Question Trainer 2

The older client with a history of hypertension and angle-closure glaucoma visits the clinic for a routine check-up. Which medication, if ordered by the health care provider, should the nurse question? 1. Propranolol, 80 mg PO QID. 2. Verapamil, 40 mg PO TID. 3. Tetrahydrozoline, 2 gtt both eyes TID. 4. Timolol, 1 gtt both eyes daily.

Strategy: "Medication should the nurse question" indicates a contraindication. (1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma (2) calcium channel blocker used as antianginal; not contraindicated (3) correct—contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension (4) reduces aqueous formation and increases outflow, used for glaucoma

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

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) not highest priority (2) infant needs to be held and cuddled due to a poorly developed CNS (3) usually unnecessary (4) correct—frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

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

Strategy: Answers are all implementation. Determine the outcome of each answer. Is it desired? (1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (3) correct—important that accurate documentation be maintained on the internal radium implant (4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

A client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings? Select all that apply. 1. Hypotension. 2. Low back pain. 3. Wet breath sounds. 4. Fever. 5. Urticaria. 6. Severe shortness of breath.

Strategy: Think about a hemolytic reaction and the symptoms. 1) CORRECT - blood pressure drops. 2) CORRECT - classic symptom related to hemolytic reaction. 3) related to circulatory overload. 4) CORRECT - fever is an expected symptom. 5) related to an allergic reaction. 6) related to circulatory overload.

The nurse recognizes which symptoms as characteristic of a panic attack? Select all that apply. 1. Decreased blood pressure. 2. Palpitations. 3. Decreased perceptual field 4. Bradycardia 5. Diaphoresis 6. Fear of going crazy

Strategy: Think about a panic attack and the neurological changes that occur. 1) blood pressure increases. 2) CORRECT - the heart rate increases and palpitations occur. 3) CORRECT - the visual field narrows; part of the fight or flight reaction. 4) tachycardia occurs. 5) CORRECT - neurological changes cause diaphoresis. 6) CORRECT- clients fear they are going crazy; part of the neurological changes.

Which assessment finding should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and decreased serum potassium. 4. Tachycardia with reports of night sweats..

Strategy: Think about each answer. (1) BP increases and client gains weight (2) correct—clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising (3) no correlation with urinary output; potassium decreases (4) no correlation with Cushing's syndrome

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

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

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

Strategy: Think about each answer. (1) correct—children have difficulty putting feelings into words; play is how they express themselves (2) somewhat true, but not best reason for play therapy (3) not reason play therapy is used; is used because it is the best way for children to express themselves (4) may encourage child to act out earlier developmental stage to reveal underlying conflicts

A client receives morphine sulfate after admission to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. Which finding should the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure. 2. Decrease in anxiety. 3. Depression of the sympathetic nervous system. 4. Enhanced ventilation and decreased cyanosis.

Strategy: Think about each answer. (1) is not affected by morphine sulfate (2) correct—morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema (3) is not the action of the medication (4) medication does not improve ventilation

An older client has a modified radical mastectomy and axillary dissection. Which nursing diagnosis is a correctly stated, priority nursing diagnosis for the client immediately after the procedure? 1. Anxiety related to the mastectomy. 2. Impaired skin integrity related to the mastectomy. 3. Pain related to surgical incision. 4. Self-care deficit related to dressing changes.

Strategy: Think about each answer. (1) is stated incorrectly with "related to the mastectomy" (2) is stated incorrectly with "related to the mastectomy" (3) correct—immediately after surgery the priority is optimizing the client's comfort (4) is not an immediate priority

When assessing orientation to person, place, and time for an elderly hospitalized client, which principle should be understood by the nurse? 1. Short-term memory is more efficient than long-term memory. 2. The stress of an unfamiliar environment may cause confusion. 3. A decline in mental status is a normal part of aging. 4. Learning ability is reduced during hospitalization of the elderly client.

Strategy: Think about each answer. (1) just the opposite is true; long-term memory is more efficient than short-term memory (2) correct—stress of an unfamiliar situation or environment may lead to confusion in elderly clients (3) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things (4) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things

The client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm3, RBC 5.1 million/mm3, total serum calcium 9.3 mg/dL (2.3 mmol/L). Based on the lab values, the nurse determines which is the priority nursing diagnosis? 1. Risk for activity intolerance related to decrease in red cells. 2. Risk for infection related to low white cell count. 3. Risk for anxiety secondary to hypoparathyroid disease. 4. Risk for fluid volume deficit due to decreased fluid intake.

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

The nurse develops care plans for these clients. The nurse should plan to use a restraint for which client? 1. An infant with septicemia. 2. A child with a tonsillectomy. 3. An infant with cleft lip repair. 4. A child with meningitis.

Strategy: Think about each answer. (1) not in need of restraints (2) not in need of restraints (3) correct—arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line (4) not in need of restraints

The nurse evaluates the nutritional intake of an adolescent girl attending camp. The adolescent eats all of the food provided to her at the camp cafeteria. Each of the day's three meals contains foods from all areas of the "My food plate", and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating monthly for about two years. Which description, if made by the nurse, best describes the girl's intake if her weight is appropriate for her height? 1. Her diet is low in calories and high in iron. 2. Her diet is low in calories and low in iron. 3. Her diet is high in calories and low in iron. 4. Her diet is high in calories and high in iron.

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

The nurse cares for a client the first day postoperative after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asks why the client has the CBI. Which response by the nurse is best? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."

Strategy: Think about each answer. (1) refers to a possible preoperative complication of infection due to the enlarged prostate (2) not the reason for the CBI (3) correct—continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client (4) medication is not routinely administered via a CBI in a first-day postop TURP

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

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

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? Select all that apply. 1. Paranoia. 2. Grandiose delusions. 3. Somatic difficulties. 4. Difficulty concentrating. 5. Agitation. 6. Distorted perceptions.

Strategy: Think about mania and how it is manifested. 1) related to schizophrenia. 2) CORRECT - delusions of grandure are common during mania. 3) related to personality disorders. 4) CORRECT - due to excessive activity. 5) CORRECT - clients are constantly in motion. 6) related to depression.

Which assessment information indicates to the nurse the client has hypocalcemia? 1. Constipation. 2. Depressed reflexes. 3. Decreased muscle strength. 4. Positive Trousseau's sign.

Strategy: Think about the cause of each answer. (1) symptom associated with hypercalcemia (2) symptom associated with hypercalcemia (3) symptom associated with hypercalcemia (4) correct—positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia

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

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

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

(1) not highest priority action related to the diagnosis (2) correct—cardiac dysrhythmias related to low serum calcium would be the highest priority (3) potential for respiratory infection is not a major threat (4) not highest priority action related to the diagnosis

The client reports a severe headache, nausea, and photophobia. The health care provider orders a complete blood count (CBC) and a lumbar puncture (LP). Which laboratory result would the nurse expect if a diagnosis of bacterial meningitis is made? 1. Cerebrospinal fluid (CSF) cloudy, hemoglobin (Hgb) 13 g/dL (130 g/L), hematocrit (HCT) 38%, white blood cell count (WBC) 18,000/mm3. 2. CSF with red blood cells (RBCs) present, Hgb 10 g/dL (100g/L), HCT 37%, WBC 8,000/mm3. 3. CSF cloudy, Hgb 12 g/dL (120 g/L), HCT 37%, WBC 7,000/mm3. 4. CSF clear, Hgb 15 g/dL (150 g/L), HCT 40%, WBC 11,000/mm3.

Strategy: Think about each answer and how it relates to bacterial meningitis. (1) CORRECT— cerebrospinal fluid (CSF) normally clear, colorless; normal white blood cell count (WBC) 5,000 to 10,000 per mm3, normal hemoglobin (Hgb) (male 13 to 18 g/dL (130-180 g/L), female 12 to 16 g/dL)(120-160 g/L), normal hematocrit (HCT) (male 42 to 52%, female 35 to 47%); CSF is cloudy indicating inflammation/infection; Hgb and HCT are within the normal ranges; WBC is elevated indicating infection (2) indicates trauma or hemorrhage (3) WBC too low, not typical of bacterial meningitis (4) indicates viral meningitis

A client has a nasogastric tube connected to intermittent low suction. At 0700, the nurse documents there is 235 mL of greenish drainage in the suction container. At 1500, the nurse notes that there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 mL of normal saline, as ordered by the health care provider. Which is the actual amount of drainage from the nasogastric tube for 0700 to 1500? 1. 150 mL. 2. 210 mL. 3. 295 mL. 4. 385 mL.

Strategy: Think about each answer. (1) correct-445 − 235 = 210 − 60 = 150 (2) does not subtract 60 mL of fluid used to irrigate Levin tube (3) does not take into account solution added to container during day shift; does not subtract for fluids used to irrigate Levin tube (4) does not subtract 235 mL that was in container from night shift

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

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

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

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

Which action is the most reliable client measure for the nurse to use to evaluate the desired client response to diuretic therapy? 1. Obtain daily weights. 2. Obtain urinalysis. 3. Monitor Na+ and K+ levels. 4. Measure intake.

Strategy: Think about each answer. (1) correct—effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights (2) does not relate to the effects of diuretic therapy (3) important to consider, but is not a priority (4) important to consider, but is not a priority

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

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

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

Strategy: Think about each answer. (1) correct—major side effects of haloperidol include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS) (2) not seen with haloperidol (3) not seen with haloperidol (4) not seen with haloperidol

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

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

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

Strategy: Think about each answer. (1) describes an erroneous rationale for the nausea (2) describes an erroneous rationale for the nausea (3) correct—during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system (4) describes an erroneous rationale for the nausea

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

Strategy: Think about each answer. (1) does not contribute to support of the lumbar spine (2) correct—strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine (3) does not contribute to support of the lumbar spine (4) does not contribute to support of the lumbar spine

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

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

The client with type 1 diabetes asks the nurse why the health care provider prescribed regular insulin instead of intermediate-acting insulin. Which response by the nurse is best? 1. "More injections are required with intermediate-acting insulin than with regular insulin." 2. "Hypoglycemia and hyperglycemia are more common with intermediate-acting insulin." 3. "Development of eye and kidney damage is less likely with regular insulin." 4. "Blood glucose levels can be controlled more accurately with regular insulin."

Strategy: Think about each answer. (1) fewer injections are required with intermediate-acting insulin (2) no change in incidence of hypoglycemia or hyperglycemia (3) complications are caused by blood vessel damage from sugar and fat deposits, not type of insulin used (4) correct— tighter blood glucose control occurs with regular insulin, especially initially

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

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

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

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

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

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

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

Strategy: Think about each answer. (1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries (2) correct—clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do issues (3) do not have problems with reality (4) these clients do have problems with family boundary intrusion; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries

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

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

A client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. When the nurse assesses the client, the client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride, 0.4 mg IV is ordered stat. In planning care for this client, it is important for the nurse to consider which action? 1. The BP and respirations will need to increase before a second dose of naloxone hydrochloride can be given. 2. Naloxone hydrochloride should not be given to the client because of his DNR status. 3. A dose of naloxone hydrochloride may need to be repeated in 2 to 3 minutes. 4. Naloxone hydrochloride is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.

Strategy: Think about each answer. (1) will not change without naloxone hydrochloride, respirations increase within 2 min (2) DNR indicates no resuscitation should be done if heart stops; does not preclude administration of drugs to correct iatrogenic problems (3) correct—half-life of naloxone hydrochloride is short; may go back into respiratory depression; may need to be repeated (4) used for respiratory depression of opiates, not used with barbiturates or sedatives

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

Strategy: Think about growth and development. (1) not able to physiologically control sphincters until 18 months of age (2) not able to physiologically control sphincters until 18 months of age (3) not able to physiologically control sphincters until 18 months of age (4) correct—by 24 months may be able to achieve daytime bladder control

The nurse observes a student nurse auscultate the lungs of a client. The nurse knows that the student nurse is correctly auscultating the right middle lobe (RML) if the stethoscope is placed in which position? 1. Posterior and anterior base of right side. 2. Right anterior chest between the fourth and sixth intercostals. 3. Left of the sternum, midclavicular, at right fifth intercostal. 4. Posterior chest wall, midaxillary, right side.

Strategy: Think about the anatomy of the lung. (1) cannot auscultate the RML from the posterior (2) correct—RML is found in the right anterior chest between the fourth and sixth intercostal spaces (3) point of maximum impulse or apical pulse (4) cannot auscultate the RML from the posterior

The client develops a low intestinal obstruction. The nurse anticipates which findings? Select all that apply. 1. Nausea. 2. Vomiting. 3. Explosive diarrhea. 4. Tarry stool 5. Abdominal distention. 6. Rectal bleeding.

Strategy: Think of intestinal anatomy. 1) CORRECT - nothing moving in the intestine causes nausea. 2) CORRECT - nothing moving in the intestine causes vomiting. 3) blockage causes no stool. 4) blockage results in no stool. 5) CORRECT - as stool backs up, abdominal distention occurs. 6) blockage results in no stool and no bleeding is associated.

The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms? Select all that apply. 1. Glucosuria. 2. Cracked lips. 3. Weight gain of 5 lb. 4. BP 160/100, pulse 56. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004.

Strategy: Think of water loss with diabetes insipidus. 1) occurs with diabetes mellitus. 2) CORRECT- due to dehydration caused by excessive water loss. 3) weight loss occurs; symptom of SIADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus. 4) late signs of increased intracranial pressure or brain damage. 5) CORRECT - excessive fluid loss is major occurrence of diabetes insipidus. 6) CORRECT - specific gravity very low as urine is not concentrated in the kidney.

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

The nurse assesses a client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction? 1. Protruding soft abdomen with frequent diarrhea. 2. Distended abdomen with ascites. 3. Minimal bowel sounds in all four quadrants. 4. Distended abdomen with reports of pain. Show/hide explanation Strategy: Determine how each answer relates to an intestinal obstruction. (1) does not support intestinal obstruction (2) does not support intestinal obstruction (3) immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen (4) correct—if an obstruction is present, the abdomen will become distended and painful

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

The nurse identifies which psychosocial stage should be a priority to consider while planning care for a 20-year-old client? 1. Identity versus identity diffusion. 2. Intimacy versus isolation. 3. Integrity versus despair and disgust. 4. Industry versus inferiority. Show/hide explanation Strategy: Think about each answer. (1) appropriate for adolescents (2) correct—is the stage for 19- to 35-year-olds (3) for 65 years and older (4) for 6 to 12 years of age

During an initial interview at an outpatient clinic, a 34-year-old single parent tells the nurse of having had difficulty forming relationships and is worried that the 7-year-old child will have the same problem. Which statement, if made by the nurse, is best? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."

Strategy: "BEST" indicates discrimination is required. Topic of question is unstated. Read answer choices to determine topic. (1) correct—Erikson states that trust results from interaction with dependable, predictable primary caretaker (2) toddler stage concerns autonomy verses shame and doubt (3) preschool state concerns initiative versus guilt (4) latency or school age stage concerns industry versus inferiority

A client returns from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 mL/h into the left forearm. Several hours later, the IV infiltrates. The nurse supervises a student nurse preparing to insert a new peripheral intravenous catheter. The nurse should intervene in which situation? 1. The student nurse selects a site where the veins are soft and elastic. 2. The student nurse selects a site on the distal portion of the left arm. 3. The student nurse selects a site close to wrist joint. 4. The student nurse holds the skin taut.

Strategy: "Nurse should intervene" indicates an incorrect action. (1) acceptable site selection (2) acceptable site selection (3) correct inappropriate; movement in area could cause displacement (4) acceptable procedure

The nurse reviews procedures with the health care team. The nurse should intervene if the RN staff member makes which statement? 1. "It is my responsibility to ensure that the consent form has been signed and is attached to the client's chart." 2. "It is my responsibility to witness the signature of the client before surgery is performed." 3. "It is my responsibility to explain the surgery and ask the client to sign the consent form." 4. "It is my responsibility to answer questions that the client may have before surgery."

Strategy: "Nurse should intervene" indicates that you should look for an incorrect statement. Question is unstated. Read answer choices for clues. (1) describes the nurse's responsibility in obtaining consent (2) signature indicates that the nurse saw the client sign the form (3) correct— health care provider should provide explanation and obtain client's signature (4) the nurse should answer questions after the health care provider has obtained consent

The nurse recognizes which nursing intervention is most important when caring for the client just placed in physical restraints? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints. 4. Monitor the client's needs for hydration and nutrition while restrained.

Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; inappropriate for the client in restraints (2) correct—assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained (3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints (4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained

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

Strategy: Determine how each answer relates to a urinary catheter. (1) correct—bladder distention is one of the earliest signs of obstructed drainage tubing (2) seen with a urinary tract infection (3) seen with dehydration (4) seen with a urinary tract infection

Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as "My breathing is much improved now." 2. Notes objective findings, such as decreased respiratory rate and pulse. 3. Consults with the respiratory therapist to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds.

Strategy: Determine how each answer relates to suctioning. (1) subjective data and not as conclusive (2) correct but not as effective (3) not appropriate (4) correct—to assess the effectiveness of suctioning, auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions

Promethazine hydrochloride 25 mg IV push is ordered for a client. Prior to administering this medication to the client, the nurse should check which assessment? 1. The color of the medication solution. 2. The client's pulse and temperature. 3. The time of the last analgesic dose the client received. 4. The patency of the client's vein.

Strategy: Determine how each assessment relates to the medication. (1) is true, but not as high a priority as answer choice (4) (2) no relevance to the question asked (3) promethazine hydrochloride is used as an adjunct to analgesics but has no analgesic activity itself (4) correct—is very important to determine absolute patency of the vein; extravasation will cause necrosis

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

Strategy: Determine the cause of each sympton and how it relates to Buerger's disease. (1) no cardiac involvement (2) dizziness not seen; intermittent claudication (pain with exercise) seen (3) optic nerve not affected (4) correct—vasculitis of blood vessels in upper and lower extremities

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

Strategy: Determine the outcome of each answer. (1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state (2) correct—to improve the quality of ventilation refers to levels of carbon dioxide and oxygen (3) not appropriate for the situation (4) not appropriate for the situation

The home care nurse plans activities for the day. In which order should the nurse see the clients? Please place the answer in priority order. All options must be used.

Strategy: Identify the most unstable clients to see first. 1) First (4) symptoms of pulmonary edema; requires immediate attention. 2) Second (1) still potential for problems related to heparin; assess for bleeding gums, hematuria. 3) Third (2) potential for relapse; assess breath sounds, encourage fluids, cough and deep breathe. 4) Fourth (3) stable client, least critical/priority.

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

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

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

Strategy: Think about each answer and how it relates to AIDS-related dementia. (1) not relevant to this condition (2) not relevant to this condition (3) correct—approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation (4) is a sign of early-onset dementia

The older adult receives dexamethasone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding to the health care provider? 1. Prothrombin time (PT) 12 seconds and hemoglobin (hgb) 15 g/dL (150 g/L). 2. Blood urea nitrogen(BUN) 18 mg/dL (6.4 mmol/L) and creatinine 1.0 mg/dL (88 µmol/L). 3. Serum potassium (K) 3.4 mEq/L(3.4 mmol/L) and serum calcium (Ca)7.8 mg/dL (2 mmol/L) . 4. Aspartate aminotransferase (AST) 18 U/L and alanine aminotransferase (ALT) 12 U/L.

Strategy: "Most important to report to the physician" indicates a complication. (1) normal PT 9.5 to 12 sec, normal Hgb male: 13 to 18 g/dL (130-180 g/L), female: 12 to 16 g/dL (120-160 g/L) (2) normal BUN 10 to 20 mg/dL (3.6-7.2 mmol/L)60 years or younger, normal creatinine 0.7 to 1.4 mg/dL(62-124 µmol/L) (3) correct— normal K 3.5 to 5.0 mEq/L, normal Ca 8.5 to 10.5 mg/dL (2.2-2.6 mmol/L), indicates hypokalemia and hypocalcemia (4) normal AST 8 to 40 units, normal ALT 8 to 40 units

A client comes to the clinic for the results of a glycosylated hemoglobin (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of the procedure? 1. "This test is performed by sticking my finger and measuring the results." 2. "This test needs to be performed in the morning before I eat breakfast." 3. "This test indicates how well my blood sugar has been controlled the past 6 to 8 weeks." 4. "I must follow my diet carefully for several days before the test."

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) 3 to 5 ml of blood is needed (2) timing of test is not important (3) correct—when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5 to 6% (4) current blood sugar doesn't affect test

When obtaining a specimen from a client for sputum culture and sensitivity (C and S), the nurse identifies which instruction is best? 1. After pursed lip breathing, cough into a container. 2. Upon awakening, cough deeply and expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) coughing into a container is indicated, but not pursed-lip breathing (2) correct—specimens should be obtained in the early morning because secretions develop during the night (3) appropriate for acid-fast stain for TB (4) earliest specimen is most desirable

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

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) no dye is used for an MRI (2) client is not anesthetized for this procedure (3) correct—procedure takes approximately 90 minutes, not painful (4) indicates misunderstanding of MRI because no wires are used

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

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eat at regular time; remain in the seclusion room for client's safety

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

Strategy: Answers are a mix of assessment and implementation. Is there an appropriate assessment? Yes. (1) does not experience vertigo (2) fluid and electrolytes usually not a problem for this patient (3) increased intracranial pressure is not associated with myasthenia gravis (4) correct—client has increased muscle fatigue, needs more assistance toward end of day

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

Strategy: Answers are implementation. Determine the outcome of each answer. Is it desired? (1) would be noted, but is not as high a priority (2) inappropriate (3) correct—suspected reaction to drugs should be reported to the health care provider and noted on list of possible allergies (4) inappropriate

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

Strategy: Determine how each answer relates to Addison's disease. (1) correct—increase in melanocyte-stimulating hormone results in "eternal tan" (2) not seen with Addison's disease (3) not seen with Addison's disease (4) not seen with Addison's disease

The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistive personnel (NAP). The RN should care for which client? 1. The client with a chest tube who is ambulating in the hall. 2. The client with a colostomy requiring assistance with an irrigation. 3. The client with a right-sided stroke requiring assistance with bathing. 4. The client declining medication to treat cancer of the colon.

Strategy: Determine the skill level involved with each patient's care. The RN cares for patients who require assessment, teaching, and nursing judgment. (1) stable client with an expected outcome; assign to the LPN/LVN (2) stable client with an expected outcome; assign to the LPN/LVN (3) standard, unchanging procedure; assign to the NAP (4) correct— requires assessment skills of the RN

The nurse cares for a client diagnosed with Ménière's syndrome. The nurse stands directly in front of the client when speaking. Which best describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips. 2. The client does not have to turn the head to see the nurse. 3. The nurse will have the client's undivided attention. 4. There is a decrease in client's peripheral visual field.

Strategy: Think about each answer. (1) client is not hard of hearing (2) correct—by decreasing movement of client's head, vertigo attacks may be decreased (3) there is no problem with visual fields (4) there is no problem with visual fields

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

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

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

Strategy: Think about each answer. (1) correct—client with reactive depression has the highest level of physical and psychic energy in the morning (2) as the day progresses, energy level declines (3) as the day progresses, energy level declines (4) as the day progresses, energy level declines

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

Strategy: Think about the cause of each symptom. Determine how it relates to TPN. Remember the "comma, comma, and" rule. (1) not seen (2) suggestive of infection (3) correct—insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination (4) not seen

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

Strategy: Think about the indications of an increased metabolic rate. (1) will be restless (2) will have heat intolerance due to increased metabolic rate (3) correct—increased metabolic rate causes weight loss even with increased appetite (4) reflexes will be hyperactive

The health care provider prescribes estrogen 0.625 mg daily for a 43-year-old woman. The nurse identifies which symptom as a common initial side effect of this medication? 1. Nausea. 2. Visual disturbances. 3. Tinnitus. 4. Ataxia.

Strategy: Think about what causes each symptom and determine its relationship to Premarin. (1) correct—common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence (2) seen with long-term use (3) ringing in the ears is seen with long-term use (4) unsteady gait rarely seen

Place the steps in the correct order, starting with the first step. All options must be used. Show/hide explanation Strategy: Think of aseptic technique. 1) First Use clean gloves to remove old dressing to protect nurse. 2) Second Prepare the cotton swabs with providone-iodine. 3) Third Use circular motion going from center to outside area; clean to dirty. 4) Fourth Apply dressing to area. 5) Last Tape dressing in place.

Strategy: Think of aseptic technique. 1) First Use clean gloves to remove old dressing to protect nurse. 2) Second Prepare the cotton swabs with providone-iodine. 3) Third Use circular motion going from center to outside area; clean to dirty. 4) Fourth Apply dressing to area. 5) Last Tape dressing in place.

The nursing assistive personnel (NAP) reports to the RN that the client with anemia reports weakness. Which response by the nurse to the NAP is best? 1. "Listen to the client's breath sounds and report back to me." 2. "Set up the client's lunch tray." 3. "Obtain a diet history from the client ." 4. "Instruct the client to balance rest and activity."

Strategy: Topic of question not clearly stated. (1) requires assessment; should be performed by the RN (2) correct—standard, unchanging procedure; decreases cardiac workload (3) involves assessment; should be performed by the RN (4) assessment and teaching required; performed by the RN

The nurse cares for a client diagnosed with a recurrent urinary tract infection. The health care provider prescribes methenamine mandelate. The nurse should instruct the client to limit intake of which fluid? 1. Milk. 2. Cranberry juice. 3. Water. 4. Tea.

The nurse cares for a client diagnosed with a recurrent urinary tract infection. The health care provider prescribes methenamine mandelate. The nurse should instruct the client to limit intake of which fluid? 1. Milk. 2. Cranberry juice. 3. Water. 4. Tea. Show/hide explanation Strategy: Think about each answer. (1) correct—should limit intake of alkaline foods and fluids (2) should be increased to acidify urine (3) does not need to be restricted (4) does not need to be restricted