths to showering *Cystitis is an inflammation of the bladder lining that commonly occurs with a urinary tract infection (UTI). Women who are at risk for UTIs should avoid tub baths because they increase the risk for infection. The nurse should remind the client to take showers instead of tub baths.

A nurse is reinforcing teaching with a client who has a spinal cord injury and will need to perform intermittent urinary self catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? "I'll drink less water so I don't have to catheterize myself too often." "I must use sterile technique to do each of the catheterizations." "I should stop the catheterization when I have removed 150 mL of urine." "I will perform intermittent self-catheterization every 2 to 3 hours."

I will perform intermittent self catheterization every 2 to 3 hours *The client may initially require self-catheterization every 2 to 3 hr with the frequency eventually increasing to every 4 to 6 hr. A longer interval can result in bladder distention and increased risk for urinary tract infection.

A nurse is reinforcing teaching with the parent of a child who has type one diabetes how to manage the child's disorder during illness, such as cold. Which of the following statements by the parent indicates an understanding of the teaching? "I'll reduce my child's food intake." "I'll check his blood glucose more often." "I'll limit his fluid intake between meals." "I won't administer his long-acting insulin dose."

I'll check his blood glucose more often *The parent should check the child's blood glucose every 3 hr during an illness because it tends to rise, even if the child eats less food. Children often report lack of appetite even with a minor respiratory ailment. Unless the child is nauseated or actively vomiting, the parent should encourage the usual food intake. Substituting foods the child can digest easily can help prevent dehydration and promote recovery. The parent should encourage increased fluid intake to promote excretion of ketones and prevent dehydration Unless the provider prescribes a change, the parent should adhere to child's usual regimen of long-acting insulin with adjustments in short-acting insulin according to blood glucose levels.

A nurse is caring for a client who is taking warfarin. Which of the following laboratory values should the nurse recognize as an effective response to the medication? Hct 45% Hgb 15 g/dL aPTT 35 seconds INR 3.0

INR 3.0 *Warfarin is an anticoagulant that prevents thrombus formation in susceptible clients. The INR measures its effectiveness. For most clients taking warfarin, an INR of 3.0 indicates effective therapy.

A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further instruction is required? "I should not leave all four side rails up unless there is a prescription for restraints." "An alert client will be safest if I raise the two upper side rails at the head of the bed." "If the client seems confused, I'll raise all four side rails so that he doesn't hurt himself." "If a client is sedated I should raise all four side rails to prevent a fall out of bed."

If the patient seems confused, I will raise all four side rails so that he doesn't hurt himself *Raising all four side rails can put the client at greater risk for injury. He might try to climb over the side rails, which could result in a fall or injury.

During a client care staff meeting, A charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing client information? In the unit medication room. Outside the door of a client's room In the cafeteria during break In the hallway near the nurses' station

In the unit medication room *Nurses should only discuss clients' information in areas where no one else can overhear the discussion. A unit medication room is a nonpublic area where nurses can privately discuss client information that pertains to the client's care.

A nurse is reinforcing teaching with a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include? Reduce her total hours of sleep. Keep her immediate environment warm. Increase her caloric intake with meals. Gradually increase her activity.

Increase her caloric intake with meals Clients whose thyroid hormone levels are high have increased protein, lipid, and carbohydrate metabolism, resulting in the loss of protein stores and a negative nitrogen balance. Even with an increased appetite, it is often difficult to meet energy demands, and weight loss is common. Muscle weakness and wasting can develop without adequate caloric and protein intake.

A nurse is assisting with the admission of a client who has manifestations that suggest tuberculosis. Which of the following actions is the nurses priority? Initiate airborne precautions. Administer antimicrobial therapy. Tell the client that his infection will be communicable for 2 to 3 weeks from the start of medication therapy. Reinforce teaching about the manifestations of tuberculosis.

Initiate airborne precautions *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client, and in this case, to other clients and staff. When there are several risks to safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat. Clients who have or might have tuberculosis require airborne isolation precautions immediately because of the highly communicable nature of the infection. Airborne precautions prevent transmission of pathogens that remain infectious in the air, including Mycobacterium tuberculosis, the bacterium that causes tuberculosis.

The charge nurse is coordinating the evacuation of clients from the facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? Call in the clients' family members to provide additional help with moving the clients. Ask clients who are able to ambulate to assist in moving the unstable clients. Instruct clients who are able to ambulate to leave. Direct staff members to close the doors and windows as each room is evacuated.

Instruct clients who are able to ambulate to leave *Clients who are able to ambulate should leave first in an evacuation process because it quickly reduces the number of clients who require evacuation assistance.

A nurse is caring for a client who takes more friend to treat chronic a fib and has early manifestations of Alzheimer's disease. The clients partner asked the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make? "It is likely that ginkgo biloba will interfere with the effectiveness of his other medications." "You should ask his provider if ginkgo biloba is safe." "Ginkgo biloba is most effective in the later stages of Alzheimer's disease." "People who have Alzheimer's disease should adhere to the medication regimen their provider prescribes."

It is likely that ginkgo biloba will interfere with the effectiveness of his other medications *Some experts believe that ginkgo biloba can delay the mental deterioration of Alzheimer's disease if the client takes it in the early stages. Research, however, has not demonstrated this, and more importantly, ginkgo biloba increases the client's risk for bleeding when taken with warfarin.

A nurse in an urgent care center is collecting data from an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report to the provider as an indication of impending airway obstruction? Bradycardia Respiratory depression Nasal flaring Barking cough

Nasal flaring *Acute laryngotracheobronchitis, or croup, causes dyspnea and swelling of the upper airway. Indications of impending airway instruction include tachycardia, tachypnea, increasing restlessness, flaring nares, and intercostal retractions.

A nurse is reinforcing teaching with the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the instructions? "Donepezil might slow the progression of the disorder." "My child will prefer group therapy with other children." "It will help our child if we structure our daily routine." "Our child probably has this as a result of prematurity."

It will help our child if we structure our daily routine *Children who have autism spectrum disorder benefit from a structured routine. A structured environment can help minimize the anxiety the child might have with sudden schedule changes and socialization requirements, as well as satisfy his preference for ritualistic behavior.

A nurse at a long-term care facility hears an AP talking with an older adult client who has dementia with periods of confusion. Which of the following statements indicates that the AP requires further instructions? "We will be serving breakfast in 10 minutes. I will stay here while you get ready." "It's Monday morning. I know that your favorite television shows are on this evening." "I see that you have a new photo on the wall. Can you tell me who that girl is?" "It's almost time for your appointment.. Let me do your hair for you and brush your teeth."

It's almost time for your appointment. Let me do your hair for you and brush your teeth *When a client who has dementia has periods of confusion, the AP should allow the client additional time to complete activities that she is able to perform independently. Insisting on completing the task for her, or attempting to hurry her, can provoke agitation. The AP should encourage independence and provide assistance only if the client asks for or needs it.

A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? Lateral Lithotomy Trendelenburg Prone

Lateral *A lateral, or side-lying position, promotes uteroplacental blood flow and thus helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness.

A provider tells a client who reports practicing Hinduism that at 12 weeks gestation she needs more protein in her diet and suggest eating more meat. After the provider leaves examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? "Let's discuss other foods that are also high in protein that you could substitute for meat." "Eating meat during pregnancy provides necessary protein and does not cause miscarriage." "Why do you think that eating animal products will cause you to have a miscarriage?" "Your doctor is recommending what is best for you and your baby."

Let's discuss other foods that are also high in protein that you could substitute for meat *Many cultures have beliefs about food that the nurse should respect. Discussing nonanimal protein sources can help the client identify those that do not conflict with her religious and cultural beliefs.

A nurse is collecting data from a client who has tuberculosis and a prescription for EthAmbutol. The nurse should inform the client that he is likely to develop which of the following alterations as an adverse effect of this medication? Mottling of the extremities Orange-red urine and bodily secretions Yellowing of the sclera Loss of red/green color discrimination

Loss of red\green color discrimination *Ethambutol is an antitubercular medication that impairs ribonucleic acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect a prescription to discontinue the medication.

A nurse is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following recommendations should the nurse make? Turn off ventilator alarms when performing endotracheal suctioning. Maintain the head of the bed at 30 degrees. Provide oral care at a minimum of every 12 hr. Initiate enteral feeding with a low-calorie formula.

Maintain the head of the bed at 30° *The nurse should recommend that the client's head of the bed remain elevated at 30 to 45 degrees to decrease the risk for ventilator-acquired pneumonia.

A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurses priority to collect? Measure the client's weight daily. Observe tears. Palpate the fontanel. Check skin turgor.

Measure the clients weight daily *The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent findings the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical for infants and children because fluid accounts for a greater portion of body weight.

A nurse is caring for a client who has chronic phantom limb pain following and above the knee amputation. Which of the following medication prescriptions should the nurse verify with the provider? Meperidine Amitriptyline Gabapentin Propranolol

Meperidine *Opioids are more effective for residual limb pain rather than phantom limb pain; additionally, meperidine is not recommended for chronic pain because using it long-term can cause accumulation of a toxic metabolite.

A nurse is talking with the parent of a four month old infant about growth and development. Which of the following statements indicates that the parent needs further instruction? "I need to remind my older kids to keep small objects out of the baby's reach." "I let my baby play on his stomach when she is awake and I am watching." "My baby loves to play with the pillows in her crib." "I put my baby in a rear-facing car seat in the back seat of the car."

My baby loves to play with pillows in her crib *Parents should never place pillows in their infant's crib. They pose a suffocation hazard.

A nurse is assisting with the plan of care for a client who is post operative following a hip arthroplasty. In the clients medical record, the nurse notes a history of COPD. Which of the following oxygen delivery method should the nurse recommend to use this client? A simple face mask A nonrebreather mask A bag-valve-mask device A nasal cannula

Nasal cannula *A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.

A nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The clients neighbor, who speaks to the clients native language and the nurses, arrives to drive the client home. Which of the following actions should the nurse take? Ask the client's neighbor to call a family member to interpret. Ask the client's neighbor to translate the information. Obtain the services of an interpreter. Document the inability to provide discharge instructions.

Obtain the services of an interpreter *Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language.

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize her femur fracture. Which of the following actions should the nurse recommend for the clients plan of care? Offering the client a diet high in fluid and fiber Encouraging active range of motion of the affected leg Removing the weights prior to repositioning the client Assisting the client to a lateral position every 4 hr.

Offer the client a diet high in fluid and fiber *A client who is immobile is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function.

A nurse is reinforcing teaching with the parent of a client who has severe reactive airway disease about Glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it Orally. Which of the following information should the nurse provide to the parent? Inhaled glucocorticoids are less likely to cause thrush. Oral glucocorticoids are hazardous during times of stress. Oral glucocorticoids are more likely to slow linear growth in children. Inhaled glucocorticoids are more effective for acute bronchospasm.

Oral glucocorticoids are more likely to slow linear growth in children *Chronic use of oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (the client's airways), resulting in a decreased risk for adrenal suppression.

I nurse is assisting with the care of a client who had a precipitous delivery. The nurse should identify the collection which of the following data as a priority during the fourth stage of labor? Obtaining the client's temperature. Inspecting the client's perineum. Palpating the client's fundus. Checking the client for hemorrhoids.

Palpating the clients fundus *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery is one that follows labor of less than 3 hr. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage.

A nurse is caring for a client who has a pseudomembranous colitis do to CDIff. Which of the following interventions is the nurses priority? Performing hand hygiene before and after contact with the client Reducing the client's anxiety due to isolation procedures. Assisting the client in making nutritional choices Monitoring the client's intake and output

Performing hand hygiene before and after contact with the client *The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores spread easily by contact with body fluids and inanimate objects. The greatest risk to this client, as well as to the nurse and others, is injury from infection transmission; therefore, the priority intervention is hand hygiene.

A nurse is reinforcing teaching with a client who has a new prescription for a Doxycycline. The nurse should reinforce to the client the need to monitor for which of the following adverse effects of this medication? Photosensitivity Constipation Ototoxicity Blurry vision

Photosensitivity *An adverse effect of doxycycline, a tetracycline antibiotic, is photosensitivity. The skin reacts abnormally to light, especially ultraviolet radiation or sunlight. Prevention involves avoiding direct exposure to sunlight and ultraviolet light, wearing protective clothing outdoors, and using sunscreen.

A nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the clients level of orientation? Encourage the client to make choices about meals and activities. Use written signs to label specific rooms. Post a large calendar on the bulletin board. Place a wander alert electronic alarm bracelet on the client's wrist.

Post a large calendar on the bulletin board *Posting a large calendar in a central location will assist this client with orientation.

A nurse is assigned to care for several clients who are post operative. The nurse should identify the client taking which of the following medications is at risk for delayed wound healing? Nifedipine to treat hypertension Prednisone to treat persistent arthritis exacerbations Albuterol to treat asthma Chlorpromazine to treat schizophrenia

Prednisone to treat persistent arthritis exacerbations *Prednisone is a corticosteroid that is associated with delayed wound healing. Clients who have arthritis often require high doses of prednisone to help resolve exacerbations. Nifedipine does not affect wound healing; however, it can cause dermatitis and urticaria Albuterol does not affect wound healing and does not cause integumentary effects. Chlorpromazine does not affect wound healing; however, it can cause dermatitis and eczema.

A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication? Pain scale score of 5 out of 10 Urine output of 65 mL/hr 10 mL of bright red drainage from the drain Pulse oximetry of 85%

Pulse ox of 85% *Clients who have had abdominal surgery should have an oxygen saturation above 95%. A client whose oxygen saturation is 85% has hypoxemia and requires immediate intervention.

A nurse is reinforcing teaching with the Parent of a child who has a new prescription of lamotrigine For a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider? Diplopia Dizziness Rash Headache

Rash The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the greatest risk to this client is injury from Stevens-Johnson syndrome or toxic epidermal necrolysis, which are life-threatening reactions that manifest initially as a rash in the first 2 to 8 weeks of treatment with lamotrigine. The nurse should instruct the parents to report a rash immediately to the provider.

A nurse is reinforcing discharge teaching with a client who has had a transient ischemic attack. Which of the following instructions should the nurse include? Reduce dietary sodium. Decrease dietary potassium. Restrict intake of soluble fiber. Limit alcohol intake to three or fewer servings per day.

Reduce dietary sodium A temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurologic function. The most common causes are atherosclerotic plaque in the carotid arteries and hypertension; therefore, the client should limit sodium intake to help control hypertension and prevent future TIAs.

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following findings should indicate to the nurse that the AAA is expanding? Increased BP and decreased pulse rate Jugular-vein distention and peripheral edema Report of sudden, severe back pain Report of retrosternal chest pain radiating to the left arm

Report of sudden severe back pain *An aortic aneurysm is a weak spot in the wall of the aorta that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.

A newly licensed nurse in an urgent care center is caring for a client who has bruises that the nurse suspects are due to child abuse. Which of the following actions should the nurse take? Ask the child if his parents are responsible for the abuse. Notify the facility's risk manager. Interview the child with his parents present. Report the suspected abuse to local authorities.

Report the suspected abuse to local authorities *The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement.

A nurse is collecting data from a client who has an acute visual disturbance and describes it as a curtain pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? Cataracts Angle-closure glaucoma Retinal detachment Macular degeneration

Retinal detachment *The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. Retinal detachment is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.

A nurse is reinforcing teaching about self a ministration of NPH insulin with a client who has type two diabetes. Which of the following instructions should the nurse include? Alternate injecting into the abdomen and the thigh. Shake the vial before withdrawing the dosage. Rotate injection sites within the same area. Discard the vial if the insulin is cloudy.

Rotate injection sites within the same area *To prevent lipodystrophy, the client should rotate injection sites, making them about 2.5 cm (1 in) apart, within the same anatomical area.

A charge nurse in a long-term care facility notes that several staff members are linked in completing an annual mandatory educational session about extremity restraint safely. Which of the following actions should the nurse plan take? Make a general announcement at the next staff meeting asking all employees to check their adherence to the requirement. Post a list in the employees' break room naming those who are nonadherent and the date by which they must complete the requirement. Place a written warning in each nonadherent employee's personnel file. Send an e-mail to each nonadherent employee that includes a link to upcoming educational sessions.

Send an email to each nonadherent employee that includes a link to upcoming educational sessions *E-mail provides a simple yet efficient way for the charge nurse to inform nonadherent employees about options they have for achieving adherence without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates adherence by helping each employee identify an upcoming session that coordinates with his work schedule.

A charge nurse in a skilled nursing facility notes several recent conflicts among staff on different shifts. Which of the following strategies should charge nurse plan to use to resolve these conflicts? Ask the charge nurses for each shift to get together and discuss the issues between shifts. Direct the staff from each shift to discuss their issues and present their solutions to their charge nurse. Set up a series of meetings for all staff members to attend to discuss issues. Remain uninvolved and allow the staff from each shift to resolve the issues among themselves.

Set up a series of meetings for all staff members to discuss issues *The charge nurse is using the conflict resolution strategy of collaboration by involving the staff to communicate and work together to devise and implement win-win solutions.

A nurse is reinforcing teaching with a client who has a new prescription for sertraline. The client asked the nurse if we should continue to take St. John's wort for depression. Which of the following instructions should the nurse to give the client? Take the medication and herbal supplement together. Stop taking the herbal supplement while taking the medication. Take the herbal supplement and the medication at least 2 hr apart. Take an antacid with both the herbal supplement and the medication.

Stop taking the herbal supplement while taking the medication *Taking the antidepressant sertraline and the herbal supplement St. John's wort together puts the client at risk for serotonin syndrome

A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse take first when suspecting a transfusion reaction? Prepare emergency medications. Monitor vital signs every 5 minutes. Stop the infusion. Send the blood container and tubing to the laboratory.

Stop the infusion *The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. For this client, it could be a life-threatening event such as circulatory collapse. Therefore, the first action the nurse should take is to stop the infusion to prevent any further administration of blood.

A nurse on a pediatric mental health unit is caring for a school age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in the conversation? "Do you like school?" "Tell me about your favorite video game." "We have another child your age on the unit." "Would you like your friends to come and visit you?"

Tell me about your favorite videogame *The nurse uses the therapeutic communication technique of exploring to encourage the child to respond with more than just the name of the game. This type of communication fosters rapport and encourages communication.

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make ? "It's important that you focus on getting better right now." "Why do you think you'll be hospitalized for a long time?" "All of your needs will be taken care of while you are in the hospital." "Tell me what concerns you the most about being hospitalized."

Tell me what concerns you most about being hospitalized

A nurse is collecting data from a client who is receiving clozapine to treat schizophrenia. The nurse should identify that an increase in which of the following parameters is an early indication of agranulocytosis? Urine specific gravity Urine output Blood pressure Temperature

Temperature *Antipsychotic medications, such as clozapine, can cause agranulocytosis, which is the depletion of WBCs. This increases the client's risk for infection. Fever is an early indication that the client should have a WBC count checked to detect agranulocytosis.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the clients insomnia? The client watches television in her bed during the day. The client drinks warm milk before bedtime. The client goes to bed at 2200 every night. The client gets up to use the bathroom once during the night.

The client watches television in her bed during the day To promote sleep, the client should avoid watching television in bed. She should be in bed only for sleep or sexual activities.

A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make? "Have you discussed this with your doctor yet?" "The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common." "Women who are already prone to vaginal yeast infections get them during pregnancy." "Why are you concerned about yeast infections during pregnancy?"

The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common *This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she is requesting.

A nurse is assisting to plan teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse recommend to include Smoking cessation The benefits of a diet high in cruciferous vegetables New types of ostomy appliances The importance of colonoscopy screening starting at age 50 years old

The importance of colonoscopy screening starting at age 50 years old *Screening examinations for colorectal cancer are secondary prevention.

Results of enzyme linked immunosorbent assay testing for an 18 month old infant who has pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors? The infant's mother is likely HIV positive. The infant's ELISA test result is probably a false positive for HIV. Antiretroviral medications are inappropriate for infants and children who have HIV. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations.

The infants mother is likely HIV positive *Transmission of HIV from a woman to her infant can occur during pregnancy, delivery, or through breastfeeding. Though it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants.

A nurse is reinforcing teaching with the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include? "The doctor will replace the tubes routinely about every 2 years." "Getting water in her ears will not cause any further problems." "The tubes should stay in place until they fall out on their own." "Now that the tubes are in place, she should not have any further problems with hearing."

The tubes should stay in place until they fall out on their own *Tympanostomy tubes allow for drainage from and ventilation to the middle ear. They usually fall out on their own 6 to 12 months after insertion. Most children do not need tympanostomy tubes for more than 1 year. With tympanostomy tubes in place, the child should wear earplugs whenever there is a possibility of getting contaminated or soapy water inside her ears. Hearing impairment is common with recurrent otitis media and can possibly continue after the tympanostomy tubes are in place.

A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse why did this happen to me? Which of the following responses should the nurse make? "I understand how you feel." "You are young and can have healthy babies when you are older." "Sometimes this is nature's way." "This must be so difficult for you."

This must be so difficult for you *This therapeutic response shows empathy and encourages the client to continue to express her feelings.

A nurse is assisting to prepare for the transfer of a client from the post anesthesia care unit following a sub total thyroidectomy. Which of the following equipment should the nurse have available at the patient's bedside? Cardiac monitor Defibrillator Thoracotomy tray Tracheostomy tray

Tracheostomy tray *With the laryngeal edema that is common post thyroidectomy, respiratory distress could result in airway obstruction. Emergency intubation can be difficult due to laryngeal swelling, and endotracheal intubation can increase the risk for hemorrhage by increasing tension on the incision during insertion. The nurse should have a tracheostomy tray available for this client.

A nurse is talking with a parent of a preschooler. The parent reports that her child grows upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent? "Use a stable, relaxing routine, such as a bath and story time, before bed." "Make sure the room is completely dark when placing your child in bed." "Let your child go to sleep in your lap and then put him in his bed." "Respond consistently if your child cries out for you after putting him to bed."

Use a stable relaxing routine such as a bath and bedtime story before bed *Routines are reassuring to preschoolers because they allow them to anticipate their environment and adapt appropriately. These actions help the child settle down prior to bedtime. They also provide for parental-child interaction prior to bed.

A nurse is preparing to administer 10 units of insulin glargine and four units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse take? Verify with the provider about giving insulin glargine at 1700. Ensure the insulin glargine is a cloudy suspension. Request a prescription for giving insulin glargine twice daily. Use separate syringes for administering insulin glargine and NPH insulin.

Use separate syringes for administering insulin glargine and NPH insulin *The nurse should not mix insulin glargine with any other insulin. The nurse should administer the NPH insulin and insulin glargine separately.

A nurse at a family planning clinic is preparing to give a presentation to clients about to use a diaphragm. Which of the following information should the nurse plan to include in the session? "Use spermicidal jelly whenever you use your diaphragm." "Insert the diaphragm about 8 hours before sexual activity." "You should remove the diaphragm 30 minutes after intercourse." "A diaphragm comes in one size and does not require fitting."

Use spermicidal jelly whenever you use your diaphragm A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but the use of spermicidal jelly with it increases the effectiveness of the device.

A nurse is assisting with planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse recommend for the client? Walking with a staff member Playing ping-pong in the dayroom with another client Playing basketball with other clients in the gym Riding on a stationary bike alone in the fitness room

Walking with a staff member *The nurse should plan to encourage the client to participate in nonthreatening, noncompetitive physical activities. Walking with the staff also provides an opportunity for verbal interaction between the client and the staff.

Ours in an acute mental health facility is caring for a client who has schizophrenia. The client asks the nurse can I vote in the upcoming presidential election? Which of the following responses should the nurse make? "Why do you want to vote while you are here in the hospital?" "I wouldn't worry about voting right now." "We can work together to find out how you can get a mail-in ballot." "You'll have a lot more opportunities to vote after you get better."

We can work together to find out how you can get a mail in ballot *The nurse provides a therapeutic response by suggesting collaboration and formulating a plan of action that will result in giving the client information and addressing the client's need.