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The nurse knows that the blood urea nitrogen can be expected to change as one ages. Which statement best explains this expected change?

BUN increases because of a decrease in renal functioning and a decrease in cardiac output

A Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.

A home care nurse is making home visits to an older client with urinary incontinence who is very disturbed by the incontinent episodes. The nurse assesses the client's home situation to determine environmental barriers to normal voiding. The nurse determines that which item may be contributing to the client's problem.

Bathroom located on the second floor bedroom on the first floor

A nurse is providing instructions to a client with a diagnosis of artial fibrillation about the need to begin long-term anticoaglant therapy. Which explanation would the nurse provide the client to describe the reasoning for this therapy?

Because the artia are qivering blood flows sluggishly through them, and clots can form long the heart wall, which could then lossen and travel to the lungs or brain.

A nurse is caring for a postoperative client who underwent pelvic exenteration. The physician has changed the client's diet from nothing by mouth to clear liquids. The nurse checks which of the following before administering the diet

Bowel Sounds

A Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit

A 35-year-old client says to the nurse, "I got divorced less than a year after getting married. I left the Navy SEALs shortly after I joined. Now I teach in the air marshal program to avoid being recalled for war, but I'd really like to quit. I start something, am great at it, then get bored and move on. I date, but I'm still living at home. I never seem to be on my own like other guys my age." Which response by the nurse is most appropriate? A. "You made the Navy SEALs but can't live on your own like an adult and can't stick with anything." B. "Can you tell me more about your marriage and relationships? If you leave home, what do you fear will happen?" C. "You have many years to find a new relationship, but moving out of your parents' home is a first step to growing up." D. "When will your mother let you go? Seems to me that jobs have come easy to you but that you can't grow up and separate from your parents."

B. "Can you tell me more about your marriage and relationships? If you leave home, what do you fear will happen?"

A client with an anxiety disorder who has been prescribed an antibiotic for otitis media asks the nurse, "Why'd the doctor tell me not to discontinue the medication until the pills are gone?" Which response by the nurse is appropriate? A. "Doctors always tell clients to take all of their medicine." B. "Completing the medication ensures that the infection will be resolved." C. "Medication is always prescribed for 1 month. Do you have a month's supply?" D. "It's because insurance companies pay for the medications and want to make sure that the client is healed."

B. "Completing the medication ensures that the infection will be resolved."

A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask? A. "Are you dieting?" B. "Do you smoke cigarettes?" C. "Do you engage in strenuous exercise such as jogging?" D. "Do you normally have menstrual cramps with your periods?"

B. "Do you smoke cigarettes?"

A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information? A. "My temperature needs to remain within a normal range." B. "Frequent urination and burning when I urinate are expected." C. "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." D. "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs."

B. "Frequent urination and burning when I urinate are expected."

A 62-year-old woman says, "Since my husband retired, 4 months ago, he's started playing golf 24/7, so after rearing our children alone while my workaholic husband ran his business I'm suddenly a golf widow." Which response by the nurse is appropriate? A. "Do other people call you a golf widow?" B. "Have you shared your feelings with your husband?" C. "'When you can't beat 'em, join 'em' — that's what I always say. Why not play golf with him?" D. "Some women wish they had your problem. My mother keeps complaining that Dad is always messing around in the house, driving her nuts."

B. "Have you shared your feelings with your husband?"

A schizophrenic client says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my health care provider told me to." Which intervention would the nurse suggest as a distraction technique? A. "Pretend that you're on the phone and talk to the voices." B. "Have you tried to count back from 100 or listen to music?" C. "The next time this happens, try telling the voices to go away." D. "Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening."

B. "Have you tried to count back from 100 or listen to music?"

The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A. "I need to keep the sun off the radiation site." B. "I can use over-the-counter cortisone cream on the radiation site if it gets red." C. "I need to be careful not to wash off the marks that the radiologist made on my skin." D. "I need to wash the skin at the radiation site with a mild soap and water and pat it dry."

B. "I can use over-the-counter cortisone cream on the radiation site if it gets red."

A nurse, assessing a client's readiness for discharge, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further? Select all that apply. A. "I live in a single-story house." B. "I don't have any nightlights in the house." C. "I've removed the scatter rugs from the house." D. "I keep my personal items within reach when I sit in my easy chair." E. "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

B. "I don't have any nightlights in the house." E. "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? A. "I need to avoid eating fried or greasy foods." B. "I need to be sure to drink adequate fluids with my meals." C. "I should eat five or six small meals a day rather than three full meals." D. "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning."

B. "I need to be sure to drink adequate fluids with my meals."

A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. A. "I need to use night lights." B. "I need to remove my wall-to-wall carpeting." C. "I need to get handrails put up in the bathroom." D. "I need to use the staircase handrails when I go up the stairs." E. "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor."

B. "I need to remove my wall-to-wall carpeting." E. "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor."

A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? A. "I should sit up in my recliner." B. "I should lie on my right side in bed." C. "I should sit on the side of my bed and lean on the overbed table." D. "I should stand with my back and hips against the wall and my shoulders bent slightly forward."

B. "I should lie on my right side in bed."

The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states: A. "I should take an antacid at bedtime." B. "I should sleep flat on my right side." C "The histamine antagonist will help me." D. "I should avoid eating in the 3 hours before bedtime."

B. "I should sleep flat on my right side."

A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, "I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It's so bad that my mouth has a sore." How does the nurse respond to the client? A. "I wouldn't be upset. It happens when you aren't drinking enough water." B. "I think you need to come in for blood work today, because this may be an adverse effect of your medicine." C. "Do you remember when you started this medication? Your psychiatrist told you how important it is to keep your appointments with him." D. "You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash every 2 hours or so and drink plenty of water."

B. "I think you need to come in for blood work today, because this may be an adverse effect of your medicine."

Warfarin sodium has been prescribed, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? A. "I won't play football anymore." B. "I won't take any over-the-counter medications except aspirin." C. "I'll use an electric shaver until the doctor stops the Coumadin prescription." D. "I'll buy one of those medication alert tags that tells people I'm taking an anticoagulant."

B. "I won't take any over-the-counter medications except aspirin."

The nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client makes which statement? A. "I need to go to the bathroom." B. "I'm no longer a threat to myself or others." C. "I want to be alone for a while in my own room." D. "I can't breathe in here. The walls are closing in on me."

B. "I'm no longer a threat to myself or others."

A nurse is describing the procedure for testicular self-examination (TSE) to a male client. Which statement should the nurse make to the client? A. "A good time to examine the testicles is just before you take a shower." B. "If you notice an enlarged testicle or a lump, you need to notify the physician." C. "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency." D. "Perform a testicular exam at least every 2 months to detect early signs of testicular cancer."

B. "If you notice an enlarged testicle or a lump, you need to notify the physician."

A survivor of a nightclub fire that killed more than 100 people says to the nurse, "It should have been me. How come I got out and they didn't?" Which response by the nurse is appropriate? A. "I don't know what to say. It was a terrible fire. I'm so sorry this happened." B. "It seems that you're blaming yourself for something that was beyond your control." C. "It seems to me that you're making this all about you when many people died in that fire." D. "You should be thankful that you're a survivor. The victims and their families lost, not you."

B. "It seems that you're blaming yourself for something that was beyond your control."

During a mental health intake interview, a young adult client who lives with his family rent free says, "I'm tired of not being able to offer my friends a beer just because my folks don't believe in taking a drink socially." Which nursing response would be therapeutic? A. "Well, I guess you could move out and live on your own if you wanted to." B. "It seems that your parents expect you to follow their rules when you live under their roof." C. "You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?" D. "Well, if you directly discussed your concerns with them, I guess it's a case of 'When in Rome, do as the Romans do.'"

B. "It seems that your parents expect you to follow their rules when you live under their roof."

A 79-year-old client, recently widowed, says to the nurse, "My wife kept up our condominium single-handedly, and now my kids expect me to cook and clean for myself. I'm not lazy, but I don't know how to cook and I've burnt myself twice just frying up what was supposed to be bacon and eggs. I'm so frustrated and I've already lost 10 lb this month." Which initial nursing statement should the nurse make to the client? A. "I'm calling the doctor immediately to obtain a homemaker for you!" B. "Seems as if you feel lost without your wife and maybe a bit ignored by your children." C. "First things first. What are you doing eating bacon and eggs? That's not a good meal for you." D. "Meals-on-Wheels can help you minimize the frustration you are having cooking. Are you a member of the local senior center?"

B. "Seems as if you feel lost without your wife and maybe a bit ignored by your children."

The nurse is caring for an older adult client who says, "I don't want to talk with you — you're only a nurse. I'll wait for my health care provider." Which response by the nurse would be therapeutic? A. "I'll leave you now and call your health care provider." B. "So you're saying that you want to talk to your health care provider?" C. "I'm angry with the way you've dismissed me. I am your nurse!" D. "I'm assigned to work with you. Your health care provider placed you in my hands."

B. "So you're saying that you want to talk to your health care provider?"

The 45-year-old husband of a client with breast cancer who just died says to the nurse, "If our doctor had operated sooner, my wife would be alive now." Which statement by the nurse would be therapeutic? A. Say nothing. Simply nod and say "Mm-hmm" noncommittally. B. "Sounds as if you're feeling angry and pretty helpless right now." C. "Let's focus not on what was not done but instead on what was done for your wife." D. "Your doctor did all he could for your wife. You know, health care providers can only apply their best clinical judgment."

B. "Sounds as if you're feeling angry and pretty helpless right now."

A single parent whose son was suspended from school for carrying a gun into the school says to the nurse, "I know he has no dad, but I've brought him up to know better, and anyway, where did he get the stupid gun? What should I do? He just won't listen to me." Which nursing response would be helpful at this time? A. "Boys who are cared for only by their moms are at highest risk for violent behavior." B. "There is quite a bit that you can do. Let's talk about what you're already doing first." C. "Do you know all of your son's friends, or is he left alone after school because you work?" D. "Many young people die of gunshots every day in this country, so your son's behavior is unacceptable."

B. "There is quite a bit that you can do. Let's talk about what you're already doing first."

A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he has gonorrhea." How should the nurse respond to the secretary? A. "Oh, really? I didn't see that!" B. "We can't discuss a client's medical condition." C. "Yes, that's why we've imposed contact precautions." D. "Yes, he does, but be sure not to discuss this with anyone else."

B. "We can't discuss a client's medical condition."

A young female client with schizophrenia says to the nurse, "Since I started on olanzapine last year, I'm doing well in school and all, but I've gained so much weight, and it's really bothering me. What can I do about this?" Which response by the nurse would be therapeutic? A. "Well, I think you're overreacting. Today people think they should be skinny-minnies, even though it's not healthy." B. "Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?" C. "That medication isn't any more likely to cause weight gain than the others you're taking. Perhaps we could go over your diet and exercise habits." D. "I want you to stop taking this medication immediately, and I'm calling the doctor, because this is a very serious side effect and you may need dialysis."

B. "Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?"

A health care provider (HCP) tells a client that she has cancer, that her illness is terminal, and that she has a 6-month prognosis. After the health care providerHCP leaves the client's room, which therapeutic statement should the nurse make to the client? A. "I am so sorry about this. You are my favorite client, and I will take good care of you." B. "What did your HCP tell you about your condition? Can you tell me what you're thinking about?" C. "Do you have any questions about what is happening with you? I can assure you that I will do everything I can to help minimize your pain." D. "Do you want me to get the phone so you can talk to your loved ones, or do you have questions for me about what's happening with you?"

B. "What did your HCP tell you about your condition? Can you tell me what you're thinking about?"

The parent of a 25-year-old man who has just been found to have a left frontal brain tumor says to the nurse, "At the local hospital, our doctor thought that his headaches were nothing and prescribed an analgesic. If I hadn't insisted on a CT scan, no one would have found the tumor." Which statement by the nurse would be therapeutic? A. "What's being planned for your son now?" B. "You and your son are having a very trying time. What's happened since your son's diagnosis?" C. "These days only the squeaky wheel gets the grease in medicine. Your squeaking was excellent advocacy." D. "Sounds like you have to be your own health care provider these days — good for you! — but I'm sure your health care provider was following medical protocol."

B. "You and your son are having a very trying time. What's happened since your son's diagnosis?"

The widow of a man who was killed a week ago in a hit-and-run accident while walking the family dog says, "I should have just let the dog run in the backyard or gone with my husband. Our own parish priest hit my husband and finally surrendered to the police. He brought a lawyer with him because he's worried about himself, not my husband. I hate him so much, my stomach hurts." Which nursing statement would be therapeutic? A. "Of course you're angry. Who wouldn't be? Yet nothing is ever clear cut, is it?" B. "You not only lost your husband but also learned it was at the hands of someone you looked up to." C. "You're having stomach pain? You should get checked for an ulcer or other gastric problem." D. "I wouldn't blame you if you never entered a church again. This is a terrible thing for the head of a church to do."

B. "You not only lost your husband but also learned it was at the hands of someone you looked up to."

The nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic? A. "I can see that this isn't a good time to visit." B. "You seem to be having a very difficult time." C. "Do you think your wife would want you to behave like this?" D. "What are you doing? How much are you drinking, and how long has this been going on?"

B. "You seem to be having a very difficult time."

The mental health home care nurse says to the client, "Do you feel ready to try attending a group session at the clinic?" The client shakes his head. Which nursing statement would be therapeutic? A. "No? Why not?" B. "You seem to be saying no. Would you tell me more about your reluctance?" C. "OK, but I hope you will let me know when you feel ready to attend a group session at the clinic." D. "Perhaps a group session would be too overwhelming for you right now. How about just seeing me?"

B. "You seem to be saying no. Would you tell me more about your reluctance?"

A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of medications being taken. Which serum creatinine result does the nurse document as normal? A. 0.2 mg/dL (17.6 μmol/L) B. 1.0 mg/dL (88.3 μmol/L) C. 2.8 mg/dL (247.3 μmol/L) D. 3.9 mg/dL (344.5 μmol/L)

B. 1.0 mg/dL (88.3 μmol/L)

At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood bank. The nurse calculates that the transfusion must be started by which time? A. 1315 B. 1330 C. 1345 D. 1400

B. 1330

A nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. For how long does the nurse plan to stay with the client after the unit of blood is hung? A. 5 minutes B. 15 minutes C. 45 minutes D. 60 minutes

B. 15 minutes

Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the health care provider's prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? A. 1 L/min B. 3 L/min C. 4 L/min D. 6 L/min

B. 3 L/min

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up? Select all that apply. A. A client is performing his own colostomy irrigations. B. A client with a central venous catheter has a temperature of 100.6° F. C. A client with a new diagnosis of diabetes mellitus is self-administering insulin. D. A client who has just undergone surgery has a urine output of more than 30 mL/hr. E. A client who has just undergone surgery is getting relief from the prescribed pain medication.

B. A client with a central venous catheter has a temperature of 100.6° F.

A nurse is planning the client assignments for the shift. Which client should the nurse assign to the nursing assistant? A. A client who needs a blood transfusion B. A client with diarrhea on whom contact precautions have been imposed C. A client with angina who needs to be ambulated for the first time since admission D. A client with a draining abdominal wound that requires frequent dressing changes

B. A client with diarrhea on whom contact precautions have been imposed

A nurse, newly employed by a home health agency, is told that the organization's decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in: A. Every employee B. A few individuals, such as the board of directors C. All nursing employees, pharmacists, and hospital physicians D. Many individuals, with decisions filtering down to the individual employee

B. A few individuals, such as the board of directors

A nurse conducting a physical assessment of a client plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal: A. Loss of hearing acuity B. A problem with balance C. A problem with distant hearing D. A problem discriminating high-pitched and low-pitched sounds

B. A problem with balance

A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply. A. Hypotension B. Abdominal distention C. Trousseau sign D . Skeletal muscle weakness E. Decreased deep tendon reflexes

B. Abdominal distention C. Trousseau sign

An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply. A. Keep visitors to a minimum B. Acknowledge the client's feelings C. Provide information about hospital routines D. Put the client in a room far from the nurses' station E. Keep the door open and the room lights on at all times F. Allow the client to have as many choices regarding his care as possible

B. Acknowledge the client's feelings C. Provide information about hospital routines F. Allow the client to have as many choices regarding his care as possible

A nurse is assessing the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform? Select all that apply. A. Put on and tie his shoes B. Align two or more blocks C. Dress himself appropriately D. Go to the bathroom without help E. Turn the pages of a book one at a time

B. Align two or more blocks E. Turn the pages of a book one at a time

A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A. Giving the client thin liquids B. Alternating liquids with solids C. Giving foods that are primarily liquid D. Placing food in the affected side of the client's mouth

B. Alternating liquids with solids

An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin? A. An open ulcer B. An itchy bump C. A weeping blister D. A black skin area of skin

B. An itchy bump

The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant? A. A client scheduled for a liver biopsy B. An unconscious client who requires oral care C. A client who has just undergone cardiac catheterization D. A client who is getting up to ambulate for the first time after surgery

B. An unconscious client who requires oral care

Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication? Select all that apply. A. Prunes B. Apples C. Peaches D. Avocados E. Nectarines F. Cranberries

B. Apples C. Peaches F. Cranberries

A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. What should the nurse tell the client about the medication? A. Place the patch in the area of a skin fold to promote adherence B. Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed C. If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch. D. Alternate daily dose times between the morning and the evening to prevent the development of tolerance to the medication

B. Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed

A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? A. Collect health history information first, then perform the physical examination B. Ask health history questions while performing the examination and initiating emergency measures C. Collect all information requested on the history form, including social support, strengths, and coping patterns D. Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room

B. Ask health history questions while performing the examination and initiating emergency measures

The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? A. Asking the client to remove the medal until the x-ray has been completed B. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms C. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department D. Telling the client that the medal and chain will be kept at the nurses' station for safekeeping while the client is undergoing the x-ray

B. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms

A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. Where should the nurse place the tape measure? A. In the axillary area B. At the level of the nipples C. 2 inches below the nipples D. At the level of the umbilicus

B. At the level of the nipples

A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis? A. Acetylcysteine B. Atropine sulfate C. Protamine sulfate D Pyridostigmine bromide

B. Atropine sulfate

The nurse, performing an abdominal examination, inspects the client's abdomen. Which assessment technique does the nurse perform next? A. Percussion B. Auscultation C. Light palpation D. Deep palpation

B. Auscultation

A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client? A. Expect excessive ear drainage for about 2 weeks. B. Avoid rapidly moving the head and bending over for at least 3 weeks. C. Rinse the ear canal at least twice a day to clear out any excess drainage. D. It is all right to shower as long as the ear dressing is changed immediately after the shower

B. Avoid rapidly moving the head and bending over for at least 3 weeks.

During a one-to-one nurse-client session, the client plays with her pack of cigarettes and says, "I just get a couple of DVDs and watch movies so I won't have to look at my husband or talk to him." Which coping mechanism does the nurse recognize in the client's behaviors? A. Self-blame B. Avoidance C. Reframing D. Wishful thinking

B. Avoidance

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area? A. Chest of the fetus B. Back of the fetus C. Carotid artery in the neck of the fetus D. Brachial area of one extremity of the fetus

B. Back of the fetus

A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply. A. Avocados B. Baked tuna C. Green olives D. Baked potato E. Fresh cherries F. Cream cheese

B. Baked tuna D. Baked potato E. Fresh cherries

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart so that he will: A. Understand the organization's reason for existence B. Be familiar with the organization's line of authority C. Be familiar with the beliefs and values of the organization D. Be aware of the geographical area that the organization serves

B. Be familiar with the organization's line of authority

A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective? A. Weight and BUN B. Blood pressure and weight C. Potassium and creatinine levels D. Blood urea nitrogen (BUN) and creatinine levels

B. Blood pressure and weight

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? A. Cleansing breaths B. Blowing repeatedly in short puffs C. Holding her breath and using the Valsalva maneuver D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction

B. Blowing repeatedly in short puffs

A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will: A. Bottle feed only B. Breastfeed the newborn every 2 to 3 hours C. Provide water feedings between breast feedings D. Feed her newborn less frequently until the bilirubin level drops

B. Breastfeed the newborn every 2 to 3 hours

A school nurse provides information to the parents of school-age children regarding appropriate dental care. What should the nurse tell the parents their children should do? A. Brush their teeth every morning and at bedtime B. Brush and floss their teeth after meals and at bedtime C. Brush and floss their teeth every morning and at bedtime D. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime

B. Brush and floss their teeth after meals and at bedtime

A nurse reviewing a client's record notes documentation that the client has melena. How does the nurse detect the presence of melena? A. By checking the client's urine for blood B. By checking the client's stool for blood C. By checking the client's urine for a decrease in output D. By checking the client's bowel movements for diarrhea

B. By checking the client's stool for blood

The home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic antidepressant lying near the client. What action must the nurse take immediately? A. Inducing vomiting B. Calling an ambulance C. Administering syrup of ipecac D. Counting the pills remaining in the bottle

B. Calling an ambulance

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by taking which action? A. Reassuring the client that the risks are minimal B. Calling the surgeon and asking that the risks be explained to the client C. Noting in the client's record that the client was not told about the risks of the surgery D. Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room

B. Calling the surgeon and asking that the risks be explained to the client

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? A. Contact the health care provider B. Check for kinks in the drainage system C. Check the client's blood pressure and heart rate D. Connect a new drainage system to the client's chest tube

B. Check for kinks in the drainage system

The nurse and an unlicensed assistive personnel (UAP)enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Ask the nursing assistant to complete an incident report B. Check the client's level of consciousness and vital signs C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client's health care provider be called

B. Check the client's level of consciousness and vital signs

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? A. Continue suctioning to remove the blood B. Check the degree of suction being applied C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth

B. Check the degree of suction being applied

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first: A. Check the client's apical pulse B. Check the placement of the tube C. Check when the last feeding was given D Check when the last medications were given

B. Check the placement of the tube

A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? Select all that apply. A. Lettuce B. Cherries C. Broccoli D. Cabbage E. Potatoes

B. Cherries E. Potatoes F. Spaghetti

The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action? A. Obtain blood for culture B. Clamp the TPN infusion line C. Obtain an electrocardiogram (ECG) D. Obtain a sample for blood glucose testing

B. Clamp the TPN infusion line

A nurse manager arrives at work and is immediately faced with several activities that require his attention. Which activity will the nurse manager attend to first? A. Stocking the medication closet B. Client assignments for the day C. A phone message from a client's wife D. A phone message from employee health services

B. Client assignments for the day

A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply. A. Family history B. Client needs and priorities of care C. Current diagnosis and any secondary diagnoses D. Results of laboratory studies conducted that day E. Client response to treatments implemented that day F. The steps used to perform the procedure for changing the client's sterile dressing at the gastrostomy tube site

B. Client needs and priorities of care C. Current diagnosis and any secondary diagnoses D. Results of laboratory studies conducted that day E. Client response to treatments implemented that day

Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa)., and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as indicative of which disorder? A. Compensated metabolic acidosis B. Compensated respiratory alkalosis C. Uncompensated metabolic alkalosis D. Uncompensated respiratory acidosis

B. Compensated respiratory alkalosis

A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should take which action? A. Apply the cold compress to the ankle B. Consult with the HCP before applying the cold compress C. Apply the cold compress for 20 minutes, and then apply a hot compress for 20 minutes D. Elevate the ankle and place cold compresses under and on top of the ankle

B. Consult with the HCP before applying the cold compress

A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next? A. Remove the IV catheter B. Contact the health care provider C. Change the solution to 5% dextrose in water D. Obtain a culture of the tip of the catheter device removed from the client

B. Contact the health care provider

A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. Based on this result, which action should the nurse take first? A. Hold the next scheduled feeding B. Contact the nurse-midwife or health care provider C. Document the results in the newborn's medical record D. Ask the laboratory to draw another blood sample in 2 hours and repeat the test

B. Contact the nurse-midwife or health care provider

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse? A. Telling the client that it is her surgeon's responsibility to explain the procedure B. Contacting the surgeon and requesting that she visit the client to answer her questions C. Informing the client that she has the right to cancel the surgical procedure if she wishes D. Telling the client that she needed to ask these questions before signing the informed consent for surgery

B. Contacting the surgeon and requesting that she visit the client to answer her questions

Risperidone is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study does the nurse expect to see among the health care provider's prescriptions? A. Platelet count B. Creatinine level C. Sedimentation rate D. Red blood cell count

B. Creatinine level

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect? A. Be drying to nasal passages B. Decrease the client's oxygen-based respiratory drive C. Increase the risk of pneumonia as a result of drier air passages D. Decrease the client's carbon dioxide-based respiratory drive

B. Decrease the client's oxygen-based respiratory drive

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output C. Increased blood pressure D. Increased respiratory rate E. Decreased respiratory depth

B. Decreased urine output

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply. A. Are specific guidelines B. Define professional practice C. Have some similarity to policies and procedures D. Are statements that relate only to the agency in which the nurse is employed E. Are authoritative statements that describe a common or acceptable level of client care or performance

B. Define professional practice C. Have some similarity to policies and procedures E. Are authoritative statements that describe a common or acceptable level of client care or performance

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. What should the nurse tell the client? A. Complementary alternative therapies should not be used during pregnancy B. Devices that apply pressure alone are available over the counter C. The health care provider or nurse-midwife needs to provide a prescription for acupressure D. It is all right to try any type of complementary alternative therapy to relieve the nausea

B. Devices that apply pressure alone are available over the counter

A nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa, to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single-use vial. What should the nurse do to prepare the medication? A. Shake the vial before drawing up the medication B. Draw up the medication and discard the unused portion C. Obtain the medication from the medication freezer and allow it to thaw D. Mix the medication with 0.1 mL of heparin before administration to prevent clotting

B. Draw up the medication and discard the unused portion

A home health nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which instruction should the nurse provide to the client? A. Place an ice pack on the lips if they swell B. Drink at least 8 glasses of fluid every day C. Take the medication on an empty stomach 2 hours before meals D. Use an over-the-counter (OTC) antihistamine lotion if a rash develops

B. Drink at least 8 glasses of fluid every day

A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client? A. Administering a laxative B. Encouraging fluid intake C. Maintaining the client on strict bed rest D. Holding all medications for at least 2 hours

B. Encouraging fluid intake

The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed C. Ask the client whether she would like to remove the wedding band or wear it to surgery D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery

B. Explain to the client why the wedding band must be removed

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should: A. Allow the television crew to videotape the program B. Explain to the television crew that videotaping is not allowed C. Ask the television crew to interview the individuals attending the program individually D. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization

B. Explain to the television crew that videotaping is not allowed

A nurse performing a cranial nerve assessment is testing the function of the oculomotor, trochlear, and abducens nerves. Which of the following parameters does the nurse check to determine the function of these nerves? A. Tongue symmetry B. Eye movements C. Facial symmetry D. Corneal reflex

B. Eye movements

A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? A. Emergency B. Follow-up C. Complete (total) D. Problem-centered

B. Follow-up

A nurse manager discusses staff empowerment with the nursing team. The nurse manager explains that staff empowerment: A. Allows the staff to make every decision regarding employee scheduling B. Fosters the growth of others so that they are less dependent on the leader C. Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery D. Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes

B. Fosters the growth of others so that they are less dependent on the leader

A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse understands that this indicates: A. Full range of motion (ROM) with gravity B. Full ROM against gravity with some resistance C. Full ROM with gravity eliminated (passive motion) D. Full ROM against gravity with full resistance

B. Full ROM against gravity with some resistance

A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain? Select all that apply. A. Mask B. Gown C. Gloves D. Face shield E. Shoe protectors

B. Gown C. Gloves D. Face shield

An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the motherneeds further instruction if she indicates that she will: A. Avoid giving citrus juices to her child B. Have her child use a straw to make drinking easier C. Give acetaminophen (Tylenol) to her child for discomfort D. Give her child extra fluids to relieve a foul odor from the mouth

B. Have her child use a straw to make drinking easier

The nurse brings a meal tray to a psychotic client in his hospital room. The client refuses the meal and says, "I'm not eating any more poisoned food while I'm vacationing here. I'm starting on a fast to stay healthy and alive." Which nursing intervention would be most appropriate initially? A. Taking the tray away and canceling all meals until further notice B. Having the client eat with other clients in the community dining room C. Eating some of the food from the client's tray to prove that it isn't poisoned D. Telling the client that the psychiatrist will be called for a prescription for a tube feeding

B. Having the client eat with other clients in the community dining room

A client with chronic kidney disease is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client? A. Fever and tachycardia B. Headache and confusion C. Bradycardia and hypothermia D. Irritability and generalized weakness

B. Headache and confusion

A client is taking a folic acid supplement. Which laboratory parameter does the nurse use to evaluate the effectiveness of this therapy? Select all that apply. A. Magnesium B. Hemoglobin C. Blood glucose D. Hematocrit E. Alkaline phosphatase

B. Hemoglobin D. Hematocrit

A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which of the following topics does the nurse ask the client about first? A. Her sexual history B. Her menstrual history C. Her obstetrical history D. The presence of vaginal drainage

B. Her menstrual history

Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? A. Low in fat B. High in fiber C. Low in residue D. High in carbohydrates

B. High in fiber

A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, shares with peers, and makes appropriate suggestions during group discussions. Which is most consistent with the client's behavior? A. Manipulation B. Improvement C. Attention-seeking D. A desire to be accepted

B. Improvement

Fluoxetine hydrochloride is prescribed for a client, and the nurse provides instruction regarding the use of the medication. The nurse tells the client that it is best to take the medication at what time? A. At lunchtime B. In the morning C. With the evening meal D. Midafternoon, with an antacid

B. In the morning

A client taking a potassium-retaining diuretic has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). The nurse understands that the kidneys will respond to this via which physiological action? A. Increased sodium retention B. Increased sodium excretion C. Increased glucose retention D. Increased magnesium excretion

B. Increased sodium excretion

The nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the mental health unit observes the client for certain characteristic behaviors. Which characteristic behavior should the nurse observe? A. Hostility B. Inflexibility C. Adaptability D. Extreme fear

B. Inflexibility

The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? A. Enteric B. Inhalation C. Gastrointestinal D. Through open wounds

B. Inhalation

A nurse is inserting an indwelling urinary catheter into a female client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse should take which action? A. Immediately inflate the balloon B. Insert the catheter 2.5 to 5 cm and inflate the balloon C. Wait until the urine flow stops and inflate the balloon D. Insert the catheter until resistance is met and inflate the balloon

B. Insert the catheter 2.5 to 5 cm and inflate the balloon

A nurse is monitoring a client's fluid balance. Which 24-hour intake and output totals indicates to the nurse that the client has the proper fluid balance? A. Intake 1600 mL, output 800 mL B. Intake 1500 mL, output 1400 mL C. Intake 2400 mL, output 2900 mL D. Intake 3000 mL, output 2400 mL

B. Intake 1500 mL, output 1400 mL

A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing: A. Venous insufficiency B. Intermittent claudication C. Sore muscles from overexertion D. Muscle cramps related to musculoskeletal problems

B. Intermittent claudication

A nurse notes that a client has a diagnosis of acute back pain. The nurse plans care based on which characteristic of acute pain? A. It has a prolonged presence B. It is a result of injury C. It lasts longer than 6 months D. It is usually the result of a chronic disorder

B. It is a result of injury

A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which, if documented in the assessment data, indicates to the nurse that the client may be experiencing an adverse effect of the medication? A. Tinnitus B. Jaundice C. No change in peripheral vision D. Pupillary constriction in response to light

B. Jaundice

A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, which action should the nurse take? A. Spend as much time as possible with the toddler B. Keep hospital routines as similar as possible to those at home C. Allow the toddler to play with other children in the nursing unit playroom D. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room

B. Keep hospital routines as similar as possible to those at home

A client who has recently been started on enteral feedings complains of abdominal cramping and diarrhea. The nurse reviews the nutritional content on the label of the can of feeding solution. Which ingredient is the nurse looking for that may be causing this problem? A. Maltose B. Lactose C. Sucrose D. Fructose

B. Lactose

A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips: A. Behind the knee B. Lateral to the extensor tendon of the big toe C. In the groove between the malleolus and the Achilles tendon D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines

B. Lateral to the extensor tendon of the big toe

A client and her newborn have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time? A. Describe the stages of and treatments for HIV B. Listen quietly while the mother talks and cries C. Discuss with the mother how she might have gotten HIV D. Call an HIV counselor and make an appointment for the woman

B. Listen quietly while the mother talks and cries

A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy, nursing assessment is the priority? A. Heart rate B. Lung sounds C. Peripheral pulses D. Level of consciousness

B. Lung sounds

A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain. Which instruction should the nurse provide to the client? A. Decrease fluid intake B. Maintain a high-fiber diet C. Avoid all exercise to help prevent lightheadedness D. Avoid the use of stool softeners to help prevent diarrhea

B. Maintain a high-fiber diet

A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosi

B. Metabolic alkalosis

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3. Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply. A. Providing a soft toothbrush for oral care B. Monitoring the client's oral temperature C. Maintaining sterile occlusion of intravenous (IV) catheters D. Requiring the client to use an electric shaver rather than a razor E. Performing meticulous skin decontamination before venipuncture F. Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure

B. Monitoring the client's oral temperature C. Maintaining sterile occlusion of intravenous (IV) catheters E. Performing meticulous skin decontamination before venipuncture

A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? A. Asks the mother to lie still while both the FHR and the radial pulse rate are counted. B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. C. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. D. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.

B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client needs further teaching if the client is observed doing what? A. Holds the cane on the right side B. Moves the cane when the right leg is moved C. Leans on the cane when the right leg moves forward D. Keeps the cane 6 inches out to the side of the right foot

B. Moves the cane when the right leg is moved

A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if cholecystitis is present? A. Homan sign B. Murphy sign C. Blumberg sign D. McBurney sign

B. Murphy sign

A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A. Paresthesias B. Muscle weakness C. Increased urine output D. Chvostek sign E. Hyperactive deep tendon reflexes

B. Muscle weakness C. Increased urine output

Baclofen is prescribed for a client with a spinal cord injury who is experiencing muscle spasms. While providing instructions to the client, which side effect does the nurse tell the client is possible? A. Photosensitivity B. Nasal congestion C. Increased appetite D. Increased salivation

B. Nasal congestion

A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion (ROM) of the cervical spine? A. Headache B. Neck trauma C. Sinus infection D. Muscle spasms

B. Neck trauma

The nurse in the emergency department is helping care for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors as which type of reaction? A. Signs of depression B. Normal reactions to a devastating event C. Indicative of the need for hospital admission D. Evidence that the client is at high risk for suicide

B. Normal reactions to a devastating event

A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action? A. Recheck the vital signs in 1 hour B. Notify the nurse-midwife of the findings C. Continue collecting subjective and objective data D. Document the findings in the client's medical record

B. Notify the nurse-midwife of the findings

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding? A. Ptosis B. Nystagmus C. Scleral icterus D. Exophthalmos

B. Nystagmus

The nurse is preparing to provide nursing unit information to a client who does not speak English who is being admitted to the mental health unit. Which action is best for the nurse to take to ensure that the client understands the information? A. Asking a family member to translate for the client B. Obtaining a hospital interpreter to communicate with the client C. Asking a hospitalized client who speaks the same language as the client to translate D. Providing the client with a pamphlet that explains the nursing unit information in the client's language

B. Obtaining a hospital interpreter to communicate with the client

A client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which action will be taken after eating the nonfat yogurt? A. Not eating ice cream for 2 days B. Omitting 8 oz of skim milk from that meal C. Omitting salad dressing and butter at lunchtime D. Eating only half of an allowed meat product at supper

B. Omitting 8 oz of skim milk from that meal

A nurse reviewing a client's healthcare record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the nurse determine that the client has? A. Scoliosis B. Osteoarthritis C. Rotator cuff lesions D. Carpal tunnel syndrome

B. Osteoarthritis

A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement: A. Describes the benefits available to employees B. Outlines what the organization plans to accomplish C. Identifies the policies and procedures of the organization D. Defines the rules of the organization that the employees must follow

B. Outlines what the organization plans to accomplish

A nurse observes an unlicensed assistive personnel (UAP) communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the UAP performs which action? A. Uses short sentences B. Overarticulates words C. Uses facial expressions or gestures D. Speaks at a normal rate and volume

B. Overarticulates words

A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client's medical history? A. Pancreatitis B. Pacemaker insertion C. Type 1 diabetes mellitus D. Chronic airway limitation

B. Pacemaker insertion

A nurse is reviewing the medical notes of a client seen by the health care provider to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which finding is documented? A. Amenorrhea B. Palpable fetal movement C. Thinning of the cervix D. Positive result on home urine test for pregnancy

B. Palpable fetal movement

Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner because: A. It is less painful for the client B. Palpation and percussion can increase peristalsis C. It identifies any potential areas of abdominal tenderness D. It gives the client more time to become comfortable with the examiner

B. Palpation and percussion can increase peristalsis

A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which foods? Select all that apply. A. Milk B. Peanuts C. Chicken D. Broccoli E. Asparagus F. Whole-grain cereals

B. Peanuts E. Asparagus F. Whole-grain cereals

A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign? A. Testing the strength of each muscle joint B. Percussing at the location of the median nerve C. Checking for repetitive movements in the joints D. Asking the client to hold the hands back to back while flexing the wrist 90 degrees

B. Percussing at the location of the median nerve

A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? A. Restricting fluid intake for the first 24 hours B. Periodically testing the urine for occult blood C. Avoiding the administration of opioid analgesics D. Having the client ambulate in the room and hall for short distances

B. Periodically testing the urine for occult blood

A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. A. Holding the pair of sterile forceps below waist level area B. Positioning the sterile field so that it remains in full view C. Reaching across the sterile field to pick up a sterile gauze D. Leaving the room to obtain a bottle of sterile normal saline solution E. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand F. Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

B. Positioning the sterile field so that it remains in full view E. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand F. Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record? A. Night sweats and a low-grade fever B. Positive result on an acid-fast bacillus smear C. Cough and expectoration of mucopurulent sputum D. A tuberculin skin test result that indicates 5 mm of redness

B. Positive result on an acid-fast bacillus smear

Methylergonovine intramuscularly is prescribed for a postpartum client. Before administering the medication, the nurse explains to the client that the medication will promote which effect? A. Reduce lochial drainage B. Prevent postpartum bleeding C. Maintain a normal blood pressure D. Decrease the strength of uterine contractions

B. Prevent postpartum bleeding

A nurse planning care for her assigned clients understands that the purpose of the hospital's standards of care is to: A. Identify methods of treatment B. Provide direction for the practice of nursing C. Provide direction for care on the basis of the client's diagnosis D. Identify new care methods on the basis of current medical research

B. Provide direction for the practice of nursing

Which step should be included in the care of a 13-year-old hospitalized child who has been abused? A. Encouraging the child to avoid the abuser B. Providing a caring environment that fosters the development of trust C. Teaching the child to make intelligent choices when confronted with an abusive situation D. Having the child identify the abuser if that person should visit while the child is hospitalized

B. Providing a caring environment that fosters the development of trust

The nurse coordinates the use of hospice care to visit a dying client who will be going home with his family. Which is a function of hospice services that the nurse should tell the family? A. Helping the client focus completely on his physical health B. Providing bereavement support to the family after the client's death C. Helping the family stop the client's efforts to go out at night with his friends D. Working with the client to sustain hope by talking of recent research breakthroughs regarding his illness

B. Providing bereavement support to the family after the client's death

A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? A. Declaring a disaster B. Providing disaster relief C. Activating disaster medical assistant teams D. Developing a federal disaster response plan

B. Providing disaster relief

According to Erik Erikson's developmental theory, which is a developmental task of the middle adult? A. Redefining self-perception and capacity for intimacy B. Providing guidance during interactions with his children C. Verbalizing readiness to assume parental responsibilities D. Making decisions concerning career, marriage, and parenthood

B. Providing guidance during interactions with his children

A young widow of 18 months says to the nurse, "I'm going to need a babysitter, because I'm going on a blind date at my brother and sister-in-law's house. They fixed me up, but I think it may be too soon." Which statement by the nurse would be therapeutic? A. "Hello? You go girl! You can see it's only natural, can't you?" B. "By the end of a year, most people are able to renew their interest in other people and activities." C. "Nonsense. Your children need a new father, as your family knows. Your husband would want you to go on with life." D. "If it were me, I would be dating other men by now. After 6 months of mourning, most of society feels that it's okay."

B. "By the end of a year, most people are able to renew their interest in other people and activities."

A nurse caring for a 9-month-old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request? A. Remove both restraints B. Remove a restraint from one extremity C. Tell the mother that the restraints may not be removed D. Loosen the restraints after telling the mother that they may not be removed

B. Remove a restraint from one extremity

A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure? A. Eat a regular supper and breakfast B. Remove all metal and jewelry before the test C. Expect diarrhea for a few days after the procedure D. Take all oral medications as scheduled with milk on the day of the test

B. Remove all metal and jewelry before the test

The nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which action is the most appropriate for the nurse to take? A. Contact the client's health care provider B. Report the incident to the nursing supervisor C. Tell the client that the nurse did the right thing in giving the enema D. Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery

B. Report the incident to the nursing supervisor

How does a client who has lost a spouse show that she is successfully completing the tasks of mourning? Select all that apply. A. Relating that its better "he went first" B. Reporting that sleeping alone is so hard now C. Purchasing a smaller car she is comfortable driving D. Placing a picture of her husband on the bedside stand E. Heard explaining to family that illness "took" her husband

B. Reporting that sleeping alone is so hard now C. Purchasing a smaller car she is comfortable driving D. Placing a picture of her husband on the bedside stand

A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take? A. Shake the bottle vigorously B. Request a new bottle from the pharmacy C. Rotate the bottle gently back and forth to mix the globules D. Run the bottle under warm water until the globules disappear

B. Request a new bottle from the pharmacy

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of which? A. Bradycardia CorrectB. Respiratory distress C. Hematoma in the right groin D. Discomfort in the right groin

B. Respiratory distress

A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client? A. Immediately expel the enema B. Retain the enema for several hours C. Expect to defecate within 30 minutes D. Expect to experience cramping induced by the solution

B. Retain the enema for several hours

A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to: A. Sit in soft, deep chairs B. Rock back and forth to start movement C. Exercise in the evening to combat fatigue D. Perform tasks with only the hand that has the tremor

B. Rock back and forth to start movement

A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode? A. Peaked T waves B. ST-segment depression C. Widened QRS complex D. An isolated premature ventricular contraction (PVC)

B. ST-segment depression

A schizophrenic client arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client's hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate? A. Saying nothing and contacting the psychiatrist to sign a commitment order B. Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?" G. Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit D. Asking, "Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?"

B. Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?"

A client who is taking bupropion in an attempt to stop smoking tells a nurse that he has been doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client? A. Insomnia B. Seizures C. Weight gain D. Orthostatic hypotension

B. Seizures

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? A. Supine B. Semi-Fowler C. On the side that has undergone surgery D. Prone on the side that has undergone surgery

B. Semi-Fowler

A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease? A. Hemoglobin B. Serum bilirubin C. Blood urea nitrogen (BUN) D. Erythrocyte sedimentation rate (ESR)

B. Serum bilirubin

A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. A. Bradypnea B. Severe chest pain C. Absence of fetal heart tones D. Increased blood pressure E. Increased frequency of uterine contractions

B. Severe chest pain C. Absence of fetal heart tones

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? A. A bone scan is being performed. B. She will have to discuss the prescribed test with the client. C. The radiology department is not clear as to which test has been prescribed. D. She can read the client's medical record to determine what the health care provider prescribed.

B. She will have to discuss the prescribed test with the client.

A nurse is to administer a dose of digoxin to a client with atrial fibrillation and notes that the client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The nurse determines which about the administration of the dose? A. Should be withheld that day B. Should be administered as prescribed C. Should be preceded with a dose of potassium D. Should be withheld and the health care provider notified

B. Should be administered as prescribed

A health care provider states that a client's insensible fluid loss is approximately 600 mL/day. The nurse interprets this statement to reflect fluid loss occurring through which routes? A. Wound drain and skin B. Skin and mechanical ventilator C. Nasogastric tube and wound drain D. Foley catheter and nasogastric tube

B. Skin and mechanical ventilator

A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure? A. Flexing the feet against a footboard B. Slightly elevating the foot of the bed C. Keeping the head of the bed elevated 45 degrees D. Placing the bed in reverse Trendelenburg position

B. Slightly elevating the foot of the bed

A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the client understands the prescribed regimen? A. Chicken, potatoes, and cranberries B. Spinach salad, milk, and a banana C. Peanut butter sandwich, milk, and prunes D. Linguini with shrimp, tossed salad, and a plum

B. Spinach salad, milk, and a banana

A 35-year-old recently divorced parent of twins comes to the intake office of the psychiatric clinic for the first time with a possible diagnosis of generalized anxiety disorder. The client says to the nurse, "My mother always called me a worrywart like my nana, so I guess I come by my problems naturally. I keep worrying about things I can't change, like my divorce, and blaming myself when I know I'm not the only one responsible for the divorce." Which nursing statement would be therapeutic? A. "Yet you seem to be dwelling on the thought that the divorce is all your fault." B. "Can you tell me more about the worrying and blaming you are experiencing?" C. "I wonder whether you think you're responsible for making everything turn out right." D. "So you're a natural worrywart, divorced with twins. I guess you can be forgiven for a little worrying, but tell me about the blaming you've been doing."

B. "Can you tell me more about the worrying and blaming you are experiencing?"

A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside? A. Flashlight B. Sterile dressing C. Cardiac monitor D. Blood pressure cuff

B. Sterile dressing

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which assessment finding indicates to the nurse that the client is experiencing magnesium toxicity? A. Proteinuria of +3 B. Sudden drop in fetal heart rate C. Presence of deep tendon reflexes D. Serum magnesium level of 2.5 mEq/L (1.25 mmol/L)

B. Sudden drop in fetal heart rate

An adolescent is returning home after an acute psychiatric hospitalization for a suicide attempt. Which strategy will be least effective in preparing the client for discharge? A. Encouraging the sharing of feelings B. Suggesting that the client's mother quit her job C. Identifying the family's strengths and weaknesses D. Offering and providing the family options and resources

B. Suggesting that the client's mother quit her job

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? A. Assessing the client's chest for crepitus once every 24 hours B. Taping the connections between the chest tube and the drainage system C. Adding 20 mL of sterile water to the suction control chamber every shift D. Recording the volume of secretions in the drainage collection chamber every 24 hours

B. Taping the connections between the chest tube and the drainage system

A client who has undergone adrenalectomy is prescribed prednisone. Which finding indicates that the client is experiencing an adverse effect of the medication? A. Dry mouth B. Tarry stools C. Hypotension D. Hypoglycemia

B. Tarry stools

A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client?Select all that apply. A. Tinnitus B. Tarry stools C. Slowed pulse D. Bleeding from the gums E. Increased blood pressure

B. Tarry stools D. Bleeding from the gums

The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client's permission

B. Telling the client that he or she may not leave the hospital

A nurse provides instructions to a female client regarding the procedure for collecting a midstream urine specimen. What should the nurse tell the client? A. That she should douche before collecting the specimen B. That she should cleanse the perineum from front to back C. That she should collect the urine in the cup as soon as the urine flow begins D. That she should collect the specimen at bedtime and bring it to the laboratory the next morning

B. That she should cleanse the perineum from front to back

The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. Which instruction should the nurse give the mother? A. To bring the infant to the pediatrician's office to be checked B. That the crust is to be expected as a normal part of healing C. To remove the crust, using a warm, wet face cloth and a mild soap D. That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours

B. That the crust is to be expected as a normal part of healing

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands that: A. The DNR order may not be changed once it is in effect B. The DNR order requires frequent review as specified by state or agency policy C. The only people who may change the DNR order are members of the client's immediate family D. The DNR order, as written on admission, must remain in effect for the duration of the client's hospitalization

B. The DNR order requires frequent review as specified by state or agency policy

A registered nurse is instructing a group of nursing assistants in the principles of body mechanics. Which of these observations tell the nurse that a student is using the principles appropriately? Select all that apply. A. The assistant leans forward when turning a client in bed. B. The assistant positions a box that is to be lifted between his knees. C. The assistant turns his back to change position while moving a client. D. The assistant keeps the object to be moved as close to his body as possible. E. The assistant helps a client requiring total care into a chair without additional assistance.

B. The assistant positions a box that is to be lifted between his knees D. The assistant keeps the object to be moved as close to his body as possible

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation? A. The client seems anxious B. The client's intake was 360 mL C. The client's wound is healing well D. The client is voiding large amounts

B. The client's intake was 360 mL

A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? A. The infant babbles. B. The infant says "Mama." C. The infant smiles and coos. D .The infant babbles single consonants.

B. The infant says "Mama."

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is especially important? A. The religious affiliation or church of preference B. The names of close friends and family member C. What medications have been prescribed and what the client knows about their side effects D. The name of the person from whom the client contracted TB, so that the person may be reported for follow-up care

B. The names of close friends and family members

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? A. Improvement in the client B. The need for antiretroviral therapy C. The need to discontinue antiretroviral therapy D. An effective response to the treatment for HIV

B. The need for antiretroviral therapy

The nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, "The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection." Which statement accurately describes the nurse's response to the client? A. The nurse could be charged with battery. B. The nurse could be charged with assault. C. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the physician

B. The nurse could be charged with assault.

After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. A. The restraints are applied tightly. B. The restraints are being released every 2 hours. C. A safety knot has been used to secure the restraints D. The restraints have been tied to the siderails of the bed. E. The call light has been placed within reach of the client.

B. The restraints are being released every 2 hours. C. A safety knot has been used to secure the restraints E. The call light has been placed within reach of the client.

A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. A. The use of latex gloves B. The use of shielded needles C. The use of recessed needles D. The use of needleless devices E. Disposal of needles in special puncture-resistant containers

B. The use of shielded needles C. The use of recessed needles D. The use of needleless devices E. Disposal of needles in special puncture-resistant containers

A nurse is providing instructions to a client regarding quinapril hydrochloride. The nurse should teach the client to implement which measure? A. To take the medication with meals B. To rise slowly from a lying to a sitting position C. To discontinue the medication if nausea occurs D. That a therapeutic effect will be felt immediately

B. To rise slowly from a lying to a sitting position

A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client's condition? A. Complaint of headache B. Trace protein in the urine C. Blood pressure 148/94 mm Hg D. Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L)

B. Trace protein in the urine

A nurse preparing to perform an abdominal assessment asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity? A. Dullness B. Tympany C. Borborygmus D. Hyperresonance

B. Tympany

A health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? A. Supine B. Upright C. Left side-lying D. Right side-lying

B. Upright

Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client? A. Nausea B. Vertigo C. Vomiting D. Hypotension

B. Vertigo

A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which parameter should the nurse assess just before hanging the transfusion? A. Skin color B. Vital signs C. Latest platelet count D. Urine output over the last 24 hours

B. Vital signs

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items: A. Within the client's reach on the left side B. Within the client's reach on the right side C. Just out of the client's reach on the left side D. Just out of the client's reach on the right side

B. Within the client's reach on the right side

A 35-year-old female client asks the clinic nurse when she should begin to have yearly mammograms. What does the nurse tell the client? A. Yearly mammograms are recommended starting at age 25. B. Yearly mammograms are recommended starting at age 40. C. Yearly mammograms are not necessary unless there is a family history of breast cancer. D. Yearly mammograms are recommended starting at the age of 20 and continuing until menopause begins.

B. Yearly mammograms are recommended starting at age 40.

A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods listed on the client's shopping list indicate to the nurse that the client has understood the information? Select all that apply. A. Eggs B. Yogurt C. Parsley D. Broccoli E. Cucumbers F. Cranberry juice

B. Yogurt C. Parsley F. Cranberry juice

APTT

(Heparin) 60-70 sec (INR and PT TR=1.5-2.5 times normal)

omphalocele and gastroschisis

(herniation of abdominal contents) dress with loose saline dressing covered with plastic wrap, and keep eye on temp. Kid can lose heat quickly.

A client in halo traction says to the nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which response by the nurse is therapeutic? A. "No one ever gets used to that thing! It's horrible." B. "If I were you, I'd have had the surgery rather than suffer like this." C. "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move." D. "Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don't you think?"

C. "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move."

A client in the mental health unit tells the nurse, "My husband makes all the decisions about money, but I'm the one who's making the money now, not him. He needs to back off, but he's always directing every decision we make." Which nursing response would be the most therapeutic? A. "Have you told your husband to back off"? B. "You're making the most money, so the decisions should be left to you." C. "How do you feel the money decisions could best be handled in your household?" D. "You seem frustrated with your husband's habit of controlling financial decisions."

C. "How do you feel the money decisions could best be handled in your household?"

A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states: A. "It's important for me to drink a lot of fluids." B. "A fad diet or starvation diet can cause an acute attack." C. "I don't need medication unless I'm having a severe attack." D. "Physical and emotional stress can cause an attack."

C. "I don't need medication unless I'm having a severe attack."

A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? A. "I should always maintain good posture." B. "I should stop my exercises if I get tired." C. "I should avoid all exercise when my joints are inflamed." D. "Doing range-of-motion exercises every day will ease the pain."

C. "I should avoid all exercise when my joints are inflamed."

The nurse is evaluating the coping skills of a client with a diagnosis of depression. Which statement indicates to the nurse the need to help the client learn and appropriately use these skills? A. "I need to take my medications." B. "I know that I can't do everything." C. "I won't ever be depressed again." D. "I have learned ways to deal with stress."

C. "I won't ever be depressed again."

A schizophrenic client is seen seemingly talking to someone who isn't there. Which nursing statement would be most therapeutic initially? A. "Today is my birthday. Would you like to go on an outing with my family?" B. "You need to wash up and get ready to go to supper in the cafeteria with the other clients now." C. "I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices." D. "You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?"

C. "I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices."

The wife of an alcoholic client says to the nurse, "I can't afford to bail my husband out of this mess. Our business is filing for bankruptcy, and the Internal Revenue Service has posted a notice of auction on our home." Which statement by the nurse would be therapeutic? A. "You're having a very difficult time, and the problem stems entirely from your husband's drinking." B. "It's a shame. So many troubling things have been happening to you both because of the disease of alcoholism." C. "The lack of money has stopped you from saving your husband? It sounds like you need to help yourself right now. What do you think?" D. "You're codependent with your husband. Don't you see this? Are you willing to attend some group meetings to learn about ways to deal more effectively with your problem?"

C. "The lack of money has stopped you from saving your husband? It sounds like you need to help yourself right now. What do you think?"

A client in group therapy says to the two nurses conducting the group, "You two are great at psychoanalyzing us, but what about you two? Do you have trouble being assertive with your bosses or the doctors like we do?" Which statement by one of the nurses would be most therapeutic? A. "Maybe some others in this group want to talk about the assignment that we all agreed would be completed today." B. "Why do I feel attacked by someone whom I'm trying to help? Could it be that you don't want to work in this group anymore?" C. "You're interested in talking with us about our assertiveness, but this group is for all of you here to help you to deal with problems more effectively." D. "Your deflection from your own problems here in this group is inappropriate. Let us remind you that you signed up for this group and agreed to participate in it."

C. "You're interested in talking with us about our assertiveness, but this group is for all of you here to help you to deal with problems more effectively."

The wife of a victim of a gas explosion says, "It's not bad enough that I've been left alone to care for two children — now the company is denying our claim for compensation and we have to join a class action suit to get my husband's pension." Which statement by the nurse would be therapeutic? A. "Get a lawyer! That's what you all need to do." B. "Do you believe that a class action suit is the correct thing and that you are in the right?" C. "You're saying that being left a widow with children is difficult enough, but now you've got to fight for your benefits." D. "Walk away. It's too much to even think about at your age, and how can you get caught up in all this with children and work, too?"

C. "You're saying that being left a widow with children is difficult enough, but now you've got to fight for your benefits."

A client who has twice attempted suicide says, "If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do." Which response should the nurse give to the client? A. "Of course you can't be left alone to get on with what you want to do." B. "Okay, go ahead and do whatever you want to do. Human beings have free will." C. "You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?" D. "Sounds like you're angry with people for caring enough about you to try to keep you from hurting yourself."

C. "You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?"

A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately: A. Calls a code B. Holds the infant in an upright position C. Places the infant in the knee-chest position D. Contacts the respiratory therapy department

C. Places the infant in the knee-chest position

A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which actions does the nurse tell the client to take? Select all that apply. A. Sleep lying on her back B. Shower daily but avoid sitting in a bathtub C. Apply cool compresses to the hemorrhoids D. Contact the nurse-midwife if any bleeding occurs E. Elevate her hips on a pillow when resting or during sleep

C. Apply cool compresses to the hemorrhoids E. Elevate her hips on a pillow when resting or during sleep

A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teachingif the client indicates that he plans to do what as part of aftercare? A. Use the antibiotic ointment as prescribed B. Return in 7 days to have the sutures removed C. Apply cool compresses to the site twice a day for 20 minutes D. Call the health care provider if excessive drainage from the wound occurs

C. Apply cool compresses to the site twice a day for 20 minutes

A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor's house and notes that the child has sustained a contusion of the eye. The nurse advises the child's mother to immediately: A. Call an ambulance B. Call an optometrist C. Apply ice to the affected eye D. Irrigate the eye with cool water

C. Apply ice to the affected eye

A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precaution does the nurse understand is most appropriate to help ensure the safety of this client? A. Doubling the dose of anticoagulant B. Applying a pressure bandage to the site after each IM injection C. Applying prolonged pressure to the sites of the IM and SC sites D. Decreasing the sizes of the needles used for the IM and SC injections

C. Applying prolonged pressure to the sites of the IM and SC sites

A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? A. Planning to have the nuclear scan performed at the bedside B. Asking the technicians in the nuclear scan department to wear masks C. Placing a surgical mask on the client for transport and for contact with other individuals D. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued

C. Placing a surgical mask on the client for transport and for contact with other individuals

A client has just undergone insertion of a central venous catheter by the health care provider at the bedside. Which result would the nurse be sure to check before initiating infusion of the IV solution that the health care provider has prescribed? A. Serum osmolality B. Serum electrolytes C. Portable chest x-ray D. Intake and output record

C. Portable chest x-ray

A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. Which action should the nurse take immediately? A. Notify the nurse-midwife or health care provider B. Perform a vaginal examination on the mother C. Position the mother so that her hips are elevated D. Insert a gloved finger into the mother's vagina to feel for cord compression

C. Position the mother so that her hips are elevated

A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relations are poor. He then tells the nurse that the symptoms started after his best friend was killed in the terrorist attack at the World Trade Center. The nurse suspects that the client is experiencing which disorder? A. Social phobia B. Panic disorder C. Post-traumatic stress disorder D. Obsessive-compulsive disorder

C. Post-traumatic stress disorder

The nurse working in a mental health unit reads a client's medical record and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of which disorder? A. Depression B. Schizophrenia C. Post-traumatic stress disorder D. Obsessive-compulsive disorder

C. Post-traumatic stress disorder

A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which substance? A. Fats B. Vitamins C. Potassium D. Carbohydrates

C. Potassium

The mental health nurse is conducting the initial assessment of an obese client. The client confides that she was sexually molested at age 7 and began putting on weight thereafter. The nurse determines that the client's symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents which? A. Satisfaction with self B. A form of functional coping C. Protection from the risk of intimacy D. Long-term lack of compliance with weight programs

C. Protection from the risk of intimacy

A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which intervention does the nurse include in the plan? A. Keeping the room warm B. Placing extra blankets on the client C. Providing a high-calorie, high-protein diet D. Encouraging frequent ambulation and activities

C. Providing a high-calorie, high-protein diet

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately: A. Refuse to do the assignment B. Tell the nurse manager to call the nursing supervisor C. Ask the nurse manager of the intensive care unit to discuss the assignment D. Return to the medical care unit and discuss the assignment with the nurse manager on that unit

C. Ask the nurse manager of the intensive care unit to discuss the assignment

A nurse is developing a plan of care for a client who reports difficulty sleeping. Which initial intervention does the nurse include in the plan of care? A. Offering the client a sleeping pill at night B. Providing the client with a snack at bedtime C. Asking the client what is done to prepare for sleep D. Leaving the television in the client's room on at a very low volume

C. Asking the client what is done to prepare for sleep

A nurse is developing a plan of care for an older client who is being admitted to a long-term care facility. Which intervention should the nurse include in the plan of care to help maintain an appropriate bowel elimination pattern? A. Limiting vegetable intake to one serving per day B. Limiting whole grains to three servings per week C. Providing cooked fruits such as prunes or apricots D. Including spicy foods in the diet to increase peristalsis

C. Providing cooked fruits such as prunes or apricots

A home health nurse is performing an assessment of a client's skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client? A. Putting on a pair of gloves B. Donning a mask and gloves C. Putting on a gown and gloves D. Avoiding sitting on the client's furniture

C. Putting on a gown and gloves

A nurse is admitting a postoperative client from the postanesthesia care unit to the surgical nursing unit. Which of the following measures should the nurse take for the safety of the client? A. Asking the client to slide from the stretcher to the bed B. Quickly moving the client from the stretcher to the bed C. Putting the siderails up after moving the client from the stretcher D. Uncovering the client before making the transfer from the stretcher to the bed

C. Putting the siderails up after moving the client from the stretcher

A client with obsessive-compulsive disorder who continually cleans her room with paper towels becomes enraged with her roommate for throwing the package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which action would the nurse take first? A. Restraining the client B. Filling out an incident report C. Removing both clients to safe locations D. Calling the hospital's risk-management department

C. Removing both clients to safe locations

A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which intervention should the nurse implement? A. Restricting visitors B. Placing the client in a private room and locking the bathroom door C. Removing perfume, shampoo, and other toiletries from the client's room D. Placing flowers brought to the client in a small glass vase and putting them in the client's room

C. Removing perfume, shampoo, and other toiletries from the client's room

The nurse is caring for a client who has been identified as a victim of physical abuse. Which action is the priority as the nurse plans care for the client? A. Notifying the caseworker of the situation B. Adhering to mandatory abuse reporting laws C. Removing the client from any immediate danger D. Obtaining treatment for the abusing family member

C. Removing the client from any immediate danger

A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa), HCO3 26 mEq/L (26 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid-base imbalance does the nurse recognize in these findings? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the following actions does the nurse ask the client to take to aid assessment of this nerve? A. Smiling B. Clenching the teeth C. Shrugging the shoulders against the nurse's resistance D. Identifying by taste a substance placed on the back of the tongue

C. Shrugging the shoulders against the nurse's resistance

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? A. Remove the IV B. Sit the client up in bed C. Shut off the IV infusion D. Slow the rate of infusion

C. Shut off the IV infusion

A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness D. Hyperactive bowel sounds E. Hyperactive deep tendon reflexes

C. Skeletal muscle weakness D. Hyperactive bowel sounds

Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. A. The client's temperature B. The client's 24-hour urine output C. Skin integrity of the restrained body part D. The procedure used in applying the restraint E. The date and time of application of the restraint F. Circulatory and neurovascular status of the restrained extremities

C. Skin integrity of the restrained body part D. The procedure used in applying the restraint E. The date and time of application of the restraint F. Circulatory and neurovascular status of the restrained extremities

A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client's physician does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is appropriate? A. Asking a family member to sit with the client B. Asking a nursing assistant to monitor the client C. Staying with the client and consulting with the nurse manager about the situation D. Telling the family that the application of wrist restraints is critical in preventing injury to the client

C. Staying with the client and consulting with the nurse manager about the situation

A nurse has a written prescription to remove an intravenous (IV) line. Which item should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter? A. Alcohol swab B. Adhesive bandage C. Sterile 2 × 2 gauze D. Povidone-iodine (Betadine) swab

C. Sterile 2 × 2 gauze

A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? A. Diaphragm B. Spermicide C. Sterilization D. Male condom

C. Sterilization

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink? A. Straw B. Napkin C. Suction equipment D. Oxygen saturation monitor

C. Suction equipment

A client is receiving intravenous meperidine hydrochloride as prescribed. For which side/adverse effects does the nurse assess the client while the clientis receiving this medication? Select all that apply. A. Polyuria B. Diarrhea C. Tachycardia D. Hypotension E. Mental clouding

C. Tachycardia D. Hypotension E. Mental clouding

A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

C. Tachypnea, dizziness, and paresthesias

A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse tells the client to: A. Contact the health care provider if a fever over 102° F occurs B. Refrain from eating or drinking during periods of vomiting C. Take the prescribed insulin dose even if he is unable to eat D. Contact the health care provider when the premeal blood glucose value is greater than 350 mg/dL

C. Take the prescribed insulin dose even if he is unable to eat

A young adult client who is dying says to the nurse, "I keep asking my wife what I can do for her and our daughter before I die, but she refuses to tell me." Based on the client's statement, what is the appropriate nursing intervention? A. Teaching the client's wife to write down her thoughts and feelings and to read them to her husband B. Saying to the client, "It sounds to me like your wife is truly comfortable and doesn't want you to worry needlessly" C. Talking with both the client and his wife about the importance of expressing their feelings and how to do it in healthy ways D. Talking with all family members, including the daughter, about the importance of expressing their concerns and feelings to the dying client

C. Talking with both the client and his wife about the importance of expressing their feelings and how to do it in healthy ways

A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict? A. Ignoring the resistance B. Telling the LPN that his noncompliance will be documented in his personnel record C. Confronting the LPN and encouraging him to express his feelings regarding the change D. Telling the LPN that a registered nurse will perform all of the computer documentation if he will document all intake and output and vital signs

C. Confronting the LPN and encouraging him to express his feelings regarding the change

A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict? A. Ignoring the complaints B. Avoiding assigning the nurse mandatory overtime C. Confronting the nurse regarding her behavior regarding the overtime policy D. Providing a positive reward system for the nurse so that the nurse will agree to work the mandatory overtime

C. Confronting the nurse regarding her behavior regarding the overtime policy

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately: A. Suctions the client B. Obtains a pulse oximeter C. Contacts the health care provider D. Increases the rate of the client's intravenous (IV) solution

C. Contacts the health care provider

A nurse is preparing to perform a digital removal of feces on a client with an impaction. The nurse checks the client's heart rate before performing the procedure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the procedure to allow the client to rest. During this time the nurse checks the client's heart rate again and counts 82 beats per minute. The nurse should take which action? A. Contact the health care provider B. Discontinue the digital removal procedure C. Continue the digital removal procedure D. Wait 1 hour and then continue the digital removal procedure

C. Continue the digital removal procedure

The nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should have which focus? A. Follow-up appointments B. Providing the hospital phone number C. Contracts and immediate available crisis resources D. Encouraging the family to always be with the client

C. Contracts and immediate available crisis resources

Which food should the nurse offer to a client who has been prescribed a full liquid diet? A. Toast B. Plain bagel C. Cooked custard D. Scrambled eggs

C. Cooked custard

A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. Which items in the home increase the client's risk for injury? Select all that apply. A. A nightlight in the bathroom B. Elevated toilet seat with armrests C. Cooking equipment such as a stove D. Smoke and carbon monoxide detectors E. Common household objects such as doormats F. A water heater thermostat adjusted to a low setting

C. Cooking equipment such as a stove E. Common household objects such as doormats

A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? A. Data related to follow-up care B. A complete (total health) database C. Data related to the respiratory system D. Data related to the treatment for the cold

C. Data related to the respiratory system

A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 88 seconds (88 seconds). The client's baseline before the initiation of therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is needed? A. Shutting off the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is

C. Decreasing the rate of the heparin infusion

A nurse is preparing to initiate a continuous tube feeding, using a tube-feeding pump. On bringing the pump to the bedside and preparing to plug the pump in, the nurse discovers that there is no available plug in the wall socket. What should the nurse do? A. Plug in the pump cord into an available plug above the sink B. Ask the physician to change the prescription to intermittent feedings C. Determine the need for the appliances now plugged into the needed wall socket D. Use a regular extension cord to allow the use of more than one electrical appliance

C. Determine the need for the appliances now plugged into the needed wall socket

A nurse is reviewing the medical record of an older client with presbycusis. Which finding should the nurse expect to note in the client's record? A. Unilateral conductive hearing loss B. Difficulty hearing low-pitched tones C. Difficulty hearing whispered words in the voice test D. Improved hearing ability during conversational speech

C. Difficulty hearing whispered words in the voice test

A client who needs to receive a blood transfusion has experienced a pruritic rash during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which medication does the nurse anticipate will most likely be prescribed before the transfusion? A. Ibuprofen B. Acetaminophen C. Diphenhydramine D. Acetylsalicylic acid

C. Diphenhydramine

The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother scolded her for picking the neighbors' flowers. Which defense mechanism used by the child does the nurse identify in the mother's report? A. Projection B. Sublimation C. Displacement D. Identification

C. Displacement

A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring? A. Decreasing pulse B. Rising blood pressure C. Distant muffled heart sounds D. Falling central venous pressure (CVP)

C. Distant muffled heart sounds

Polyethylene glycol-electrolyte solution is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? A. Administering a cleansing enema. B. Calling the health care provider C. Documenting the diarrhea in the medical record D. Giving intravenous replacement fluids in large amounts

C. Documenting the diarrhea in the medical record

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? A. Fetoscope B. Stethoscope C. Doppler transducer D. Pulse oximetry on the client and a fetoscope

C. Doppler transducer

A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure? A. Eat only a light breakfast B. Wear comfortable clothing and shoes C. Drink 6 to 8 glasses of water without voiding D. Stop eating or drinking at midnight before the test

C. Drink 6 to 8 glasses of water without voiding

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which menu selection, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction? A. Pork B. Beef C. Eggs D. Raisins

C. Eggs

The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution? A. Pulse oximeter B. Blood glucose meter C. Electronic infusion device D. Noninvasive blood pressure monitor

C. Electronic infusion device

A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse include in the plan? A. Encouraging at least one daytime nap B. Discouraging the use of a night light at bedtime C. Encouraging bedtime reading or listening to music D. Discouraging social interaction, particularly at bedtime

C. Encouraging bedtime reading or listening to music

A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Whichpriority intervention does the nurse include in the plan? A. Encouraging oral fluid intake B. Maintaining the client in a supine position C. Encouraging coughing and deep breathing D. Administering the morphine sulfate around the clock

C. Encouraging coughing and deep breathing

The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. When should the nurse tell the mother the child should have dental examinations? A. Once a year B. Every 3 months C. Every 6 months D. Whenever a new primary tooth erupts

C. Every 6 months

A schizophrenic client in the psychiatric inpatient unit is yelling, "The CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." Based on the client's statement, which clinical manifestation should the nurse document in the client record? A. Demonstrates paranoia B. Exhibits ideas of reference C. Evidence of persecutory delusions D Evidence of ideas of somatic delusions

C. Evidence of persecutory delusions

A nurse educator is providing an inservice program to emergency department nurses about the signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of inhalation anthrax is: A. Hemorrhage B. Signs of shock C. Flulike symptoms D. Respiratory distress

C. Flulike symptoms

A physician writes a prescription for the application of a heating pad to a client's back. Which of the following actions should the nurse take when implementing this prescription? Select all that apply. A. Placing the heating pad under the client B. Adjusting the heating pad to the high setting C. Frequently assessing the client's skin for signs of burns D. Assessing the client's medical history and risk factors for burns E. Assessing the heating pad periodically for proper electrical function

C. Frequently assessing the client's skin for signs of burns D. Assessing the client's medical history and risk factors for burns E. Assessing the heating pad periodically for proper electrical function

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Which of the following protective devices worn by the LPN would cause the RN to determine that the LPN was performing the procedure safely? A. Gloves and mask B. Gloves and gown C. Gloves, gown, and face shield. D. Gown and protective eyewear

C. Gloves, gown, and face shield.

The nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD). Which should be the nurse's primary focus? A. Group therapy B. Recreational therapy C. Goals and objectives D. The client's medical diagnosis

C. Goals and objectives

A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first? A. Call the health care provider B. Call the pharmacy for further instructions C. Hang a solution of 10% dextrose in water D. Hang a solution of 5% dextrose in 0.9% sodium chloride

C. Hang a solution of 10% dextrose in water

A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? A. Pruritus B. Vomiting C. Headache D. Hypertension

C. Headache

A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and do what? A. Exhale during tube removal B. Bear down during tube removal C. Hold the breath during tube removal D. Breathe normally during tube removal

C. Hold the breath during tube removal

A nurse performing a musculoskeletal assessment of a client with suspected carpal tunnel syndrome plans to perform the Phalen test. The nurse should ask the client to: A. Dorsiflex the foot B. Plantarflex the foot C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds

C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds

A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? A. Prevent the client from getting a nosebleed B. Give the client added fluid by way of the respiratory tree C. Humidify the oxygen that is bypassing the client's nose D. Prevent fluid loss from the lungs during mouth breathing

C. Humidify the oxygen that is bypassing the client's nose

While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which of the following findings does the nurse expect to note when auscultating the client's bowel sounds? A. Hypoactive bowel sounds B. Low-pitched bowel sounds C. Hyperactive bowel sounds D. An absence of bowel sounds

C. Hyperactive bowel sounds

A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client? A. Age B. Ethnicity C. Hypertension D. Genetic inheritance

C. Hypertension

The psychiatric nurse is caring for a 15-year-old girl who has been hospitalized for bipolar disorder. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. Which defense mechanism should the nurse recognize that the client is using? A. Projection B. Regression C. Identification D. Intellectualization

C. Identification

A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reports that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: A. Suggesting a reduction of medication B. Allowing increased in-room activities C. Increasing the level of suicide precautions D. Allowing the client off-unit privileges as necessary

C. Increasing the level of suicide precautions

A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child's condition: A. Indicates improved neurological status B. Indicates decreased intracranial pressure C. Indicates deterioration in neurological function D. Is unchanged from the previous neurological assessment

C. Indicates deterioration in neurological function

A client's son and daughter were killed during a fellow student's murderous rampage at their high school 9 months ago. The client says to the nurse, "My wife and I just feel empty and exhausted. I can't believe that I had a vasectomy after our son and daughter were born because we wanted to give them both whatever they needed. We have college funds for both of them that they'll never use now." The nurse should make which appropriate statement to the client? A. "My parents would be devastated if they lost me and my sister, too. How can I be of service to you?" B. "Your feelings are appropriate for the extent of your loss and how your children's deaths happened." C. "Your loss touches me so. How truly devastated you both must be. Can you share what things you have been doing to grieve?" D. "Your loss is incalculable. Perhaps you could consider some ways in which to commemorate their lives for you and in your community."

C. "Your loss touches me so. How truly devastated you both must be. Can you share what things you have been doing to grieve?"

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? A. 3 mcg/mL B. 8 mcg/mL C. 16 mcg/mL D. 28 mcg/mL

C. 16 mcg/mL

A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of: A. 1 inch B. 1½ inches C. 2 inches D. 4 inches

C. 2 inches

A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse? A. 4+ B. 3+ C. 2+ D. 1+

C. 2+

A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How should the nurse document this finding? A. 1+ edema B. 2+ edema C. 3+ edema D. 4+ edema

C. 3+ edema

A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of of how many inches? A. 1½ inches B. 3 inches C. 4 inches D. 6 inches

C. 4 inches

An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the clientestimating that the client has approximately how many mL inthe bladder if the client is feeling a sensation of fullness? A. 100 mL B. 250 mL C. 400 mL D. 800 mL

C. 400 mL

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? A. 85% B. 89% C. 95% D. 100%

C. 95%

Which client is at the highest risk for suicide? A. A 24-year-old man who is angry with his family B. A 71-year-old man with mild depression and social withdrawal C. A 75-year-old woman with severe depression and crippling arthritis D. A 30-year-old newly divorced woman who has custody of her children

C. A 75-year-old woman with severe depression and crippling arthritis

A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? A. A client on bedrest who needs assistance with feeding B. A client who must be turned and repositioned every 2 hours C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments D. A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures

C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments

A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? A. A client who requires periodic suctioning B. A client who needs a colostomy irrigation C. A client who needs frequent ambulation with a walker D. A client who has undergone an arteriogram and requires close monitoring

C. A client who needs frequent ambulation with a walker

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply. A. A client with a permanent tracheostomy B. A client requiring a gastrostomy tube dressing change C. A client who requires transport to the radiology department in a wheelchair D. A client with a Foley catheter for whom a 24-hour urine collection is in progress E. A client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter

C. A client who requires transport to the radiology department in a wheelchair D. A client with a Foley catheter for whom a 24-hour urine collection is in progress

A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms

C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema

An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of which type of crisis? A. A situational crisis B. An individual crisis C. A maturational crisis D. An adventitious crisis

C. A maturational crisis

The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the health care provider. The health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first? A. Call the nursing supervisor B. Explain the procedure to the client, then remove the chest tube C. Inform the health care provider that removal of a chest tube is not a nursing procedure D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube

C. Inform the health care provider that removal of a chest tube is not a nursing procedure

A client is found to have AIDS. What is the nurse's highest priority in providing care to this client? A. Providing emotional support to the client B. Discussing the cause of AIDS with the client C. Instituting measures to prevent infection in the client D. Identifying risk factors related to contracting AIDS with the client

C. Instituting measures to prevent infection in the client

A nurse has taught a client who is taking lithium carbonate about the medication. The nurse determines that the client needs additional teaching if the client makes which comment to the nurse? A. The medication should be taken with meals B. The lithium blood levels must be monitored very closely C. It is important to decrease fluid intake while taking the medication to avoid nausea D. The health care provider must be called if excessive diarrhea, vomiting, or diaphoresis occurs

C. It is important to decrease fluid intake while taking the medication to avoid nausea

A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. A. Fresh apple B. Raw celery C. Italian bread D. Tossed salad E. Baked chicken F. Well-cooked cheeseburger

C. Italian bread E. Baked chicken F. Well-cooked cheeseburger

A nurse is determining the estimated date of delivery for a pregnant client, using Nägele's rule, and notes documentation that the date of the client's last menstrual period was August 30, 2015. When does the nurse determine the estimated date of delivery to be? A. July 6, 2016 B. May 6, 2016 C. June 6, 2016 D. May 30, 2016

C. June 6, 2016

A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by: A. Palpating the carotid artery in the upper third of the neck B. Palpating both arteries simultaneously to compare amplitude C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery

C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits

A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? A. Infection B. Hypertension C. Low blood pressure D. Loss of cough reflex

C. Low blood pressure

Acccording to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, in which phase are the available resources for the care of infants, older clients, the disabled, and people with chronic health problems addressed? A. Response B. Recovery C. Mitigation D. Preparedness

C. Mitigation

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: A. Normal egophony B. Abnormal vesicular breath sounds C. Abnormal bronchophony D. Normal whispered pectoriloquy

C. Abnormal bronchophony

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse mostconcerned? A. Oxygen saturation of 97% B. Equal breath sounds in both lungs C. Absence of cough and gag reflexes D. Respiratory rate of 20 breaths/min

C. Absence of cough and gag reflexes

The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen. Which medication does the nurse ensure is available? A. Pancreatin B. Phytonadione C. Acetylcysteine D. Protamine sulfate

C. Acetylcysteine

A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? A. Confining the fire B. Extinguishing the fire C. Activating the fire alarm D. Running for the fire extinguisher

C. Activating the fire alarm

A nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease D. Heart failure being treated with loop diuretics

C. Addison disease

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report the amount of lochial flow? A. Scant B. Light C. Moderate D. Heavy

C. Moderate

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should: A. Call the client's health care provider B. Contact the nursing supervisor for directions C. Administer cardiopulmonary resuscitation (CPR) D. Administer oxygen to the client and call the health care provider

C. Administer cardiopulmonary resuscitation (CPR)

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula D. Ensuring that the intravenous (IV) line is patent

C. Administering oxygen by way of nasal cannula

A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which action should the nurse include in the plan of care? A. Encouraging the client to feed herself B. Ensuring that most of the diet consists of liquids C. Monitoring the client during meals to ensure that food is swallowed D. Consulting with the health care provider regarding feeding through an enteral tube

C. Monitoring the client during meals to ensure that food is swallowed

A client asks a nurse about complementary and alternative measures to promote sleep. What should the nurse suggest? A. Herbal therapy B. Acupuncture C. Muscle relaxation techniques D. Traditional Chinese medicine

C. Muscle relaxation techniques

A heroin addict who overdoses on the drug is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are dilated. Which intervention does the nurse anticipate that the emergency department health care provider will prescribe? A. Gastric lavage B. Intravenous fluid C. Naloxone (Narcan) D. Ammonium chloride

C. Naloxone (Narcan)

A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which t signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? A. Pallor, weak pulse, and anuria B. Nausea, vomiting, and oliguria C. Nausea, thirst, and increased urine output D. Sweating, chills, and decreased urine output

C. Nausea, thirst, and increased urine output

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding? A. Document the finding B. Palpate the area for a mass C. Notify the healthcare provider D. Percuss the abdomen to check for tympany

C. Notify the healthcare provider

A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, which action should the nurse take? A. Check the infant for jaundice B. Check the infant's temperature C. Obtain parental consent to administer the vaccine D. Request that a hepatitis blood screen be performed on the infant

C. Obtain parental consent to administer the vaccine

A nurse performing a neurological assessment of an adult client asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing? A. Optic B. Abducens C. Olfactory D. Hypoglossal

C. Olfactory

Erythromycin is prescribed for a client with a respiratory tract infection. The nurse provides instructions to the client regarding the administration of the oral medication and tells the client that it is best to take the medication in which way? A. With juice B. With a meal C. On an empty stomach D. At bedtime, with a snack

C. On an empty stomach

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? A. On the client's teeth B. On the client's forehead C. On the client's mastoid bone D. On the midline of the client's skull

C. On the client's mastoid bone

A nurse teaches a client about healthy dietary measures and explains the MyPlate food plan. The nurse determines that the client understands the information if the client says how many of his grains should be whole grains? A. One-quarter B. One-third C. One-half D. Two-thirds

C. One-half

A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula? A. Irrigate the fistula with 3 mL of normal saline solution B. Infuse 50 mL of normal saline once per 24 hours C. Palpate for a vibrating sensation at the fistula site D. Flush the fistula with 1 mL of heparin solution once per shift

C. Palpate for a vibrating sensation at the fistula site

An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first? A. Heart rate B. Radial pulse rate C. Peripheral pulses D. Blood pressure (BP)

C. Peripheral pulses

The nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. Which characteristic is a hallmark of this disorder? A. Social contacts are important. B. The client is not concerned about food and meal planning. C. Personal relationships tend to become more superficial and distant. D. The client with anorexia will usually keep his or her weight near normal weight.

C. Personal relationships tend to become more superficial and distant.

A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately: A. Pushes the cord gently back into the vagina B. Prepares the client for cesarean delivery C. Places the client in the knee-chest position D. Prepares to administer a tocolytic medication

C. Places the client in the knee-chest position

A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client's vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report D. Telling the nursing supervisor that the physician did not want an incident report completed and filed

C. Telling the physician that the error warrants the completion of an incident report

A nurse is assisting with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? A. Initial B. Primary C. Tertiary D. Secondary

C. Tertiary

A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse should provide which information to the mother? A. That she may start bladder training at any time B. That her child is too young and that she should not yet be worrying about it C. That a child cannot begin to control urination until approximately the age of 24 months D. That bowel training should be started immediately and then begin bladder training in about 1 month

C. That a child cannot begin to control urination until approximately the age of 24 months

A client taking metronidazole for the treatment of trichomoniasis vaginalis calls the clinic nurse to express concern because her urine has turned dark in color. The nurse should provide which information to the client? A. To increase her fluid intake B. To discontinue the medication C. That darkening of the urine is a harmless side effect D. To report to the clinic to see the health care provider

C. That darkening of the urine is a harmless side effect

A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. What should the nurse tell the mother? A. To separate her children during playtime B. That if the behavior continues, she will need to bring her children to a child psychologist C. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity D. To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again

C. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity

A female client asks a nurse about the advantages of using a female condom. Which should the nurse tell the client? A. It can be used along with a male condom B. That it is 100% safe in preventing pregnancy C. That it offers protection against sexually transmitted infections (STIs) D. That it does not have to be discarded after use and can be used several times before a new one must be obtained

C. That it offers protection against sexually transmitted infections (STIs)

During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client: A. That he has glaucoma in the left eye B. That he has glaucoma in the right eye C. That the intraocular pressure in both eyes is normal D. That he needs to increase his fluid intake, because the pressure in the right eye is low

C. That the intraocular pressure in both eyes is normal

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that: A. Consent must be obtained from the family B. The health care provider makes the final decision about a DNR request C. The DNR request should be discussed with the physician, who will write the order D. Oral consent is sufficient and that his request will be honored by all healthcare providers

C. The DNR request should be discussed with the physician, who will write the order

A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? A. The assistant applies a tie knot in the restraint strap. B. The assistant attaches the restraint straps securely to the siderails. C. The assistant applies the restraint so that the strap does not tighten when force is applied against it. D. The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client's skin.

C. The assistant applies the restraint so that the strap does not tighten when force is applied against it.

A nurse is reading the chest x-ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above which anatomical area? A. The first tracheal cartilaginous ring B. The point where the larynx connects to the trachea C. The bifurcation of the right and left main stem bronchi D. The area connecting the oropharynx to the laryngopharynx

C. The bifurcation of the right and left main stem bronchi

An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse concludes that: A. The client has a low cardiac output B. The client has a high cardiac output C. The client has a normal cardiac output D. The client will need a blood transfusion

C. The client has a normal cardiac output

A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction if which is observed? A. The client holds the cane close to the body B. The client holds the cane on the unaffected side C. The client moves the cane and the unaffected side together D. The client uses the cane to support the affected side and to maintain balance

C. The client moves the cane and the unaffected side together

A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? A. The client appears anxious. B. Blood pressure is 170/80 mm Hg. C. The client states that he has a rash. D. The client has diminished reflexes in the legs.

C. The client states that he has a rash.

A client has been taking metoprolol. Which finding indicates to the nurse that the medication is effective? A. The client's ankles are swollen. B. The client's weight has increased. C. The client's blood pressure has decreased. D. The client has wheezes in the lower lobes of the lungs.

C. The client's blood pressure has decreased.

A home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications? A. The client's son B. The client's father C. The client's mother D. The client's grandson

C. The client's mother

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. Which priority instruction does the nurse include in the discharge plan? A. Calling the police B. Self-defense classes C. The locations of shelters D. The importance of leaving the violent situation

C. The locations of shelters

A nurse is caring for an older client who has a bronchopulmonary infection. Why should the nurse monitor the client's ability to maintain a patent airway? A. The normal aging process increases the production of surfactant B. The normal aging process increases respiratory system compliance C. The normal aging process decreases an older client's ability to clear secretions D. The normal aging process decreases the number of alveoli and increases the function of those remaining

C. The normal aging process decreases an older client's ability to clear secretions

Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client's decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.

C. The nurse administers an immunization to a child even though it may cause discomfort.

A nurse reviews a client's urinalysis report. Which finding does the nurse recognize as abnormal? A. pH of 6.0 B. An absence of protein C. The presence of ketones D. Specific gravity of 1.018

C. The presence of ketones

A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. What should the nurse tell the client? A. The test results are normal B. She has developed immunity to the rubella virus C. The test will need to be repeated during the pregnancy D. She must have been exposed to the rubella virus at some point in her life

C. The test will need to be repeated during the pregnancy

A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted? A. The infant turns to the side that is touched. B. The fingers curl tightly and the toes curl forward. C. The toes flare and the big toe is dorsiflexed. D. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.

C. The toes flare and the big toe is dorsiflexed.

An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which information should the nurse provide to the client? A. She should avoid napping during the day B. The only thing that will help is a sleeping pill C. This is a normal occurrence as a person gets older D. She needs to stay up later at night to prevent these awakenings

C. This is a normal occurrence as a person gets older

Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the nurse is providing instructions to the client. The nurse should provide which information to the client? A. To avoid salt while taking this medication B. That it is best to take the medication with food C. To increase fluid intake to 2000 mL to 3000 mL/day D. To drink at least 2 glasses of orange juice every day

C. To increase fluid intake to 2000 mL to 3000 mL/day

Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: A. To transfer the client to a semiprivate room B. That gloves only are needed to care for the client C. To wear gloves and a gown when changing the client's bed linen. D. To wear a gown when caring for the client and remove the gown immediately after leaving the client's room

C. To wear gloves and a gown when changing the client's bed linen.

During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of the: A. Trochlear nerve B. Abducens nerve C. Trigeminal nerve D. Oculomotor nerve

C. Trigeminal nerve

A nurse is caring for a client who has just returned from a cardiac catheterization through the right side of the groin. The client tells the nurse that he feels the urge to urinate. The nurse assists the client in using a urinal, but the client is unable to void. Which action should the nurse take to stimulate the client's micturition reflex? A. Helping the client stand B. Elevating the head of the bed 90 degrees C. Turning on the water in the sink in the client's room and allowing it to run D. Obtaining assistance to ambulate the client to the bathroom in the client's room

C. Turning on the water in the sink in the client's room and allowing it to run

A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she performs which action? A. Washes the diaper area first B. Washes the infant's chest first C. Uncovers only the body part being washed D. Uses a cotton-tipped swab to carefully clean inside the infant's nose

C. Uncovers only the body part being washed

A nurse is watching as an unlicensed assistive personnel (UAP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply. A. Measuring the BP after the client has sat quietly for 5 minutes B. Having the client sit with the arm bared and supported at heart level C. Used a cuff with a rubber bladder that encircles at least 60% of the limb D. Measuring the BP after the client reports that he just drank a cup of coffee E. Allowing the client to talk as the blood pressure is being measured

C. Used a cuff with a rubber bladder that encircles at least 60% of the limb D. Measuring the BP after the client reports that he just drank a cup of coffee

A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act? A. Giving a verbal report to the nurse on the oncoming shift B. Checking neurological signs in a client with a head injury C. Using clean gloves to change a gastrostomy tube dressing D. Contacting a health care provider about a change in a client's blood pressure

C. Using clean gloves to change a gastrostomy tube dressing

A nurse is preparing a plan of care for a pregnant client who will be given oxytocin to induce labor. Which occurrence does the nurse include in the plan of care as a reason for immediate discontinuation of the oxytocin infusion? A. Uterine atony B. Severe drowsiness C. Uterine hyperstimulation D. Early decelerations of the fetal heart rate

C. Uterine hyperstimulation

A nurse in a health care provider's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? A. Wear sweatpants and a heavy sweatshirt B. Eat a small meal just before the procedure C. Wear comfortable rubber-soled shoes such as sneakers D. Avoid consuming caffeine for 30 minutes before the procedure

C. Wear comfortable rubber-soled shoes such as sneakers

A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin's disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? A. Wearing gloves and a mask B. Wearing gloves and a gown C. Wearing gloves, a mask, and eye protection D. Wearing gloves, a mask, and a head covering

C. Wearing gloves, a mask, and eye protection

An emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client? A. Prone B. Supine with the legs straight C. With the knees drawn up to the chest D. Side-lying with the head of the bed flat

C. With the knees drawn up to the ches

The psychiatrist notes that a client being admitted to the inpatient mental health unit uses avoidance and denial to cope with stress. Which positive stress response will the nurse plan to focus on when working with the client? A. Reframing B. Locus of control C.Problem-solving D. Use of social supports

C.Problem-solving

Right hemisphere lesion

Can't recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgement, constantly smiles, denies illness, loss of tonal hearing

(Y)A nurse assesses a burn injury and determines that the client sustained a full-thickness fourth-degree burn if which of the following is noted at the site of injury?

Charring at the wound site.

Restraints

Check restraints every 30 minutes/2 fingers room underneath

Which assessment is most important for the nurse to make before advancing a client from liquid to solid food?

Chewing ability.

Kidney stone

Cholelithiasis Flank pain = stone in kidney or upper ureter Abdominal/scrotal pain = stone in mid/lower ureter bladder

When obtaining a health history a male client tells the nurse that, he has become impotent. What part of his health information is likely to be most significant to the sexual dysfunction he is experiencing?

Client was diagnosed with diabetes 10 years ago

The nurse counseling a client who has developed renal failure and is exploring the client's feelings about dialysis. After determining that the client is active, and is most upset about the disruption in the daily routine, the nurse advises the client to explore which treatment option with the physician?

Continous ambulatory peritoneal dialysis (CAPD)

76. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

D) Aspiration for gastric contents The correct answer is A: Abdominal x-ray

A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. Based on this finding, which priority action should the nurse take? A. Checking the client's uterine fundus B. Notifying the nurse-midwife immediately C. Documenting the vital signs in the client's medical record D. Continuing to check the client's vital signs every 15 minutes

A. Checking the client's uterine fundus

A nurse has taught a client taking a methylxanthine bronchodilator about beverages that must be avoided. Which beverage choices by the client indicate to the nurse that the client needs further education? Select all that apply. A. Cocoa B. Coffee C. Lemonade D. Orange juice E. Chocolate milk

A. Cocoa B. Coffee E. Chocolate milk

A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? A. Left Sims' position B. Lithotomy position C.Knee-chest position D. Right Sims' position

A. Left Sims' position

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? A. Pulse rate B. Blood pressure C. Pulmonary artery systolic pressure D. Pulmonary artery end-diastolic pressure

A. Pulse rate

A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value? A. 140 mg/dL (<3.64 mmol/L) B. 200 mg/dL (<5.2 mmol/L) C. 250 mg/dL (<6.5 mmol/L) D. 300 mg/dL (<7.8 mmol/L)

B. 200 mg/dL (<5.2 mmol/L)

Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level? A. 1.7 mg/dL (101.2 μmol/L) B. 4.4 mg/dL (262 μmol/L) C. 8.9 mg/dL (529.9 μmol/L) D. 12.8 mg/dL (762.1 μmol/L

B. 4.4 mg/dL (262 μmol/L)

A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The nurse immediately: A. Calls a code B. Assesses the client C. Checks the cardiac leads and wires D. Obtains a rhythm strip from the monitor device

B. Assesses the client

The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, the nurse immediately: A. Checks for a radial pulse B. Assesses the client's neurological status C. Increases the flow rate of the client's intravenous infusion D. Begins cardiopulmonary resuscitation (CPR)

B. Assesses the client's neurological status

Potassium and pH

ALKALOSIS: K is LOW Acidosis is just the opposite: K is High

Hepatic encepahlopathy lab

AMMONIA LEVELS

A nurse is reviewing the results of renal function testing in a client with renal calculi. Which finding indicates to the nurse that the client's blood urea nitrogen (BUN) level is within the normal range? A. 2 mg/dL (0.7 mmol/L) B. 18 mg/dL (6.3 mmol/L) C. 25 mg/dL (8.75 mmol/L) D. 35 mg/dL (12.25 mmol/L)

B. 18 mg/dL (6.3 mmol/L)

At 1600 the nurse checks a client's total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time? A. 1700 B. 1800 C. 2000 D. 2100

B. 1800

A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem? A. Skin breakdown B. Injury to the nerves C. An abnormal stance D. A fall and further injury

B. Injury to the nerves

A nurse has administered a dose of furosemide to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on which structure in the kidney? A. Distal tubule B. Loop of Henle C. Collecting duct D. Proximal tubule

B. Loop of Henle

A nurse performing an eye examination uses an ophthalmoscope to best visualize which area? A. Iris B. Cornea C. Optic disc D. Conjunctiva

C. Optic disc

A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication? A. Prunes B. Oranges C. Rhubarb D. Cranberries

C. Rhubarb

A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown? A. Left heel B. Scapulae C. Right heel D. Back of the head

C. Right heel

A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction? Select all that apply. A. Carrots B. Tapioca C. Scallops D. Broccoli E. Chicken liver

C. Scallops E. Chicken liver

A woman is brought to the emergency department after an assault. She presents with complaints of dizziness, dyspnea, visual disturbance, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client's presentation? A. Mild B. Panic C. Severe D. Moderate

C. Severe

MED/SURG/PEDI/GERI - A Nurse stops at the scene of an automobile accident to assist the victims. The nurse notes that a victim has sustained a traumatic open pneumothorax. The nurse implements which immediate action to assist this victim?

Covers the chest wound.

The mother of a 9 year old child who is 5 feet 1 inch in height asks a nurse about car safety seats. What should the nurse tell the mother to use? A. Front booster seat B. Rear convertible seat C. Forward-facing car seat D. Rear seat using lap and shoulder seat belts

D. Rear seat using lap and shoulder seat belts

A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? A. Harsh B. Hollow C. Tubular D. Rustling

D. Rustling

Antidotes

Digoxin...Digiband Coumadin...Vitamin K+ (keep PT/[email protected]) Benzodiazapines...Flumzaemil (Tomazicon) Magnesium sulfate...Calcium gloconate Heparin...Proamine sulfate (keep APTT/[email protected] 2.5xnormal) Tylenol...Mucomist (17 doses+loading dose) Opiates (eg. narcotic analgesics, heroin, morphine)...Narcan (Naloxone) Cholinergic meds (eg. Myesthenic Bradycardia)...Atropine Methotrexate...Leucovorin

A nurse leader of a materinity unit is concerned because staff members openly verbalize racial comments about clients on the unit. The nurse leader would most appropriately manage this concern by:

Discouraging the racial comments.

Insulin draw

Draw regular (clear) insulin into syringe first when mixing insulins

The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action should the nurse implement first?

Dry the infant under a warmer

HyperK+

Due to cell damage and release of intracellular K+

A pt with COPD !ho state that he is using is inhaler right, what should the nurse indicate the pt is not using the inhaler properly?

Pt states that he only uses the inhaler when he is having respiratory distress

If chest tube comes disconnected...

Put free end in container of sterile water

Maslow's hierarchy of needs

Pysiologic, Safety, Love and Belonging, Esteem, Self-actualization

To locate the point of maximum impulse (PMI) of a client's heart, the nurse's hand (fingertips) should be placed over which location? 1. A 2. B 3. C 4. D

QUESTION - Where do you find the PMI? STRATEGY - Picture the anatomy of the heart and its position in the body. NEEDED INFO - PMI: forward thrust of left ventricle during systole produces normal pulsation on chest wall. Indicates size and position of heart. Should be felt in 5th intercostal space. If apical impulse appears in more than one intercostal space, may indicate ventricular enlargement. CORRECT ANSWER - (3) The fifth intercostal space at the midclavicular line. (1) Wrong position. (2) Wrong position. (4) Incorrect.

In case of fire

RACE (rescue, alarm, contain, extinguish) and PASS (pull pin breaking the plastic seal, aim at the base of the fire, squeeze the handles together, and sweep from side to side

Erythema marginatum

Rash of Rheumatic fever

Alexia

Reading

TB

Respiratory isolation

Spinal cord injuries

Respiratory status paramount...C3-C5 innervates diaphram

Renal failure

Restrict protein intake Fluid and electrolyte problems...watch for hyper K+(dizzy, weak, nausea, cramps, arhythmias)

A client who is newly diagnosed with chronic renal failure is scheduled to begin hemodialysis. The nurse interprets which of the following neurological or psychological findings exhibited by the client to be atypical?

Euphoria

The nurse tests a client"s visual acuity and determines that the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye. What does this finding indicate?

Difficulty visualizing objects at a distance also Known as myopia

Hep A preicteric phase

Flulike symptoms

NG tube insertion

If cough and gag, back off a little, let calm advance again with pt sipping water from straw

Which intervention would best maintain a safe environment for a client with severe hypoparathyroidism?

Institute seizure precautions.

Long Acting Insulin

Insulin Glargine (Lantus); O: 1.1 hr. P: 14-20 hrs. (Don't Mix)

Pre-renal problem

Interference with renal perfusion

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. To ensure a safe environment, the nurse plans to have which of the following items readily available at the client's bedside?

Intubation tray

Intermediate Acting Insulin

Isophane Insulin (NPH); O: 1-2 hrs. P: 6-12 hrs.

PTCA

Percutaneous Transluminal Coronary Angioplasty

Apraxia

Perform purposeful movements

Anti-emetics given with Chemotherapy (Cytoxan, Methotrexate, Interferon, etc.)

Phenergan (promethazine HCl), Compazine (prochlorperazine), Reglan (metocolpramide), Benadryl (diphenydramine), Zofran (ondansteron HCl), Kytril (granisetron)

Opiate OD

Pinpoint pupils

Suctioning

Pre and Post oxygenate with 100% O2, no more than 3 passes, no longer than 15 seconds; Suction on withdrawal with rotation

Hypokalemia

Prominent U waves, depressed ST segment, flat T waves

CKD diet

fresh fish, fresh chicken, fresh veggies

Rhogam

given at 28 weeks, 72 hours post partum, IM. Only given to Rh NEGATIVE mother. Also if indirect Coomb's test is positive, don't need to give Rhogam cuz she has antibody only give if negative coombs

45. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output

The correct answer is C: Loss of pulse in the extremity

40. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs

The correct answer is C: Lower the oxygen rate

12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive

The correct answer is C: Participate with the compressions or breathing

77. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs

The correct answer is C: Perform frequent oral care with a tooth sponge

hypertonic solution

a solution that causes a cell to shrink because of osmosis -3% NaCl

hypotonic solution

a solution that causes a cell to swell because of osmosis -D5W

When evaluating the effectiveness of medications administered to a client with parkinson's disease' the nurse recognizes that symptom management requires a balance among which neurotransmitters?

achetylcholine and dopamine

Med of choice for SVT

adenosine or adenocard

NG tube placement

check pH

Pt on PCA pumps morphine and showing respiratory depression

check pump for amount and dose

Variable deceleration

have the client change position (relieve umbilical cord compression) *trendelenberg *If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection.

Birth length

increases by 50% at 12 months

PVD

remember DAVE (Legs are Dependent for Arterial & for Venous Elevated)

caput succinidanium

resolves on its own in a few days. This is the type of edema that crosses the suture lines.

A client who recently received a prescription for Ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug.Which side effects should the nurse report to the healthcare provider?

somnambulism

An acute care hospital has a disaster something about an outage and a generator. The UAP asks the charge nurse what she can do to help

tell the patients to stay in their rooms

Pain and hot and cold

use Cold for acute pain (eg. Sprain ankle) and Heat for chronic (rheumatoid arthritis)

what nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration?

use of a compression dressing for firm pressure to the site

Magnesium sulfate

used for preeclamptic patients to prevent seizures *monitor DTRs *level 5-8 is therapeutic

A client says to the nurse, "I've started a journal because my health care provider suggested it, and I'm writing about the things that bother me each day. Sometimes I dictate my feelings and what happened during the day into a recorder and write them up before I go to bed — and, do you know, they seem silly to me then. Is this helping me?" Which response by the nurse would be appropriate? A. "I'm not certain that using a tape recorder will help you with the journal-keeping." B. "Well, I wonder about the dictation, because the writing is what helps reduce stress." C. "Well, it will take some time, but let's see how you're doing over a month. In the meantime, keep writing." D. "It seems that people who write in their journals and can share traumatic events improve their self-awareness."

D. "It seems that people who write in their journals and can share traumatic events improve their self-awareness."

A 56-year-old client says to the nurse, "I'm a guidance counselor at the middle school, and the kids like to come to see me for help, but I just found out from my wife that my 22-year-old daughter is a lesbian, and now I'm the one who needs advice. How am I supposed to accept that? She was the boy we didn't have, and I made a tomboy of her by taking her to baseball games with me. Is that why she's gay?" Which statement by the nurse would be therapeutic? A. "Are you prejudiced against lesbian and gay people?" B. "You're good at talking with middle schoolers, but how about young adults?" C. "How did your wife happen to tell you about this? Did your daughter ask her to tell you?" D. "It sounds like you and your daughter were very close but she kept her sexual orientation from you."

D. "It sounds like you and your daughter were very close but she kept her sexual orientation from you."

The nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate? A. "It's to help get rid of the swelling in your feet." B. "You need to discuss this medication with your physician." C. "I know that it's for fluid buildup, and I think you've taken it before." D. "It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

D. "It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

A nurse instructs a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions? A. "I should take the medication in the evening." B. "I can expect diarrhea, insomnia, and excessive sweating." C. "If I feel nervous or have tremors, I should only take half the dose." D. "I need to report any episodes of palpitations, chest pain, or dyspnea."

D. "I need to report any episodes of palpitations, chest pain, or dyspnea."

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? A. "I should drink extra fluids during the summer." B. "I should wear cool, light clothing in warm weather." C. "I need to wear a hat with a wide brim when I go outdoors." D. "I need to wear additional antiperspirant and deodorant in warm weather."

D. "I need to wear additional antiperspirant and deodorant in warm weather."

A nurse provides instructions to a client who will be taking furosemide. Which statement by the client indicates to the nurse that the client needs additional instruction? A. "I need to sit or stand up slowly." B. "I need to maintain my fluid intake." C. "This medication will make me urinate." D. "I should expect to have ringing in my ears."

D. "I should expect to have ringing in my ears."

A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about low back care. The nurse determines that the client needs further instruction if the client makes which statement? A. "I should bend at the knees to pick things up." B. "I need to increase the fiber and fluids in my diet." C. "I can strengthen my back muscles by swimming or walking." D. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

D. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

The mother of a child who is taking methylphenidate hydrochloride (Ritalin) tells the school nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which response by the nurse would be appropriate? A. "His cough could be a side effect of the Ritalin." B. "Your son should never take any medicine, even if it's OTC." C. "You may administer a small amount of OTC cough syrup without a problem, but not for more than 3 days." D. "I think that you should stop giving this medicine to your son until I can check its content with the pharmacy."

D. "I think that you should stop giving this medicine to your son until I can check its content with the pharmacy."

Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective? A. "I no longer have to lose weight." B. "I won't starve myself anymore." C. "I'll eat until I don't feel hungry." D. "I went out to lunch today with my cousin."

D. "I went out to lunch today with my cousin."

A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? A. "I should wear a sock over my stump." B. "I can wash my leg with a mild soap." C. "I need to check my leg for irritation every day." D. "I'll put lotion on my leg a few times a day."

D. "I'll put lotion on my leg a few times a day."

A nurse has provided instructions to a mother regarding the use of safety seats in car travel for her newborn infant. Which statement by the mother indicates understanding of the instructions? A. "I'll put the baby's car seat in the front seat, facing forward and reclined a little." B. "I'll put the baby's car seat in the front seat, facing backward and reclined a little." C. "I'll put the baby's car seat in the middle back seat, facing forward and reclined a little." D. "I'll put the baby's car seat in the middle back seat, facing backward and reclined a little."

D. "I'll put the baby's car seat in the middle back seat, facing backward and reclined a little."

A client who was recently admitted to the mental health unit has a history of paranoia. When the meal tray is delivered, the client refuses to eat and tells the nurse that someone is poisoning the food. Which statement by the nurse is appropriate? A. "Your food is not poisoned." B. "Why do you think the food is poisoned?" C. "There is no poison in the food. Here, I'll taste the food for you." D. "It must be frightening to you. Has something made you feel that your food is poisoned?"

D. "It must be frightening to you. Has something made you feel that your food is poisoned?"

A client who is an attorney says to the clinic nurse, "I'm worried about my wife. She's been so distant and disorganized since our son died of leukemia 4 months ago. She never suggests that we go out or take our other children anywhere. Is this normal, or do I need to get her to a doctor?" Which statement by the nurse would be therapeutic? A. "Absolutely. It sounds as if she may be experiencing a severe depression." B. "To be safe, it would not hurt to have her see your family doctor, or maybe you have a member of the clergy she can talk to." C. "The reluctance to resume activities and overprotect your other children is a normal part of bereavement and will subside in 2 months." D. "It's normal, but by the end of a year you can expect that your wife is improving and able to redirect her energy. Have you expressed your concerns to her?"

D. "It's normal, but by the end of a year you can expect that your wife is improving and able to redirect her energy. Have you expressed your concerns to her?"

A client says to the nurse, "My doctor wants me to start keeping a journal every day about what's happening in my job." Which response by the nurse is appropriate? A. "You can erase your stresses by identifying things that set off negative physical experiences." B. "Well, it has always helped me to write down daily happenings and relate them to my stress level." C. "Yes, that is an excellent suggestion. You need to keep a meticulous diary of your day with all of the details." D. "Journal-keeping that identifies what seems to cause a strain in a person's life is a good way of improving one's health."

D. "Journal-keeping that identifies what seems to cause a strain in a person's life is a good way of improving one's health."

A client says to the nurse, "It's over for me — the whole thing is over." Which response by the nurse would be therapeutic? A. "What do you mean, 'The whole thing is over'?" B. "Over? Well, that sounds pretty drastic to me. Let's discuss this in the strictest confidence." C. "Can you tell me more about why it's over for you? I'll keep your thoughts strictly confidential." D. "Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."

D. "Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."

On the initial visit to the mental health clinic, a client says to the nurse, "When I married my husband, more than 30 years ago, he was a big, handsome, competent professional who never wanted me to work and was so loving. Well, two kids later he's a slob who gambles and loses one job after another. Now I'm the breadwinner and he's content to be a shiftless town joke." Which statement by the nurse would be therapeutic? A. "You sound disgusted with your husband. Is this an accurate assessment? Why not divorce him?" B. "Can you tell me how long you have felt like this and how much longer you plan to continue this way?" C. "You seem to have changed your feelings about your husband completely. This didn't happen overnight, so why are you here now?" D. "Many things have happened to you and your husband. Sounds as if you've both been struggling for some time. Would you like to have him come in with you to talk with me about all of this?"

D. "Many things have happened to you and your husband. Sounds as if you've both been struggling for some time. Would you like to have him come in with you to talk with me about all of this?"

An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic? A. "Milk thistle aside, you still need to stop using alcohol. You have a severe drinking problem." B. "If milk thistle is so effective, I wonder why the liquor industry isn't lobbying to put it in alcohol?" C. "Milk thistle is used in Europe this way, but research findings are limited, so I'd stop drinking if I had a problem like you do." D. "Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."

D. "Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."

A teenage client returns to the gynecological (GYN) clinic for a follow-up visit after diagnosis and initial treatment of a sexually transmitted infection (STI). Which statement by the client indicates the need for further teaching? A. "I finished all the antibiotic, just like you said." B. "I know you won't tell my parents that I'm sick." C. "I always make sure my boyfriend uses a condom." D. "My boyfriend doesn't have to come in for treatment."

D. "My boyfriend doesn't have to come in for treatment."

A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction? A. "I need to eat foods high in calcium." B. "How I eat can affect my baby's growth." C. "I need to take vitamins throughout my pregnancy." D. "My risk for malnourishment is much higher while I'm pregnant."

D. "My risk for malnourishment is much higher while I'm pregnant."

A 68-year-old client whose husband died 2 months ago says to the nurse, "I'm having trouble sleeping lately, even though I don't nap in the daytime. I've been using warm milk without any results." Which statement by the nurse would be therapeutic? A. "So you've started having sleeping problems but no other problems?" B. "Perhaps you should join the grieving spouses group that meets on Monday nights." C. "Since you've lost your husband, have you experienced any other problems besides trouble sleeping?" D. "One of the things that I've found has helped others is a small snack with your warm milk before sleep and a moderate increase in walking during the day. Is that something you could try?"

D. "One of the things that I've found has helped others is a small snack with your warm milk before sleep and a moderate increase in walking during the day. Is that something you could try?"

A client says to the nurse, "My doctor says he thinks I'm ready to taper off my pain medication, but the new painkiller he prescribed doesn't relieve my pain the way the other pill did. I get pain when I try to do things." Which nursing response would be most supportive to the client? A. "Your health care providerhealth care provider feels that your body is physically ready to make the change in medication." B. "I think you need to listen to your health care provider health care providerwhen it comes to taking such strong medication." C. "Well, your health care provider is concerned that you will become physically dependent on the first painkiller." D. "Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the medicine will be more effective."

D. "Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the medicine will be more effective."

A client says to the nurse, "I've been following my diet and taking my medication. What else do you want to talk about today?" Which response would be most helpful during the working phase of the therapeutic alliance? A. "Sounds fine to me. Let's meet again in 6 months." B. "I don't believe that you have been following your diet, because you haven't lost any weight." C. "Well, you've talked about diet in your terms, but perhaps I should test you on specific things." D. "Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?"

D. "Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?"

A nursing student is assigned to work in the emergency department to assist victims after a tornado. The student says to the nurse in charge, "I don't know how to help these parents. Their son was just decapitated by a flying piece of glass, and they won't leave him. They did mention that they are Catholic." Which intervention does the nurse suggest for inclusion in a plan of immediate care for the family? A. Telling the student not to disturb the family until the end of shift B. Calling their family priest immediately to come help them to let their son go C. Asking the emergency department health care provider to join the student in requesting that the family let the nursing staff care for their son D. Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son's body to the nurses

D. Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son's body to the nurses

The nurse plans outcomes for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment? A. Evaluation of neurological status B. Use of directive communications with the client C. Administration of acute psychotropic medications D. Keeping the client active with hobbies, exercise, and work

D. Keeping the client active with hobbies, exercise, and work

A nurse performing a physical examination is assessing the client for costovertebral angle tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse interprets this finding as most indicative of: A. Liver enlargement B. Ovarian infection C. Spleen enlargement D. Kidney inflammation

D. Kidney inflammation

A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? A. Monitoring urine output B. Monitoring bowel sounds C. Checking pedal pulses distal to the graft site D. Limiting elevation of the head of the bed to 45 degrees

D. Limiting elevation of the head of the bed to 45 degrees

A nurse is preparing to listen to the breath sounds of a client. The nurse should: A. Ask the client to lie prone B. Ask the client to breathe in and out through the nose C. Hold the bell of the stethoscope lightly against the chest D. Listen for at least one full respiration in each location on the chest

D. Listen for at least one full respiration in each location on the chest

A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination? A. Prone B. Left side-lying C. Sims D. Lithotomy

D. Lithotomy

A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which observation should the nurse expect to note as an age-related finding? A. Thin, ridged toenails B. Thick skin on the lower legs C. Bounding dorsalis pedis pulse D. Loss of hair on the lower legs

D. Loss of hair on the lower legs

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? A. Check the client's blood pressure B. Check the oxygen saturation level C. Have the client take some deep breaths D. Lower the head of the bed slowly until the dizziness is relieved

D. Lower the head of the bed slowly until the dizziness is relieved

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first: A. Call a code B. Suction the client C. Call the anesthesiologist D. Manually ventilate the client, using a resuscitation bag

D. Manually ventilate the client, using a resuscitation bag

A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet? A. Rice and fish B. Eggs and bacon C. Cereals and broccoli D. Meats and citrus fruits

D. Meats and citrus fruits

Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus? A. In the pelvic cavity B. 2 cm above the umbilicus C. At the level of the umbilicus D. Midway between the symphysis pubis and umbilicus

D. Midway between the symphysis pubis and umbilicus

Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that: A. Wearing a bra will increase the discomfort B. Antibiotics are not usually used to treat this disorder C. Breastfeeding must be discontinued until the condition resolves D. Moist heat will increase circulation and may be used before the breasts are emptied

D. Moist heat will increase circulation and may be used before the breasts are emptied

A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care for this client? A. Monitoring urine output B. Encouraging increased fluids C. Monitoring the client's temperature D. Monitoring the client's respiratory rate

D. Monitoring the client's respiratory rate

At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she states that: A. BSE must be performed every other month B. BSE is performed on the day menstruation begins C. Monthly BSE is the only way to ensure early detection of breast cancer D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down

D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down

The nurse observes that a client is pacing back and forth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels "out of control!" Which intervention is most appropriate initially to maintain a safe environment? A. Restraining the client B. Placing the client in seclusion C. Continuing to monitor the client D. Moving the client to a quiet room and talking about her feelings

D. Moving the client to a quiet room and talking about her feelings

Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication. What should the nurse tell the couple? A. The couple should engage in coitus once a week during treatment B. The health care provider should be notified immediately if breast engorgement occurs C. If the oral tablets are not successful, the medication will be administered intravenously D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? A. Paralytic ileus B. Incisional pain C. Urine retention D. Nausea and vomiting

D. Nausea and vomiting

A client complains of feeling fatigued because of the need to get up several times during the night to urinate. The nurse documents that the client is experiencing which problem? A. Anuria B. Oliguria C. Polyuria D. Nocturia

D. Nocturia

A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence

D. Nonmaleficence

A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data? A. Normal near vision B. Normal central vision C. Normal peripheral vision D. Normal ocular movements

D. Normal ocular movements

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

D. Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? A. Home care B. Social services C. Physical therapy D. Occupational therapy

D. Occupational therapy

A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination: A. At the onset of menstruation B. Every month during ovulation C. Weekly, at the same time of day D. One week after menstruation begins

D. One week after menstruation begins

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? A. Steak B. Veal C. Cheese D. Oranges

D. Oranges

A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next? A. Calling the health care provider B. Calling the respiratory therapist C. Rechecking the pulse oximetry reading D. Oxygenating the client with 100% oxygen

D. Oxygenating the client with 100% oxygen

A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? A. Urine output of 40 mL/hr B. Blood pressure of 118/76 mm Hg C. Respiratory rate of 18 breaths/min D. Pallor and coolness of the right leg

D. Pallor and coolness of the right leg

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason? A. It is unnecessary to use both hands B. Feeling dual pulsations may lead to an incorrect measurement C. Palpating both carotid pulses simultaneously could occlude the trachea D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurse performs this assessment by: A. Palpating for symmetric chest expansion B. Auscultating the breath sounds over the trachea and larynx C. Auscultating the breath sounds over the peripheral lung fields D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine"

D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine"

A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem? A. Reporting the employee to administration B. Documenting the employee's behavior in the personnel file C. Telling the employee that she will be fired if she calls in sick again D. Reminding the employee of the employment standards of the agency

D. Reminding the employee of the employment standards of the agency

A nurse employed in a physician's office hears a client in the waiting room call out, "Help! Fire!" The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately: A. Confines the fire B. Extinguishes the fire C. Activates the fire alarm D. Removes the clients from the waiting room

D. Removes the clients from the waiting room

A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A .Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which finding does the nurse monitor the neonatemost closely? A. Hypercalcemia B. Hyperglycemia C. Hypobilirubinemia D. Respiratory distress syndrome

D. Respiratory distress syndrome

A nurse is monitoring a client who is receiving a continuous intravenous infusion of morphine sulfate. Which finding should cause the nurse to contact the health care provider? A. Temperature of 97.6° F B. Urine output of 30 mL/hr C. Blood pressure of 100/60 mm Hg D. Respiratory rate of 10 breaths/min

D. Respiratory rate of 10 breaths/min

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? A. Pulse B. Urine output C. Temperature D. Respiratory status

D. Respiratory status

A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation? A. Telling the nurse that it is inappropriate to report other nurses B. Providing an in-service educational session on aseptic technique for everyone on the nursing unit C. Informing the nurse who reported the occurrence that intravenous ports do not need to be cleaned with alcohol before medication administration D. Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated

D. Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated

A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first? A. Left upper quadrant B. Left lower quadrant C. Right upper quadrant D. Right lower quadrant

D. Right lower quadrant

A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of the highest priority? A. Fear B. Anxiety C. Distorted body image D. Risk for impaired breathing

D. Risk for impaired breathing

A client whose husband died 2 months ago says to the nurse, "After church, I visit my husband's grave and talk to him. It comforts me, but my daughter thinks I'm morbid and crazy and is upset with me because I don't want to meet her for coffee after church like I used to." Which statement by the nurse would be therapeutic? A. "You need to stop your visits immediately, or your daughter will have you examined for a mental disorder." B. "Perhaps you could reduce your visits to his grave to once a month and meet your daughter for coffee like you used to." C. "I think your visits are perfectly normal. After all, you were married for a long time. You'll stop when the winter weather comes." D. "Sounds as if you have had difficulty letting your husband go from your life. What would happen if you visited his grave less frequently?"

D. "Sounds as if you have had difficulty letting your husband go from your life. What would happen if you visited his grave less frequently?"

A victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the assault just happened," even though it has been a few months since she was attacked. Which supportive statement should the nurse make to the client? A. "Things like this take time to get over." B. "Be realistic. Remember, the assault didn't just happen." C. "Why keep thinking about this? It'll only make matters worse." D. "Tell me more about why you feel like the assault just occurred."

D. "Tell me more about why you feel like the assault just occurred."

A client with an alcohol problem who has been sober for 8 months asks the nurse, "Do you think I should add individual therapy to my treatment plan?" Which response by the nurse would be therapeutic? A. "What do you think? What is the individual therapy all about?" B. "Are you feeling that you're vulnerable to a slip? If not, why complicate treatment further?" C. "Okay, what's going on with you? You had to be coerced into treatment, but now you seem to want the full monty." D. "The best time to add individual therapy seems to be after 2 to 5 years of sobriety. Individuals vary, though, and it may be that you are asking because you feel ready to work on your issues."

D. "The best time to add individual therapy seems to be after 2 to 5 years of sobriety. Individuals vary, though, and it may be that you are asking because you feel ready to work on your issues."

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? A. "I need to keep large toys out of the crib." B. "The drop side needs to be impossible for my infant to release." C. "Wood surfaces on the crib need to be free of splinters and cracks." D. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body."

D. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body."

The parents of an adopted child schedule an appointment at a psychiatric clinic, and when they arrive the nurse conducts an initial assessment. One of the parents says to the nurse, "We need to speak to a psychiatrist about our adopted daughter. Could you please get one for us?" Which intervention by the nurse would be therapeutic? A. "I'd like to accommodate you both, but he is busy right now and you will have to talk to me." B. "Do you feel that I am incompetent to talk with you? Everyone who comes here sees me first." C. "That is not the procedure here. If you can't work with the system, you're free to go elsewhere." D. "The doctors here feel that clients are best served when I conduct the initial assessment, after which the psychiatrist will see you with complete information."

D. "The doctors here feel that clients are best served when I conduct the initial assessment, after which the psychiatrist will see you with complete information."

A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? A. "Yes, your infant is protected from all infections." B. "If you breastfeed, your infant is protected from infection." C. "The transfer of your antibodies protects your infant until the infant is 12 months old." D. "The immune system of an infant is immature, and the infant is at risk for infection."

D. "The immune system of an infant is immature, and the infant is at risk for infection."

A client says to the nurse, "What does my psychiatrist mean when she says that my illness is biologically based?" Which nursing statement would be the most informative? A. "Mental illness always has its roots in the family." B. "Mental illness is a result of environmental factors." C. "Today we know that all mental illness is genetically inherited." D. "There are many possible physical causes of mental illness, and they include problems in the brain."

D. "There are many possible physical causes of mental illness, and they include problems in the brain."

A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? A. The client is allergic to strawberries. B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2-inch scar is present on the lower right portion of the abdomen.

D. A 1 × 2-inch scar is present on the lower right portion of the abdomen.

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply. A. Anthrax is never fatal. B. No vaccine to prevent anthrax is available. C. Anthrax can be transmitted from person to person. D. A blood test is available for the detection of anthrax. E. One way that anthrax can be contracted is through the skin.

D. A blood test is available for the detection of anthrax. E. One way that anthrax can be contracted is through the skin.

A nurse is making initial rounds on a group of assigned clients. Which client should the nurse see first? A. A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for the last 24 hours B. A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F on the previous shift C. A client receiving TPN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to void D. A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

D. A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply. A. A client who is confused and requires assistance with a shower B. A client requiring a bed bath and frequent ambulation with a cane C. A client who must be accompanied to physical therapy twice during the shift D. A client with a colostomy who requires reinforcement regarding the procedure for irrigation E A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

D. A client with a colostomy who requires reinforcement regarding the procedure for irrigation E A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

A nurse is assigned to care for four clients. Which client should the nurse assess first? A. A client scheduled for a colonoscopy B. A client preparing for discharge after surgery C. A client requiring a tube feeding through a gastrostomy tube D. A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

D. A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first? A. A victim who has died of multiple serious injuries B. A hysterical victim who has sustained a head injury C. An alert victim who has numerous bruises on the arms and legs D. A victim with a partial amputation of a leg who is bleeding profusely

D. A victim with a partial amputation of a leg who is bleeding profusely

A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. What should the nurse check for when inspecting the ears for cerumen impaction? A. Redness and swelling of the tympanic membrane B. An external auditory canal that is longer than normal C. The presence of edema in the external auditory canal D. A yellowish or brownish waxy material in the external auditory canal

D. A yellowish or brownish waxy material in the external auditory canal

A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are: A. Normally heard in the lungs B. Hollow sounds heard over the trachea and larynx C. Rustling sounds heard over the peripheral lung fields D. Abnormal sounds that should not be heard in the lungs

D. Abnormal sounds that should not be heard in the lungs

A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding? A. Myopia B. Hyperopia C. Photophobia D. Accommodation

D. Accommodation

The home care nurse makes a new-baby visit to a young husband and wife. The visit takes two-and-a-half hours because the parents are so detailed in giving information and asking questions of the nurse. Which intervention by the nurse would be therapeutic? A. Ordering a follow-up visit to the family pediatrician and mental health clinical specialist B. Informing all home care nurses to schedule their visits to the couple as their last visit of the day C. Having the home care office secretary call the nurse's cell phone 20 minutes after starting the visit to expedite the nurse's departure D. Blocking out more time for the next visit and scheduling a follow-up visit as soon as possible to assess how they are coping and gauge their level of anxiety

D. Blocking out more time for the next visit and scheduling a follow-up visit as soon as possible to assess how they are coping and gauge their level of anxiety

A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrence does the nurse expect the mother to report? A. Scleral jaundice B. Projectile vomiting C. Hard, pale stools D. Bloody mucus stools and diarrhea

D. Bloody mucus stools and diarrhea

A nurse reviewing the physical assessment findings in a client's healthcare record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has? A. Scoliosis B. Bone deformity C. Heberden nodules D. Carpal tunnel syndrome

D. Carpal tunnel syndrome

A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? A. Administer an antiemetic B. Administer the daily dose of digoxin C. Discontinue the morning dose of furosemide D. Check the result of laboratory testing for potassium on the sample drawn 3 hours ago

D. Check the result of laboratory testing for potassium on the sample drawn 3 hours ago

A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client's injury, the nurse should: A. Ask a licensed practical nurse B. Call the nurse in charge of the day shift C. Ask the police officers who brought the client to the ED D. Check the unit policy for the protocol for the care of clients who have been sexually assaulted

D. Check the unit policy for the protocol for the care of clients who have been sexually assaulted

A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? A. Ambulating the client B. Administering pain medication C. Encouraging copious fluid intake D. Checking for the return of the gag reflex

D. Checking for the return of the gag reflex

Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care? A. Assessing the pin sites at least every 8 hours B. Removing the traction weights to provide skin care C. Applying lanolin to the skin of the right leg once per shift D. Checking the skin integrity of the right leg at least every 8 hours

D. Checking the skin integrity of the right leg at least every 8 hours

A nurse is reviewing the healthcare record of a client who has just undergone an examination of the internal genitalia. Which of the following documented findings indicates an abnormality? A. The cervix is pink. B. The cervix is midline. C. The cervix is about 1 inch in diameter. D. Clear secretions with a foul odor are noted on the cervix.

D. Clear secretions with a foul odor are noted on the cervix.

An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted? A. Fecal-oral B. Airborne particles C. Respiratory droplets D. Close intimate contact

D. Close intimate contact

A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? A. Episodic B. Follow-up C. Emergency D. Complete

D. Complete

A client with HIV infection has been started on therapy with zidovudine. The nurse tells the client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which laboratory test is most important to monitor for this client? A. Creatinine B. Serum potassium C. Blood urea nitrogen (BUN) D. Complete blood count (CBC)

D. Complete blood count (CBC)

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is: A. Teaching schoolchildren about the dangers of school violence B. Looking at what other communities are doing about school violence C. Distributing fliers that identify the causes of school violence to families in the community D. Conducting a community survey to assess community perceptions regarding school violence

D. Conducting a community survey to assess community perceptions regarding school violence

A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse manager to deal with this situation? A. Ignoring the situation B. Asking other staff members to cover for the nurse C. Documenting the problem in the nurse's personnel file D. Confronting the nurse to discuss the behavior and initiate problem-solving measures

D. Confronting the nurse to discuss the behavior and initiate problem-solving measures

In which situation is the nurse upholding the ethical principle of fidelity? A. Allowing a client to decide when to receive daily hygiene care B. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion C. Providing complete information regarding treatment options to a client with newly diagnosed cancer D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

The nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the client's discharge outcomes, the most positive outcome is that the client states that he or she will perform which action? A. Learn to play tennis B. Take a painting class C. Start an exercise program D. Continue to attend Alcoholics Anonymous meetings

D. Continue to attend Alcoholics Anonymous meetings

A nurse monitoring a client in labor notes this fetal heart rate pattern (refer to figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action? A. Stop the oxytocin (Pitocin) infusion B. Notify the nurse-midwife or health care provider C. Administer oxygen with a face mask at 8 to 10 L/min D. Continue to monitor the client and fetal heart rate patterns

D. Continue to monitor the client and fetal heart rate patterns

A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions? A. Fetal hypoxia B. Discomfort with each contraction C. Increased frequency and longer duration of contractions D. Contractions that can be indented easily with fingertip pressure at their peak

D. Contractions that can be indented easily with fingertip pressure at their peak

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? A. Reinsert the chest tube B. Contact the health care provider C. Transfer the client back to bed D. Cover the insertion site with a sterile occlusive dressing

D. Cover the insertion site with a sterile occlusive dressing

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? A. Cranial nerve X B. Cranial nerve V C. Cranial nerve IX D. Cranial nerve XII

D. Cranial nerve XII

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? A. Cranial nerve V B. Cranial nerve XII C. Cranial nerves I and II D. Cranial nerves IX and X

D. Cranial nerves IX and X

A mother brings her 18-month-old child to the clinic to receive the next scheduled vaccine. The child has previously received the following vaccines: three doses of the hepatitis B vaccine (at birth and 1 and 6 months of age); three doses of the diphtheria/tetanus/acellular pertussis (DTaP) vaccine (at 2, 4, and 6 months of age); four doses ofHaemophilus influenzae type b (Hib) conjugate vaccine (at 2, 4, 6, and 12 months of age); three doses of inactivated poliovirus vaccine (IPV) (at 2, 4, and 6 months of age); one dose of measles/mumps/rubella vaccine (MMR) (at 12 months of age); varicella zoster vaccine at 12 months of age; and four doses of pneumococcal vaccine (at 2, 4, 6, and 12 months of age). After reviewing the child's immunization record, which scheduled vaccine does the nurse prepare to administer? A. Hib B. IPV C. MMR D. DTaP

D. DTaP

A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs does the nurse anticipate that this client will exhibit? A. Increased heart rate and increased blood pressure B. Increased heart rate and decreased blood pressure C. Decreased heart rate and increased blood pressure D. Decreased heart rate and decreased blood pressure

D. Decreased heart rate and decreased blood pressure

A nurse manager tells the nursing staff that the agency's disaster preparedness plan will be distributed to all employees for review. The nurse manager states that the plan is an important component of disaster readiness because it primarily: A. Identifies the location of healthcare supplies B. Identifies the types of disasters that may occur C. Aids determination of how victims will be triaged D. Describes a formal plan of action for the coordination of a response

D. Describes a formal plan of action for the coordination of a response

A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? A. Confirm the medical diagnosis B. Make accurate nursing diagnoses C. Identify any hereditary traits related to the epilepsy D. Determine what the client believes has caused the epilepsy

D. Determine what the client believes has caused the epilepsy

The nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. Which action should the nurse take? A. Informing the client that everything is all right B. Speaking to the nursing assistant immediately, while in the client's room, to solve the problem C. Explaining to the nursing assistant that yelling in the client's room is tolerated only if the client is talking loudly D. Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation

D. Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: A. Implementing a child safety program B. Planning a focused child safety program C. Performing an analysis of health problems related to child safety D. Determining the appropriateness of the planned health activity

D. Determining the appropriateness of the planned health activity

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first? A. Call a code B. Contact the health care provider C. Administer a bronchodilator D. Disconnect the suction source from the catheter

D. Disconnect the suction source from the catheter

A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? A. Staying secluded in the bedroom B. Wearing an oxygen mask at all times C. Keeping the house closed up to minimize the spread of disease D. Disposing of contaminated tissues in a container with a leak-proof bag

D. Disposing of contaminated tissues in a container with a leak-proof bag

A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? A. Suspect the presence of hydrocephalus B. Suggest to the pediatrician that a skull x-ray be performed C. Tell the mother that the infant is growing faster than expected D. Document these measurements in the infant's health-care record

D. Document these measurements in the infant's health-care record

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if he: A. Allows time for unexpected tasks B. Prioritizes client needs and daily tasks C. Gathers supplies before beginning a task D. Documents task completion and client information at the end of the day

D. Documents task completion and client information at the end of the day

A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following? A. The client had an allergy to cefazolin sodium. B. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium. C. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back. D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test? A. The test may be painful B. The test takes 2 to 3 hours C. Food and fluids are not allowed for 4 hours after the test D. Dye is injected and may cause a warm flushing sensation

D. Dye is injected and may cause a warm flushing sensation

A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A. Diarrhea B. Dyspnea C. Headache D. Dysphagia

D. Dysphagia

During a physical assessment, the client tells the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing: A. Pyrosis B. Anorexia C. Eructation D. Dysphagia

D. Dysphagia

A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

D. Dysrhythmias and decreased respiratory rate and depth

A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to: A. Maintain strict bed rest B. Limit the intake of alcohol C. Take acetaminophen for discomfort D. Eat small frequent meals that are low in fat and protein and high in carbohydrates

D. Eat small frequent meals that are low in fat and protein and high in carbohydrates

On assessing a client's skin, the nurse notes the presence of several large red-blue and purple areas on the client's body that do not blanch when pressure is applied. The nurse documents this finding as: A. Psoriasis B. Anasarca C. Petechiae D. Ecchymosis

D. Ecchymosis

A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution

D. Ensure that the medication is diluted in an appropriate amount of normal saline solution

The nurse is supervising an unlicensed assistive personnel (UAP)in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which action by the UAP while repositioning the client would cause the nurse to intervene? A. Keeping the head of the bed flat B. Placing pillows beneath the full length of the legs C. Using a log-rolling technique for repositioning D. Having the client assist by using the overhead trapeze

D. Having the client assist by using the overhead trapeze

A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete? A. Supine B. Head of bed flat C. Left lateral position D. Head of bed elevated 30 to 45 degrees

D. Head of bed elevated 30 to 45 degrees

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. Based on this finding, what does the nurse determine? A. The results are negative B. The client needs to receive the hepatitis B series of vaccines C. The results indicate that the mother does not have hepatitis B D. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth

D. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position? A. Flat on the left side B. In the prone position C. In the supine position D. In a slight Trendelenburg position

D. In a slight Trendelenburg position

A schizophrenic client is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing? A. Defensive coping B. Inability to cope effectively C. Sensory perception alterations D. Inability to communicate effectively

D. Inability to communicate effectively

The nurse is preparing a plan of care for an older client with a diagnosis of depression. In preparing the plan, which should the nurse recall? A. Older clients do not commit suicide B. Depression in an older person is never treatable C. Depression in an older person will not cause physical manifestations D. Indications of dementia may be present in an older client with depression

D. Indications of dementia may be present in an older client with depression

A resident of a long-term care facility who has Alzheimer's disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which piece of information should the nurse use when approaching the client about this behavior? A. This resident is a dangerous individual. B. Individuals with Alzheimer's disease are likely to be child molesters. C. This resident probably had an unfortunate experience while singing and dancing in his own youth. D. Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine.

D. Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine.

A client is going to receive instruction in biofeedback technique to lower his stress level. The client asks the nurse to describe this technique. What should the nurse tell the client? A. It is a technique that trains the mind to elicit a relaxation response B. It is the purposeful use of one's imagination to achieve relaxation and control C. It involves learning to contract and relax muscles in a systematic way and may be combined with breathing exercises D. It is a therapeutic modality that enables an individual to monitor skin temperature, muscle activity, heart rate, blood pressure, and other bodily functions, then learn to control these physiologic responses to stressful or challenging events

D. It is a therapeutic modality that enables an individual to monitor skin temperature, muscle activity, heart rate, blood pressure, and other bodily functions, then learn to control these physiologic responses to stressful or challenging events

The nurse is planning for the initial visit between the parents and a newborn infant diagnosed with respiratory distress syndrome. Which of the following should the nurse plan to best facilitiate bonding during the initial visit?

Encourage the parents to touch their infant.

NG tube length

End of nose, to ear lobe, to xyphoid (~22-26 inches)

Second Degree

Epidermis and dermis (deep partial thickness)

Third Degree

Epidermis, dermis and SQ (full thickness)

Head injuries

Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP

Acute pancreatitis

Fetal position, bluish discoloration of flanks (Turner's sign), bluish discoloration of pericumbelical region (Cullen's sign); Board like abdomen with guarding; self digestion of pancreas by Trypsin

A client with a diagnosis of hyperphosphatemia. The nurse teaches the clieint to eliminate which of the following from the diet?

Fish

Cardiac catheterization

Flat (HOB no more than 30 degrees), leg straight 4-6 hour, bed rest 6-12 hours

The nurse is administering oxygen to a client with pulmonary edema when a family member asks the nurse why the client needs oxygen. Which pathophysiological mechanism should the nurse explainto his family member?

Fluid collects in the chest cavity and keeps the lungs from expanding

- (Y)A client receiving lisinopril (Prinivil) has a white blood cell (WBC) count of 3,800/mm3. The nurse plans to do which of the following in the care of this client?

Follow strict aspectic technique

Before dressing changes

Give medications to help with pain

Benzos (Ativan, Lorazepam, etc.)

Good for alcohol withdrawal and status epilepticus

Brain tumor (remove benign and malignant)

HA more severe on wakening

A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the trauma unit. Ho! should the nurse position the client?

HOB elevated

Rule of 9's

Head and neck = 9% Upper Ex = 9% each Lower Ex = 9% each Front trunk = 18% Back trunk = 18%

Acute Care...CVA

Hemorrhagic = bleed Embolic = blockage of blood supply to part of the brain

In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate?

High in Calcium and low in phosphorus

A nurse is reviewing the record of a client with a diagnosis of cervical cancer. Which risk factor associated with this type of cancer would the nurse expect to note in the client's record?

History of Human Papilloma Virus

Reed-Sternberg cells

Hodgkin's

Tube feeding

Hold tube feeding if residual >100mL

The nurse is assessing a 24 week old breastfeeding infant. To obtain information about the adequate nutrition, which question should the nurse ask the breastfeeding mother?

How many diapers does the infant wet a day?

MAOI's

Hypertensive crisis with Tyramine foods; Nardil, Marplan, Parnate. Need 2 week gap from SSRI's and TCA's to admin MAOI's

The nurse is caring for a client in the Medical Intensive Care Unit. What problem is a client probably experiencing who has an easily obliterated radial pulse and below normal pressures, including blood pressure, central venous pressure, pulmonary artery pressure, and pulmonary under pressure?

Hypovolemic shock

ICP and shock vitals

ICP-increased BP, decreased pulse, decreased resp. shock- decreased BP, increased pulse, increased resp.

Heat vs cold for injury

Ice for acute pain and inflammation Warm for muscle pain or stiffness

Chest tube

If a chest tube becomes disconnected, do not clamp, put end in sterile water. Chest tube drainage system should show bubbling and water level fluctuations (tidal with breathing)

Acid-Base balance

If it comes out of your ass, it's Acidosis Vomiting = Alkalosis

A client in a mental health unit gets into a fight with another client over the use of the public telephone on the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which intervention by the nurse would be most therapeutic? A. Taking telephone privileges away from both clients for the day and giving them time-outs in their rooms B. Saying to the clients, "Okay, this is the last straw. Neither of you may use the telephone until tomorrow, and then only with a nurse timing you." C. Saying to the clients, "Go to your rooms, both of you. I don't want to hear anything more about the telephone on this unit for at least 2 hours." D. Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?"

D. Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?"

A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, "I need to be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which nursing intervention would be therapeutic? A. Sending the client to the psychiatric hospital intake center immediately for evaluation B. Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately C. Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide

D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide

A nurse notices a paranoid stare during a conversation with a client. The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be beneficial? A. Allowing the client to pace B. Escorting the client to a quiet room C. Changing the conversation to a less threatening subject D. Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings

D. Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings

A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for: A. Bleeding B. A high fever C. Failure to thrive D. Signs of congestive heart failure (CHF)

D. Signs of congestive heart failure (CHF)

A nurse is examining the peripheral vision of a client using the confrontation test. How should the nurse carry out this procedure? A. Asks the client to discriminate numbers on a chart composed of colored dots B. Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field C. Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye D. Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

D. Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse planning care for this client to understand that the client is afflicted with which disorder? A. Paranoia B. Depression C. Schizophrenia D. Somatization disorder

D. Somatization disorder

A mother asks the nurse when her child should have his first dentist visit. What should the nurse tell the mother? A. At age 3 B. Just before beginning kindergarten C. Twelve months after the first primary tooth erupts D. Soon after the first primary tooth erupts, usually around 1 year of age

D. Soon after the first primary tooth erupts, usually around 1 year of age

The nurse is trying to deescalate aggressive behavior exhibited by a client with schizophrenia. Which nursing action would be contraindicated in this situation? A. Being assertive with the client B. Negotiating options with the client C. Maintaining a nonaggressive posture D. Standing close to the client and telling the client that the behavior is unacceptable

D. Standing close to the client and telling the client that the behavior is unacceptable

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first? A. Call the health care provider B. Clamp the chest tube with a Kelly clamp C. Instruct the client to inhale and hold his breath D. Submerge the end of the chest tube in a bottle of sterile water

D. Submerge the end of the chest tube in a bottle of sterile water

The nurse is preparing to change the solution bag and intravenous tubing of a client receiving total parenteral nutrition (TPN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? A. Turn the head to the left B. Turn the head to the right C. Exhale slowly and evenly D. Take a deep breath and hold it

D. Take a deep breath and hold it

The nursing instructor enters a classroom to begin class and finds two students yelling and physically assaulting each other. Which intervention by the instructor would be most appropriate? A. Walking out of the classroom and asking the secretary to call security, then telling all of the students to leave and go to the nursing laboratory B. Getting the class to leave with her and sending everyone to the nursing laboratory, then calling security to the classroom and reentering to observe what is happening with the two students. C. Telling the class, "Take a break. I'll come and get you to restart class as soon as I can," then closing the classroom door, refusing to let anyone else in, and asking a passing instructor to get security D. Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats

D. Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats

A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client's record and interprets this sign as indicating which? A. A thinning of the cervix B. A positive sign of pregnancy C. That cervical softening is present D. That the cervix was seen to be violet

D. That the cervix was seen to be violet

A home health nurse has been called to the home of an older postoperative cardiovascular client by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my mother has fallen out of bed three times." Which observation by the nurse reflects an increased risk of this client's falling out of bed? A. The client's bed is in a low position. B. The client is oriented to person, place, and time. C. The caregiver uses the overbed table for feedings. D. The caregiver leaves both siderails down while the client is in bed.

D. The caregiver leaves both siderails down while the client is in bed.

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assessfirst? A. The client's vital signs B. The amount of drainage C. The client's lung sounds D. The chest tube connections

D. The chest tube connections

The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse should tell the mother that which observation is a sign of physical readiness? A. The child has been walking for 2 years. B. The child can eat using a fork and knife. C. The child no longer has temper tantrums. D. The child can remove his or her own clothing.

D. The child can remove his or her own clothing.

A client about to undergo surgery is instructed in postoperative pain relief measures is asked whether he would like to use a patient-controlled analgesia (PCA) pump. The client asks the nurse to describe the pump. Which information should the nurse provide to the client? A. The PCA pump eliminates the need for an intravenous (IV) line B. The client will be able to deliver his own dose of medication every 4 hours C. The client's spouse will be able to administer medication for the client D. The client administers his own medication by pressing a control button

D. The client administers his own medication by pressing a control button

The nurse caring for a schizophrenic client is assessing the client's ability to control distorted thought processes. Which finding indicates a positive outcome? A. The client is able to identify when hallucinations or delusions are real. B. The client can describe in detail the frequency and context of the hallucinatory and delusional behavior. C. The client can describe the hallucinations and delusions in detail and is able to interact with others and share in their delusional systems. D. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations.

D. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations.

The nurse is reading the medical record of a client who has a diagnosis of moderate anxiety and notes that the health care provider has documented that the client exhibits eustress. Based on this information, which finding would the nurse expect to encounter while assessing the client? A. The client complains of fatigue. B. The client complains of feeling drained. C. The client complains of feeling anxious. D. The client engages in purposeful movement.

D. The client engages in purposeful movement.

The nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which finding indicates that the client is at high risk for suicide? A. The client is impulsive. B. The client is disorganized. C. The client has a history of suicide attempts. D. The client has an immediate plan for a suicide attempt.

D. The client has an immediate plan for a suicide attempt.

A nurse reviews the health history of a client who will be seeing the health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? A. The client has hyperlipidemia. B. The client has type 2 diabetes mellitus. C. The client is being treated for hypertension. D. The client has been treated for breast cancer.

D. The client has been treated for breast cancer.

The nurse collects data from an older client and monitors him for signs of abuse. Which psychosocial factor does the nurse recognize as placing the client at risk for abuse? A. The client lives alone. B. The client is independent. C. The client shows signs and symptoms of depression. D. The client is completely dependent on family members for food and medicine.

D. The client is completely dependent on family members for food and medicine.

The nurse working in the emergency department is performing an initial assessment on a client, and notes many physical injuries. The nurse suspects family-related violence. Which finding is specific to this type of violence? A. The client lives in an assisted living facility. B. The client is financially dependent on him or herself. C. The client relies on neighbors and friends for transportation to and from appointments. D. The client lives with one of their children and requires extensive assistance with activities of daily living.

D. The client lives with one of their children and requires extensive assistance with activities of daily living.

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? A. The procedure is performed in the operating room B. It is necessary to lie quietly on a hard x-ray table for about 4 hours C. The room is bright and well lit, and it is best to keep the eyes closed D. The client may have feelings of warmth or flushing during the procedure

D. The client may have feelings of warmth or flushing during the procedure

A client comes to the mental health clinic after losing all of his personal belongings in a hurricane. The client tells the nurse that the loss of his possessions is his fault because he didn't prepare for the storm. The nurse determines that the client is coping ineffectively and develops goals with the client. Which goal is the least realistic? A. The client will identify effective coping skills. B. The client will develop and use adaptive coping patterns. C. The client will express and share his feelings about this crisis. D. The client will stop blaming himself for the loss of his belongings.

D. The client will stop blaming himself for the loss of his belongings.

A client who has been referred for group therapy asks the nurse about the therapy. The nurse tells the client that this type of therapy is focused on which purpose? A. Social skills training B. Social functioning in groups C. Cognitive behavioral therapy D. The development of interpersonal skills, resolution of family problems, and effective use of community support

D. The development of interpersonal skills, resolution of family problems, and effective use of community support

A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should provide the mother with which information? A. The child should be able to control defecation at the age of 18 months B. The child will let you know when she is ready to begin bowel training C. Girls usually achieve the neuromuscular development necessary for controlling defecation much sooner than boys do D. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

D. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

During a laboratory training session, the nurse is watching as a nursing assistant repositions a client. Which observation tells the nurse that further training is necessary? A. The nursing assistant positions himself close to the client. B. The nursing assistant keeps his neck, back, pelvis, and feet aligned. C. The nursing assistant encourages the client to assist as much as possible. D. The nursing assistant keeps his knees straight and his feet close together.

D. The nursing assistant keeps his knees straight and his feet close together.

A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which of the following observations by the instructor indicates a need for further teaching? A. The nursing student changes gloves between tasks and procedures. B. The nursing student washes hands before making contact with the client. C. The nursing student wears a gown to change the bed of an incontinent client. D. The nursing student washes her hands before glove removal after emptying a Foley bag.

D. The nursing student washes her hands before glove removal after emptying a Foley bag.

A nurse employed in a community hospital as a nurse manager understands that in this position, the term authority most appropriately refers to: A. Being responsible for what staff members do B. Accepting the responsibility for the actions of others C. Carrying the legal responsibility for others' performance of tasks D. The official power to see that an organizational decision is enforced

D. The official power to see that an organizational decision is enforced

A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over: A. Major bronchi B. The xiphoid process C. The trachea and larynx D. The peripheral lung fields

D. The peripheral lung fields

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on which client factor? A. Sources of support B. The object of the crisis C. The client's coping mechanisms D. The physical condition of the client

D. The physical condition of the client

A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't know how in the world to do it." Based on the client's statement, what does the nurse determine? A. There is no suicide risk B. There is a minimal suicide risk C. Suicide has been attempted unsuccessfully D. The risk for suicide exists and continued assessment is needed

D. The risk for suicide exists and continued assessment is needed

A client has made an appointment to for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should provide which information to the client? A. Vaginal douching is required an hour before the test B. Spicy foods should not be eaten on the day of the test C. The test has absolutely no discomfort associated with it D. The test cannot be performed while the client is menstruating

D. The test cannot be performed while the client is menstruating

A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist? A. The traction knots are intact. B. The traction weights are hanging freely. C. The clamps on the traction frame are tight. D. The traction ropes are unable to move over the pulleys.

D. The traction ropes are unable to move over the pulleys.

A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. A. The young adult is sensitive to criticism. B. The young adult verbalizes unrealistic fears. C. The young adult verbalizes disappointment with life. D. The young adult verbalizes satisfaction with friendships. E. The young adult has a sense of meaning and direction in life.

D. The young adult verbalizes satisfaction with friendship. E. The young adult has a sense of meaning and direction in life.

A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client complains of a headache. What should the nurse tell the client? A. This is an indication that the medication should not be used again B. Headache indicates medication tolerance, and the dosage must be increased C. This may be an allergic reaction to the nitroglycerin, and the health care provider must be notified D. This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

D. This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next? A. Temperature B. Time of the last dressing change C. Expiration date on the infusion bag D. Tightness of the tubing connections

D. Tightness of the tubing connections

In which of the following situations would the nurse use this type of restraint (see figure)? Select all that apply. A. To secure the shoulders and the waist B. To immobilize a client's arm and shoulders C. To prevent the client from getting out of bed D. To prevent dislodgment of an intravenous line E. To prevent the client from turning from side to side F.To prevent the use of the hands while allowing free arm movement

D. To prevent dislodgment of an intravenous line F.To prevent the use of the hands while allowing free arm movement

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? A. To resume full activity the next day B. Not to eat or drink anything until the next morning C. To keep the shoulder completely immobilized for the rest of the day D. To report to the health care provider the development of fever or redness and heat at the site

D. To report to the health care provider the development of fever or redness and heat at the site

Zidovudine (is prescribed for an adult client with HIV infection. The nurse should provide which instruction to the client about the medication? A. That the medication must be taken with milk B. That aspirin can be taken to treat headache C. To discontinue the medication if nausea occurs D. To space the doses evenly around the clock

D. To space the doses evenly around the clock

A nurse is preparing to listen to a client's breath sounds. The nurse should: A. Ask the client to lie down B. Listen to the right lung, then the left lung C. Ask the client to take shallow rapid breaths through the mouth D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest

D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest

A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A. Calling the health care provider B. Reinserting the implant into the client's vagina C. Picking up the implant with gloved hands and placing it in sterile water D. Using long-handled forceps to place the implant in a lead container

D. Using long-handled forceps to place the implant in a lead container

Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? A. Gluteal muscle B. Deltoid muscle C. Rectus femoris muscle D. Vastus lateralis muscle

D. Vastus lateralis muscle

A nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular tachycardia

D. Ventricular tachycardia

A nurse giving a client a bed bath drops the towel on the floor. The nurse should: A. Use a bath blanket as a towel B. Borrow a towel from the client's roommate C. Wash her hands, pick up the towel, and shake the towel out D. Wash her hands and go to the linen room to obtain another towel

D. Wash her hands and go to the linen room to obtain another towel

A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. What should the nurse tell the clients? A. It is best to do grocery shopping and other errands late in the day B. They must stay in the house and ask a neighbor or family member to run their errands C. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza D. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

D. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client's condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb in 24 hours

D. Weight loss of 4 lb in 24 hours

Which event would require a nurse to complete and file an incident report? A. A client has a seizure. B. The nurse determines that a client would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.

D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.

A furious and aggressive client is put in restraints and told that the restraints will be removed once the she regains control. At which time is removal of the restraints by the nurse appropriate? A. When medication that has been administered has taken effect B. When the client apologizes and tells the nurse that it will never happen again C. When the nurse explores with the client the reasons for the angry and aggressive behavior D. When no acts of aggression are observed in the hour following the release of two extremity restraints

D. When no acts of aggression are observed in the hour following the release of two extremity restraints

The client is the wife of a former workaholic who now has not worked in years, refusing to get a job or help with chores around the house. The man watches television and snacks all day. The client tells the nurse that her husband now weighs more than 300 lb and expects her to support him. The client states, "I keep saying everything will be fine. It will be if he keeps up these bad health habits, because they'll kill him, and then I would be free and wouldn't have to deal with his obnoxious behavior." Which negative stress response does the nurse recognize in the client's behavior? A. Blaming B. Daydreaming C. Problem- solving D. Wishful thinking

D. Wishful thinking

A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to: A. Place the ice pack directly on the eye B. Avoid the use of commercially prepared ice bags C. Keep the ice pack on the eye continuously for 24 hours D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

Isotonic solutions

D5W, NS (0.9% NaCl), Ringers Lactate, NS only with blood products and Dilantin

Intra-renal problem

Damage to renal parenchyma

Lesions of Midbrain

Decerebrate posturing (extended elbows, head arched back)

Lesions of Cortex

Decorticate posturing (flexion of elbows, wrists, fingers, straight legs, mummy position)

The nurse observes a client has received 250 ml of .9 normal saline through the IV line in the last hour. The client is now tachypneic, and has a pulse rate of 120 beats/minute, with a pulse volume of +4. In addition to reporting the assessment findings to the healthcare provider, what actionvshould the nurse implement?

Decrease the saline to keep open rate. The nurse should decrease the rate of the IV solution to keep open rate to avoid further fluid volume overload while awaiting a change in prescription from the healthcare provider.

Lab findings of fluid volume excess

Decreased hematocrit, decreased BUN below 10 (hemodilution)

Alcohol withdrawal

Delerium tremens- tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia. (DT's start 12-36 hours after last drink)

Stimulant withdrawal

Depression, fatigue, anxiety, disturbed sleep

D Rationale: Option D provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. Options A and B may not be related to her current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the concerns she is having.

During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns.

B Rationale: During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Standard precautions

*wash hands *wear gloves *gowns for splashes *masks *dont recap needles *

Hyperglycemia

*weakness *syncope *polydipsia *polyuria *blurred vision *fruity breath

Autonomic dysreflexia

- elevate head of bed to 90 degree - loosen constrictive clothing - assess for bladder distention and bowel impaction (triger) - Administer antihypertensive meds (may cause stroke, MI

IV's and blood product administration

-18-19 guage needle for blood with filter in tubing -Run blood with NS only and within 30 minutes of hanging -Vitals and Breath sounds before, during and after insusion (15 min after start, then 30 min later, then hourly up to 1 hour after) -Check blood for exp. date, clots, color, air bubbles, leaks -2 RN's must check order, pt , blood product, ask about Hx of blood transfusions -Stay with pt for first 15 min; if there is a transfusion rx stop and KVO with NS -Pre-medicate with Benadryl prn for previous urticaria rxn's

Perioperative Care

-Breathing is taught in advance (before and early in pre-op) -Remove nail polish

Pre-op

-Meds as ordered, NPO x 8 hrs., incentive spirometry & breathing is taught in advance; void, no NSAIDS x 48 hrs. -Increase corticosteriods for surgery (stress)...may need to increase insulin too

Post-op

-Restlessness may = hemorrhage, hypoxia -Wound dehiscence or extravisation...wet sterile dressing + call doctor -Call doctor post-op if...< 30ml/hr urine, Sys BP < 90, T > 100 or <96

Post-op breathing exercises...every 2 hours

-Sit up straight -Breath in deeply thru nose and out slowly thru pursed lips -Hold last breath 3 seconds -Then cough 3 times (unless abd wound; reinforce/splint if cough)

Head turns to locate sounds

3 months

Phos

3-4.5

monosyllabic babbling

3-6 months

Albumin

3.5-5

K+

3.5-5

Urine output

30ml/hr

Epiglotittis signs

3Ds' Drooling, Dysphonia, Dysphagia

Head control

4 months

Birth length doubles

4 years

A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which finding is noted on the electronic monitoring recording strip? A. Absence of accelerations after fetal movement B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds C. Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement D. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline

A. Absence of accelerations after fetal movement

Fetal alcohol syndrome

-upturned nose -flat nasal bridge -thin upper lip -SGA

universal blood donor and recipiant

"O" is the universal donor (remember "o" in donor) "AB" is the universal receipient

The nurse identifies which client is at risk to develop metabolic acidosis? Select all that apply 1. (1.) A client diagnosed with type 1 diabetes mellitus. 2. (2.) A client diagnosed with salicylate toxicity. 3. (3.) A client diagnosed with bilateral bacterial pneumonia. 4. (4.) A client diagnosed with acute renal failure. 5. (5.) A client diagnosed with continuous nasogastric drainage. 6. (6.) A client diagnosed with severe diarrhea.

(1.) CORRECT - At risk for diabetic ketoacidosis (2.) CORRECT - Acidic medication (3.) At risk for respiratory acidosis (4.) CORRECT - Kidneys not able to excrete acids or absorb bases (5.) At risk for metabolic alkalosis; lose acids (6.) CORRECT - Lose base in diarrhea

A client is prescribed prednisone and asks about possible adverse effects. The nurse teaches the client about which common adverse effects of prednisone? Select all that apply 1. (1.) Osteoporosis. 2. (2.) Decreased white count. 3. (3.) Low blood sugar. 4. (4.) Low serum potassium. 5. (5.) Retinal detachment. 6. (6.) Fluid retention

(1.) CORRECT-Glucocorticoids decrease bone density; calcium and vitamin D supplements or biphosphonates will decrease risk (2.) Glucocorticoids depress the immune response, but not the white cell count (3.) Glucorticoids cause hyperglycemia and glyxosuria (4.) CORRECT-Glucocorticoids cause hypokalemia and hypernatremia (5.) Glucocorticoids increase the risk of cataracts and glaucoma (6.) CORRECT-Glucocorticoids cause sodium and water retention

Sexually Transmitted Disease

-Syphilis (Treponema pallidum)...chancre + red painless lesion primary stage = 90 days; Secondary stage = up to 6 mo, rash on palms and soles plus flu-like symptoms; Tertiary stage = neurologic and cardiac destruction (10-30 yrs.), treated with penicillin G IM -Gonorrhea (Neisseria Gonorrhea)...Yellow-green urethral discharge ("the clap") -Chlamydia (Chlamydia Trachomatis)...Mild vaginal discharge or urethritis; Doxycycin, Tetracycline -Trichomoniasis (Trichomonas Vaginalis)...Frothy foul-smelling vaginal discharge; Flagyl -Candidiasis (Candida Albicans)...Yellow, cheesy discharge with itching; Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin) -Herpes Simplex 2...Acyclovir -HPV (Human Pappilovirus)...Acid, Laser, Cryotherapy -HIV...Cocktails

Post-op positioning

-THR...No adduction past midline, no hip flexion past 90 degrees -Supratentorial Sx...HOB 30-45 degrees (Semi-Fowler) -Infrantentorial Sx...Flat

Newborn calories

108/kg/day

Addison's

-not enough steriod (down down down up down) *hyponatremia *hypotension *decreased blood volume *hyperkalemia *hypoglycemia **FOR CRISIS- emergency bc of vascular collapse... give glucose and steroids IV

PSYCH PATIENTS

-safety -setting limits -establish trusting relationship -meds -leas restrictive methods/environment

Cushings syndrome

-too much steroid (up up up down up) *hypernatremia *hypertension *increased blood volume *hypokalemia *hyperglycemia

PR interval

.12-.20 *depolarization and repolarizaion

Creatinine

0.5-1.2

Lithium TR

0.5-1.5

Lithium

0.5-5 *bipolar disorder

The health care provider prescribes an intramuscular dose of 200,000 units of penicillin G benzathine for an adult client. The label on the 10-mL ampule sent from the pharmacy reads, "Penicillin G benzathine,300,000 units/mL." How many milliliters of medication does the nurse prepares to ensure administration of the correct dose? (Round to the nearest tenth.)

0.7

A nurse preparing a sterile field is placing sterile items on the field. The nurse understands that the border of the sterile drape is considered contaminated. How many inch(es) is the contaminated border? Type your answer in the box provided. _____ inch(es)

1

Spinal cord injuries

1 week to know ultimate prognosis

A client returns to the unit following a thyroidectomy. Which assessment finding requires an intervention by the nurse? 1. The client makes noises when breathing. 2. The client reports pain at the surgical site. 3. The client asks for liquids to drink. 4. The client is sleepy from anesthesia.

1) CORRECT- Assessment: outcome not expected and priority; sign of tracheal compression caused by hemorrhage or edema 2) Assessment: outcome expected; use analgesics, semi-Fowler's position 3) Assessment: outcome expected; NPO status prior to surgery 4) Assessment: outcome expected

Na+

136-145

Dilantin TR

10-20

A nurse is caring for a client with chronic renal failure whose daily fluid allotment is determined by calculating the previous day's output plus insensible losses through the lungs(Insensible loss from the respiratory tract is about 400 mls/day- minimal insensible loss in an adult is 800 msl/day). If the client's urine output for the previous day was 300 mL, the nurse anticipates how many milliliters of fluid will be allotted for today?"

700ml

D Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client.

D Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.

C Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs.

A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics.

A Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury

- A registered nurse (RN) is planning the assignments for the day and has a licensed practical nurse (LPN) and a nursing assistant (NA) working on the team. The nurse assigns which client to the LPN?

A one- day postoperative mastectomy client

Nurse assesses a client's burn injury and determines that the client sustained a partial-thickness superficial burn. Based on this determination, which finding did the nurse note?

A wet, shiny, weeping wound surface.

A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should the nurse obtain to hang with the blood product at the client's bedside? A. 0.9% sodium chloride B. Lactated Ringer's solution (LR) C. 5% dextrose in 0.9% sodium chloride D. 5% dextrose in water in 0.45% sodium chloride

A. 0.9% sodium chloride

A nurse working the 7 am-to-3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first? A. A client scheduled for hemodialysis at 10 am B. A client scheduled for a nuclear scanning procedure at 10 am C. A client scheduled for contrast computed tomography (CT) at noon D. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am

A. A client scheduled for hemodialysis at 10 am

Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply. A. A client who has undergone colectomy B. A client with acute pancreatitis C. A client who has undergone gastrectomy D. A client with renal insufficiency E. A client with Alzheimer's disease

A. A client who has undergone colectomy B. A client with acute pancreatitis C. A client who has undergone gastrectomy

A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will she plan to care for first? A. A client who is scheduled for surgery at 1 pm B. A client scheduled for physical therapy at 11 am C. A client in skeletal traction who has just received pain medication D. A client who is able to perform activities of daily living independently

A. A client who is scheduled for surgery at 1 pm

A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client's safety? A. Belt B. Wrist C. Elbow D. Mitten

A. Belt

A nurse in a long-term care facility recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. The appropriate nursing action would be to: A. Contact the physician B. Apply the restraints anyway C. Medicate the client with a sedative, then apply the restraints D. Compromise with the client and use only one wrist restraint instead of two

A. Contact the physician

A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine the effectivenessof the tube feedings? A. Daily weight B. Serum protein level C. Calorie count sheets D. Daily intake and output records

A. Daily weight

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply. A. Have a first aid kit available. B. Have a firearm or other weapon available. C. Plan a meeting place for family members. D. Obtain a 1-day supply of water (1 gallon per person). E. Have an adequate supply of prescription medications. F. Have a battery-operated radio and a flashlight and batteries available.

A. Have a first aid kit available. C. Plan a meeting place for family members. E. Have an adequate supply of prescription medications. F. Have a battery-operated radio and a flashlight and batteries available.

The nurse has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. Which nursing intervention would be least helpful to this client at this time? A. Initiating confinement measures B. Acknowledging the client's behavior C. Assisting the client to an area that is quiet D. Maintaining a safe distance with the client

A. Initiating confinement measures

A nurse is assessing language development in a toddler from a bilingual family. What should the nurse expect about the child's language development? A. Is slower than expected B. Is developing as expected C. Is more advanced than expected D. Will require assistance from a speech therapist

A. Is slower than expected

A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which problem? A. Phlebitis of the vein B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergic reaction to the IV catheter material

A. Phlebitis of the vein

A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. A. Skin B. Lung C. Immune D. Urinary E. Lymphatic F. Gastrointestinal

A. Skin Correct B. Lungs Correct F. Gastrointestinal Correct

A schizophrenic client says, "I feel like I'm rotting away inside and all of my organs are rusting." Which type of delusion does the nurse identify in the client's statement? A. Somatic B. Jealousy C. Persecution D. Idea of reference

A. Somatic

A client asks the nurse about the procedure for becoming an organ donor. What should the nurse tell the client? A. That anatomical gifts should be made in writing and signed by the client B. To speak with the chaplain about the psychosocial aspects of becoming a donor C. That this decision must be made by the next of kin at the time of the client's death D. To let the health care provider know about the request so that it may be documented in the client's record

A. That anatomical gifts should be made in writing and signed by the client

Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which of the following findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. A. The client is agitated. B. The skin under the restraint is red. C. The client's left hand is pale and cold. D. The client verbalizes the reason for the restraints. E. The client is unable to reach the gastrostomy tube with his hands. F. The client slips his hand from its restraint and pulls at his gastrostomy tube.

A. The client is agitated. B. The skin under the restraint is red. C. The client's left hand is pale and cold. F. The client slips his hand from its restraint and pulls at his gastrostomy tube.

At the beginning of the 7 am-3 pm shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 am was 149 mg/dL, notifies the physician, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? Select all that apply. INCIDENT REPORT Events that Occurred A. The physician was contacted. B. The blood glucose level at 7:15 am was 149 mg/dL. C. An IV solution of 5% dextrose in water was infusing at 7 am. D. A solution of 5% dextrose in water was infusing instead of the prescribed 0.9% normal saline solution. E. A 5% dextrose in water solution is not usually prescribed for clients with diabetes, and the solution was changed immediately on its discovery.

A. The physician was contacted. B. The blood glucose level at 7:15 am was 149 mg/dL. C. An IV solution of 5% dextrose in water was infusing at 7 am.

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the health care provider? Select all that apply. A. Unequal chest expansion B. Pulse rate of 82 beats/min C. Respiratory rate of 22 breaths/min D. Diminished breath sounds in the right lung E. Complaints of discomfort at the needle insertion site

A. Unequal chest expansion

A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply. A. Weight B. Glucose test C. Temperature D. Peripheral pulses E. Hemoglobin and hematocrit

A. Weight B. Glucose test C. Temperature

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8mg per ml. How many ml should the nurse administer? a. 0.5ml b. 1ml c. 1.5ml d. 2ml

ANS A - 0.5ml divide 4mg/8mg per ml gives you 0.5

An adolescent diagnosed with scoliosis. The nurse explains to the adolescent and the parents that treatment will correct the:

Abnormal lateral curvature of the spine.

Med Surg Hypoventilation

Acidosis = too much CO2

Liver biopsy

Adm vit k , npo morning of exam 6hr, give sedative *Teach pt that he will be asked to hold breath for 5-10sec, supine postion, lateral with upper arms elevated. *Post- postion on right side, frequent v.s., report severe ab pain stat, no heavy lifting 1wk

Menieres disease

Admin diuretics to decrease endolymph in the cochlea, restrict Na, lay on affected ear when in bed.

The client is being admitted to the hospital after receiving a radium implant for cervial cancer. The nurse takes which priority action in care of this client?

Admit the client to a private room

C Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure.

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.

ABC's

Airway, Breathing, Circulation

Nitrazine paper

Amniotic fluid is alkaline, and turns nitrazine paper blue. Urine and normal vaginal discharge are acidic, and turn it pink.

Oncology Leukemia

Anemia (reduced RBC production), immunosuppression (neutropenia and immature WBC's), Hemorrahage and bleeding tendencies (thrombocytopenia) Acute Lymphocytic = most common type, kids, best prognosis

Left hemisphere lesion

Aphasia, agraphia, slow, cautious, anxious, memory okay

Dilantin

Anticonvulsant *10-20

(Y) A nurse is caring for a client with hypoparathyroidism. In planning for discharge from the hospital, the nurse identifies which of the following as a potential psychosocial nursing diagnosis?

Anxiety related to the need for lifelong dietary interventions to control the disease.

A client who is experiencing suicidal thoughts says to the nurse, "Life is just not worth it anymore." What is the appropriate initial response? A. "You have a lot to live for." B. "Tell me what you mean by that." C. "A good night's sleep will help you feel better." D. "You should feel grateful for everything you have."

B. "Tell me what you mean by that."

A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches in which position? A. 2 inches to the front and side of the toes B. 8 inches to the front and side of the toes C. 15 inches to the front and side of the toes D. 22 inches to the front and side of the toes

B. 8 inches to the front and side of the toes

A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up? A. A client who has sustained a stroke dresses herself. B. A client exhibits signs of increased intracranial pressure after a craniotomy. C. Normal neurological findings are noted in a client with a cerebral aneurysm. D. A client with a spinal cord injury transfers himself from a bed to a wheelchair.

B. A client exhibits signs of increased intracranial pressure after a craniotomy.

A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse observes the client for compulsive behavior involving which repetative element? A. Fears B. Actions C. Thoughts D. Delusions

B. Actions

A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the client? Select all that apply. A. Custard B. Apple juice C. Orange juice D. Chicken broth E. Orange gelatin F. Vanilla ice cream

B. Apple juice D. Chicken broth E. Orange gelatin

The nurse working with a victim of rape in a clinic setting is developing a plan of care for the client. Which short-term initial goal is most appropriate? A. The client will care for her own physical wounds. B. The client will verbalize her feelings about the event. C. The client will identify an appropriate treatment plan. D. The client will resolve feelings of fear and anxiety related to the rape trauma.

B. The client will verbalize her feelings about the event.

A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? A. The client has a fever B. The skin temperature is normal C. The client needs to drink additional fluids D. The client needs to have the blanket removed

B. The skin temperature is normal

A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should tell the mother: A .That this is a normal occurrence B. To bring the newborn to the clinic C. To increase the number of cord site cleanings each day D. To place an ice pack on the cord for 10 minutes three times a day

B. To bring the newborn to the clinic

A nurse on the day shift is assigned to care for four clients. Following report from the night shfit, which client will the nurse plan to assess first?

Client with pulmonary edema who was treated with furosemide (Lasix) at 5am

Delegation: RN Only

Blood products (2RN's must check) Clotting factors Sterile dressing changes and procedures Assessments that require clinical judgement Ultimately responsible for all delegated duties UAP...non-sterile procedures

SLE

Butterfly rash...avoid direct sunlight

A nurse provides instructions to a client about the use of an electric heating pad. The nurse determines that the client needs further instruction if the client makes which statement? A. "I shouldn't lie on the pad." B. "I'll avoid using the high setting." C. "I can pin the pad around the affected area." D. "I'll need to keep an eye on my skin for redness."

C. "I can pin the pad around the affected area."

A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am-7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy

C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first: A. Weighs the child B. Takes the child's temperature C. Attaches the child to a pulse oximeter D. Administers the prescribed antibiotic

C. Attaches the child to a pulse oximeter

A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the instructions? A. Milk B. Cabbage C. Boiled potatoes D. Coffee with cream

C. Boiled potatoes

A schizophrenic client says, "I'm away for the day ... but don't think we should play or do we have feet of clay?" Which alteration in the client's speech does the nurse document? A. Neologism B. Word salad C. Clang association D. Associative looseness

C. Clang association

A nurse is caring for an older adult client. When planning care, which occurrence does the nurse recognize as part of the normal aging process? A. Tubular reabsorption increases. B. Urine-concentrating ability increases. C. Glomerular filtration rate (GFR) is diminished. D. Medications are metabolized in larger amounts.

C. Glomerular filtration rate (GFR) is diminished.

A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn? A. Greater-than-average length B. Higher-than-normal birth weight C. Short palpebral fissures and a flat midface D. Greater-than-average head circumference

C. Short palpebral fissures and a flat midface

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? A. HIV infection has been confirmed B. The client probably has an opportunistic infection C. The test will need to be confirmed with the use of a Western blot D. A positive test is a normal result and does not mean that the client is infected with HIV

C. The test will need to be confirmed with the use of a Western blot

A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to: A. Wear eyeglasses 24 hours a day B. Wear a patch on the affected eye C. Turn the head to scan the lost visual field D. Keep all objects in the impaired field of vision

C. Turn the head to scan the lost visual field

Hypoparathyroidism

CATS - convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium) *high Ca, low phosphorus diet

(Y) Epididymitis has developed as a complication of a urinary tract infection (UTI). The nurse is giving the client instructions to prevent a reoccurrence. The nurse determines that the client needs further instruction if the client states to:

Continue to take the prescribed antibiotics until all the symptoms are gone.

A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A. 15 B. 30 C. 50 D. 100

D. 100

The nurse is working with an older client who has been hospitalized and the client's family to formulate a plan for discharge. In guiding the discussion with the client and family, which living arrangement should the nurse understand most older persons prefer? A. Alone B. With their children C. In long-term care facilities D. Independently but close to their children

D. Independently but close to their children

A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? A. Fever B. Dyspnea at rest C. Dyspnea on exertion D. Nonproductive cough

D. Nonproductive cough

A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection? A. Urethra B. Nephron C. Glomerulus D. Ureterovesical junction

D. Ureterovesical junction

A nurse helps a young adult conduct a personal lifestyle assessment. Why should the nurse carefully review the assessment with the young adult? A. Young adults ignore their risk for a serious illness B. Young adults are unable to afford health insurance C. Young adults are exposed to hazardous substances D. Young adults ignore physical symptoms and postpone seeking health care

D. Young adults ignore physical symptoms and postpone seeking health care

A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. The nurse would immediately give the child: A. A sugar cube B. A teaspoon of sugar C . ½ cup of diet cola D. ½ cup of fruit juice

D. ½ cup of fruit juice

Fruity breath

Diabetic ketoacidosis

The nurse is developing a plan of care for a client who recently received a diagnosis of acquired immunodeficiency syndrome and is experiencing difficulty adjusting to the illness. Which action is an inappropriate intervention for this client? A. Monitoring the client for signs of self-harm B. Helping the client verbalize concerns related to fear C. Assisting the client with problem-solving and decision-making E. Discouraging social networking to prevent the spread of infection

E. Discouraging social networking to prevent the spread of infection

Phenothiazines (typical antipsychotics)

EPS, Photosensitivity

Restlessness and irritability

Early signs of cerebral hypoxia

Burn autograph

Elevated and Immobile 3-7 days

COPD

Emphysema = Pink puffer Chronic Bronchitis = Blue bloater (cyanosis, rt sided heart failure = boating/edema)

First Degree

Epidermis (superficial partial thickness)

A female client with chronic pyelonephritis expresses concern that she may have to undergo dialysis. What is the best initial response by the nurse?

Explain the relationship between chronic kidney infection, real failure, and dialysis

Insulin and prednisone

Extra insulin may be needed for a patient taking Prednisone (remember, steroids cause increased glucose).

Phases of labor

FIRST STAGE 1. Latent- 1-4cm 2. Active 4-7 cm intense 3. Transition 8-10 wants to give up SECOND STAGE -pushing stage, from complete dilation to delivery THIRD STAGE *Delivery of placenta FOURTH STAGE *recovery *1-4 hours after delivery of placenta

Peptic ulcers

Feed a duodenal ulcer (pain is relieved by food) Starve a gastric ulcer

Diabetic coma vs. Insulin shock

Give glucose first - if no help, give insulin

Hepatitis

Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B=Blood and Bodily fluids Hepatitis C is just like B

Permanent paralysis

If spinal cord is compressed for 12-24 hours

Posterior baby and heart sounds

If the baby is a posterior presentation, the sounds are heard at the sides.

Baby in anteror position and heart sounds

If the baby is anterior, the sounds are heard closer to midline, between teh umbilicus and where you would listen to a posterior presentation.

Breech baby and heart sounds

If the baby is breech, the sounds are high up in the fundus near the umbilicus. If the baby is vertex, they are a little bit above the symphysis pubis.

Lipitor (-statins)

In PM only; No grapefruit juice

A Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.

A client with a deep vein thrombosis is receiving a heparin protocol based on a target partial thromboplastin time & PPT' of (65 to 95 seconds. The client"s current PTT result is 35 seconds. what action should the nurse implement?

Increase the Heparin infusion rate

A client in acute renal failure has a serum potassium level of 6.5. What medication can the nurse expect the healthcare provider to prescribe?

Kayexalate retention enema

Tracheostomy patients

Keep Kelly clamp and obturator (used to insert into trachea then removed leaving cannula) at bed side

A home care nurse has instructed a client in safety measures for using oxygen in the home. The nurse determines that the client needs additional instructions if the client states he should:

Keep the oxygen concentrator as close to the room wall as possible.

Post-op (general instructions) Watch for stridor after any neck/throat Sx

Keep trach kit at bed side

Post thyroidectomy

Keep tracheostomy set by the bed with O2, suction and calcium gluconate

LOA fetus

LOA is most common

Ovarian Cancer

Leading cause of death from gynecological cancer

Ventilators

Make sure alarms are on; check every 4 hours minimum

Antabuse for alcohol deterrence

Makes you sick with OH intake

Multiple myeloma

Malignant neoplasm of bone marrow *high calcium levels because of the bone breakdown *A high fluid intake and urine output helps to prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. *Weight-bearing and ambulation are encouraged to help bone retain calcium

Important in people with Addison's disease

Managing stress in a patient with adrenal insufficiency (Addison's) is paramount, because if the adrenal glands are stressed further it could result in Addisonian crisis.

Which prescription should the nurse anticipate administering to a client who is experiencing increased intracranial pressure secondary to a head injury?

Mannitol

Insulin temp

May be kept at room temperature for 28 days

Hypoparathyroidism

May result in chronic hypocalcemia and hyperphosphatemia

C Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time.

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."

Bladder irrigation

Only isotonic sterile saline to be used

Cataract Sx

Opposite side, Semi-Fowler

Pyridium (for bladder infection)

Orange/red/pink urine

Arterial Blood Gases (Acidosis vs Alkalosis)

PH 7.35-7.45 CO2 35-45 (respiratory driver) High=Acidosis HCO3 21-28 (metabolic driver) High=Alkalosis O2 80-100 O2Sat 95-100%

Medication - Sucralfate

PN Administration= (carafate) give 1hr b4 meals on empty stomach

5 P's of neurovascular status (Important with fx's)

Pain, Pallor, Pulse, Paresthesia, Paralysis; Provide age appropriate toys for kids in traction

5 P's of NV functioning

Pain, paresthesia, pulse, pallor, paralysis

Testicular Cancer

Painless lump or swelling testicle...STE in shower > 14yrs; 15-35 = Age

Pill-rolling tremor

Parkinson's (tx with Levodopa, Carbidopa); Fall precautions, rigid, stooped, shuffling

In completing the treatment plan for an 11 year old who has bipolar disorder, the nurse plans outcomes for the nursing diagnosis, Risk for violence towards peers related to impulsivity. Which outcome is important?

Seeks out staff when having thoughts of harming others. The most important outcome is for the client to seek staff !hen thoughts of harming others occur

Droplet (Respiratory) Precautions (Wear Mask)

Sepsis, Scarlet fever, Strep, Fifth disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola, Memingitis, Mycoplasma, Adenovirus, Rhinovirus

- A nurse hangs a 1000 mL bag of intravenous (IV) fluid for an assigned client. Forty-five minutes later, the nurse notes that the client is complaining of a pounding headache, is dyspneic, apprehensive, and has an increased pulse rate. The IV bag has 500 mL remaining. The nurse should take which of the following actions first?"

Shut off the IV infusion

Smoke inhalation burns

Singed nasal hair and circumoral soot/burns

Aphasia

Speaking

Cleft palate feeding

Special soft large nipple for feeding.

Dysphasia

Speech and verbal comprehension

What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction Equipment

The nurse is performing an intake interview at a prenatal clinic. Which planned activities described by the client who is at 6 weeks gestation will the nurse investigate first?

Supervision of the renovation of an old house the family just purchased due to teratogen defect

Phlebitis

Supine, elevate involved leg

Amputation

Supine, elevate stump for 48 hours

Dysphagia

Swallowing

97. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contac

The correct answer is D: Contact

A nurse on the day shift receives her client assignments for the day. List the clients in order of their priority for assessment.

The correct order is: A client with heart failure whose condition has been stable since the administration of furosemide (Lasix) A client with gastroenteritis and diarrhea A client with suspected gallbladder disease who is scheduled for an ultrasound of the abdomen A client with a herniated disc who is scheduled to be discharged today

A nurse working the 7 am-to-3 pm shift is assigned to care for four clients. List the clients in order of priority for the nurse.

The correct order is: A client with pneumonia who is receiving oxygen A client with diabetes mellitus who requires the administration of NPH insulin before breakfast A client with a wound requiring dressing changes at 10 am and 2 pm A client preparing for discharge after surgery

A nurse is assisting a nurse-midwife in performing an amniotomy. After the procedure, the nurse should perform the following actions. Arrange the actions in the order that they should be performed. All options must be used.

The correct order is: Assess the fetal heart rate Assess the color, odor, and other characteristics of the amniotic fluid Check the woman's heart rate and blood pressure Assist the woman in cleaning the perineal area Ask the woman about the need to void

A nurse who is preparing to leave the room of a client who is under airborne precautions needs to remove the following protective items: gloves, gown, mask, and goggles. Place in order of priority the items that need to be removed.

The correct order is: Gloves Goggles Gown Mask

If chest tube drain stops fluctuating...

The lung has re-inflated (or there is a problem)

D Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication.

Lithium (a salt)

Theraputic range = 0.5-1.5

Tetralogy of fallot

Think DROP *Defect, septal *Right Ventricular hypertrophy Overriding aorts *Pulmonary stenosis

C Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.

When planning nursing care for immobilized clients, the nurse should consider which physiological alterations that frequently occur with immobility?

Urinary stasis, venous pooling and bony demineralization

Bronchodilators

Use bronchodilators before steroids for asthma; Exhale completely, inhale deeply and hold breath for 10 seconds

A female client is instructed to do kegel exercises. What statement indicates to the nurse that the client understands ho! to perform these exercises?

When I urinate I should tighten those muscles and stop the flow of urine for 10 seconds and repeat this 5 to 10 times

Diabetes and Insulin

When in doubt treat for Hypoglycemia first

D Rationale: Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter.

Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? A. Self-care deficit B. Functional incontinence C. Fluid volume deficit D. High risk for infection

A, B Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.

Atypical antipsychotics

Work on positive and negative symptoms, less EPS

Agraphia

Writing

The client is receiving an IV infusion of heparin. The bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. The heparin is to be infused at 1200 units per hour. At what rate should the nurse set the infusion pump? Calculate and record the rate in milliliters. Calculate and record the answer in the box.

Your Response: Correct Response: 24 mL X = 24

A client from a nursing home is admitted with urinary sepsis and has a single lumen, peripherally inserted central catheter. Four medications are prescribed for the a.m.and the nurse is running behind schedule. Which medication should the nurse administer first

Zosyn- the antibiotic

Hepatic encephalopathy and giving lactulose what lab to monitor

ammonia

Munchausen by proxy (MSBP)

an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care.

An antacid should be given to a mechanically ventilated patient w/

an ng tube if the ph of the aspirate is <5.0. Aspirate should be checked at least every 12 hrs.

The alarm of a client"s pulse oximeter sounds and the nurse notes that the oxygen saturation rate is indicated at 5/. )hat action should the nurse take first?

apply oxygen by mask

Client has a Lithium level of =.54

ask client if they have been taking their medication everyday

A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?

assess the client for pallor

Depressed client and best activity

assist client with making cut out cookies

Initial side effect of estrogen

ataxia

sources of potassium

bananas, potatoes, citrus fruits

PPROM

before 37 weeks

Preterm birth

before 37 weeks, 7 days

Magnesium sulfate antidote

calcium gluconate

Which of the following nursing actions has the highest priority and caring for the client with hypoparathyroidism?

cardiac dysrhythmias

Intussusception

common in kids with CF. Obstruction may cause fecal emesis, ***currant jellylike stools (blood and mucus).***

Hypoglycemia

confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring

Coreg medication

contraindicated in asthma patients

itching under a cast

cool air via blow dryer, ice pack for 10- 15 minutes. NEVER use qtip or anything to scratch area

Leisions of midbrain

decerebrate posturing

Oral Hypoglycemics

decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production; Glyburide, Metformin (Glucophage), Avandia, Actos Acarbose blunts sugar levels after meal

The nurse is assessing a 54 year old client with Guillain Barre syndrome. What symptom is this client most likely to exhibit?

decreased mobility of the legs

bronchopulmonary dysplasia

develops in premature infants, associated with high O2 concentration and ventilators

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. Swelling reabsorbs within 1 to 3 days

Digoxin antidote

digiband

D&C

dilation and curettage *commonly used to treat miscarriages

Epiglottitis

do not examine throat!!! *prepare for trach

Birth weight

doubles at 6 months, triples at 1 year

Hyperparathyroidism

fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) *low Ca, high phosphorus diet

Ulcers

feed a duodenal ulcer,starve a gastric *food worsens a gastric ulcer

Benzodiazapines antidote

flumzaemil

Women has just been raped night before

has she taken a bath?

BP and lymphedema

inform UAP no blood pressure on that arm

Iatragenic

it was caused by treatment, procedure, or medication.

first sign of cystic fibrosis at birth

may be meconium ileus at birth. Baby is inconsolable, do not eat, not passing meconium`

Folic acid deficiency

neural tube defects

Pathological jaundice

occurs before 24hrs and last7 days. Physiological jaundice occurs after 24 hours-NORMAL.

Bladder irrigation

only isotonic sterile saline

Heparin antidote

protamine sulfate

Lumbar Puncture

pt is positioned in lateral recumbent fetal position, keep pt flat for 2-3 hrs afterwards, sterile dressing, frequent neuro assessments

A hospitalized client"s bronchoscopy specimen culture result indicates the presence of the Myobacterium tuberculosis organism. Which intervention is most important for the nurse to implement?

put the client in a room with negative airflow

5 yr old burn victim has pot of hot liquid fall on him, what should nurse tell mother to do first?

remove the clothing and place in hot bath

pneumonia common sign

rusty sputum

Best diet for Chrohns Disease

select High protein, high calorie, low fat diet with limited lactose (grilled chicken sandwich, pasta, etc)

NG tube/stomach content

stomach contents pH = < 4 (gastric juices aspirated)

KAWASAKI SYNDROME sign

strawberry tongue

TPN(total parenteral nutrition) given in

subclavian line

When you see Coffee-brown emesis

think peptic ulcer

Early sign of hypoglycemia

tremors

Late deceleration

turn the mother to her left side, to allow more blood flow to the placenta

coumadin antidote

vitamin k *keep PT and INR at 1-1.5 x normal

Gullian barre syndrome

weakness progresses from legs up *resp arrest is big concern *but it is often preceded by an infectious illness such as a respiratory infection or the stomach flu

Hyperglycemia

weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath

The nurse is preparing to administer medications to a client with hepatic encephalopathy. The nurse expects to note which medication is prescribed?

Lactulose syrup ( chronulac

The nurse administers which medicaiton to a client with hepatic encephalopathy that will reduce the client's serum ammonia level?

Lactulose syrup (chronulac) laxative.

A client with cirrhosis becomes confused I think ammonia levels are up

Lactulose to lower ammonia levels

Cervical and Uterine Cancer

Laser, cryotherapy, radiation, conization, hysterectomy, exenteration; Chemotherapy = No help PAP smears should start within 3 years of intercourse or by age 21

Breast Cancer

Leading cause of cancer in women Upper outer quadrant, left > right Monthly SBE Mammography...Baseline @ 35, annually after age 50 Mets to lymph nodes, then lungs, liver, brain, spine Mastectomy...Radical mastectomy = lymph nodes too (but no mm resected) Avoid BP measurements, injections and venipuncture on the surgical side

Watch for CSF leaks from nose and ears

Leakage can lead to meningitis and mask intracranial injury since usual increased ICP symptoms may be absent

The nurse is teaching a childbirth education class of prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately?

Leaking of fluid from the vagina

Enema

Left Sims (flow into sigmoid)

Feedings for low albumin

Lepro, Ensure or TPN if pt is NPO.

Rapid acting Insulins

Lispro (Humalog) and Aspart (Novolog) O: 5-15 minutes P: .75-1.5 hours

Hgb

M 14-18 F 12-16

RBC's

M 4.7-6.1 F 4.2-5.4

Hct

M 42-52 F 37-47

IG bands on electrophoresis

MS; weakness starts in upper extremities, bowel/bladder affected in 90%

Head trauma and seizures

Maintain airway = primary concern

Addison's crisis

Medical emergency-vascular collapse, hypoglycemia, tachycardia, administer IV glucose, corticosteroids; no PO corticosteroids on an empty stomach

An infant admitted to the neonatal intensive care unit is tachypneic, tachycardia, and has bounding brachial pulses. The healthcare provider suspects that the infant has coarctation of the aorta. Which intervention is most important for the nurse to include in this infant"s plan of care?

Monitor for congestive heart failure

- (Y) A nurse is caring for a client with leukemia receiving chemotherapy. The nurse reviews the laboratory results and notes that the neutrophil count is less than 500/mm3. Based on this laboratory result, the nurse includes which of the following as a necessary component of the plan of care?

Monitoring oral temperature every 4 hours.

Steroid effects

Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain-spindle shape, osteoporosis, adrenal suppression (delayed growth in kids), cushing's syndrome symptoms

Changes in level of responsiveness

Most important indicator of increased ICP

Mental health & Psychiatry

Most suicides occur after beginning of improvement with increase in energy levels

A client is admitted to the emergency room because of an overdose of acetaminophen {Tylenol}. Following gastric lavage, the nurse should expect to administer which medication?

Mucomyst

Anthrax

Multi-vector biohazard

Gall bladder or liver disease

Murphy's sign (Rt. costal margin pain on palp with inspiration)

Hypocalcemia

Muscle spasms, convulsions, cramps/tetany, +Trousseau's (flex at wrist), +Chvostek's (hyperexcitability (tetany). It refers to an abnormal reaction to the stimulation of the facial nerve), prolonged ST interval, prolonged QT segment

First IV for DKA

NS, then infuse regular insulin IV as Rx'd

In ascending order of delivery potency:

Nasal Cannula, simple face mask, nonrebreather mask, partial rebreather mask, venturi mask

Aminocentesis

Needle puncture of the amniotic sac to withdraw amniotic fluid for analysis *perform amniocentesis before 20 weeks gestation to check for cardiac and pulmonary abnormalities

RSV

Needs contact precautions too

O2 Administration

Never more than 6L/min by cannula Must humidify with more than 4L/hr No more than 2L/min with COPD (CO2 Narcosis-a slowing of the O2 drive to breath)

Phenylalanine

New Born < 2 Adult < 6

Mastectomy

No BP or IV on side of Mastectomy

Lifting restrictions

No lifting over 10lbs for 6 weeks

kid with PKU diet

No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame)

A nurse caring for a victim of a burn injury during the emerent/resuscitative phase. On assessment of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should immediately

Notify the physician

A nurse is monitoring a client with acute hypoparathyroidism for signs of hypocalcemia. Which of the following would the nurse note if hypocalcemia was present?

Positive Trousseau's sign HYPOCALCEMIA- CHVOSTEK'S SIGN Elicitation: Tapping on the face at a point just anterior to the ear and just below the zygomatic bone Postitive response: Twitching of the ipsilateral facial muscles, suggestive of neuromuscular excitability caused by hypocalcemia.

Injury above T6

Possible hypotension and bracycardia

The nurse"s assessment of a client admitted !ith a diagnosis of diabetic Ketoacidosis include: scant urinary output, serum potassium level of 2.5, blood pH of 8.2, pulse 125 beats minute, respirations 36 breaths/minute, and blood pressure 90/52. Which prescription is most important for the nurse to implement?

Potassium IV at 20meq

The nurse is caring for the client being discharged to home with a tracheostomy. Which approach should the nurse take to help the client adjust best to caring for the tracheostomy at home?

Provide sufficient practice time for skill development before discharge.

A nurse is caring for a child with osteosarcoma after amputation of the left lower limb. The child is continously complaining of aching and cramping in the missing limb. The initial nursing action is which of the following?

Reassure the child that this is a temporary condition

Short acting Insulin

Regular (human) O: 30-60 min, P: 2-3 hours (IV okay)

Staples and sutures

Removed in 7-14 days, deep dry until then

Fractures

Report abnormal assessment findings promptly; compartment syndrome may occur = permanent damage to nerves and vessels

While assessing a client with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties are secured to the side rail using a quick release tie. what action should the nurse implement?

Reposition the restraints ties, securing them to the bed frame

C Rationale: The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed.

In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

A Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal.

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day

NSAIDS risks

Increased risk for cardiovascular events. Clients who had heart surgery should NOT take

Immediately after an abdominal surgical procedure, a nurse is caring for a client who lost a significant amount of blood during surgery. Which of the following assessment findings would indicate a sign of a potential complication?

Increasing Restlessness

Burns

Infection = primary concern

Incentive spirometry

Inhale slowly and completely to keep flow at 600-900, hold breath 5 seconds...10 times/hr

A 23 year old male client is brought to the emergency room by a group of fraternity brothers after a hazing event at the university. The client arrives with a blood alcohol level of 3.8 and a Glasgow Coma scale of 3. Which action should the nurse implement first?

Initiate IV access using Lactated Ringer's solution 1000ml with thiamine 100mg

A nurse is planning care for a hallucinating and delusional client who has been rescued from a suicide attempt. The nurse plans to:

Initiate one to one suicide precautions

- A client has Buck's extension traction applied to the right leg. The nurse delegating care to the licensed practical nurse (LPN) instructs the LPN to do which of the following to prevent complications of the device?

Inspect the skin on the right leg at least once every 8 hours

A client who suffered a stroke and is no! on a ventilator receives nutritional supplements by the tube feedings three times a day. The nurse checks the client for a residual volume before administering the next feeding. Which statement best describes the rationale for this nursing intervention?

Retention of feeding in the stomach increase the likelihood of regurgitation and aspiration

43. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation

Review Information: The correct answer is B: Leukopenia

A nursing staff member approaches a nurse manager and tells the manager that another nurse is tying knots in the air vent salem sump nasogastric tubes that are connected to suction. The nurse manager most appropriately handles this situation by:

Reviewing the skills checklist of the nurse who is trying the knots to assess if this skill has ever been performed and validated.

Side effects of aspirin

Reye syndrome in kids. Overdose may happen if your kidneys do not work correctly or when you are dehydrated. Signs include ringing in the ears, deafness, hyperactivity,dizziness

A mother tells the clinic that the healthcare provider !ants her to begin introducing solid foods to her 4month old infant. The nurse should recommend introducing foods in what order?

Rice cereal, strained apple, strained green and strained pureed

- (Y)"A female client with a history of chronic urinary tract infection complains of burning and urinary frequency. To determine whether the current problem is of renal (kidney) origin, the nurse would assess whether the client has pain or discomfort in the:"

Right or left costovertebral angle

Miller Abbott Tube

Right side for GI advancement into small intestine

Liver biopsy

Right side with pillow/towel against puncture site

Medical asepsis requires that the nurse include what hand washing technique?

Rinse soap off keeping hands and forearms lower than elbows

The nurse has identified four nursing problems for a 14year old admitted for depression and anxiety. What is the priority problem?

RisK for self directed violence related to history of self multilation

Insulin injection

Rotate injection sites (rotate in 1 region then move to new region)

Koplik spots

Rubeola (measles)

Weird miscellaneous stuff: Rifampin (for TB)

Rust/orange/red urine and body fluids

24. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? • Apply flannel pajamas to provide warmth. • Administer a PRN dose of ibuprofen. • Perform range of motion exercises in a warm tub. • Drape the sheets over the footboard of the bed.

S - Drape the sheets over the footboard of the bed. Rationale - The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint.

Air embolism

S/S- chest pain, difficulty breathing, tachycardia, impending sense of doom, pale -turn patient to left side and lower the head of the bed (trendelenberg)

Hypernatremia

Skin flushed Agitation Low grade fever Thirst

Is concerned about the type of legal consequences that can result from breaching client confidentiality. What source states the legal requirements nurses must follow to protect client confidentiality in a nurse/patient relationship?

State Nurse Practice Acts

ACE inhibitor

Stay in bed for 3 hours after first dose

The nurse is one of several people who witness a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tried to get up, and the victim's leg appears fractured. The nurse would plan to:

Stay with the victim and encourage the victim the remain still.

A client with chronic artial fibrillation is being started on quinidine sulfate (quindex extentabs) as maintenance therapy for dysrhythmia suppression. The nurse determines that the client needs instruction about this medication if the client stated he or she should:

Stop taking the prescribed digoxin (lanoxin) after starting this new medication.

A client with acute respiratory distress syndrome (ARDS) being mechanically ventilated has received a dose of vecuronium bromide (Norcuron). The nurse determines that the medication has had the intended effect if the client:

Stops fighthing (bucking) the ventilator.

Haloperidol (Haldol) 5 mg IM every 4 hours PRN is prescribed for a client. Which observation requires an IMMEDIATE intervention by the nurse? 1. Patient reports dizziness; heart rate 58 beats per minute. 2. Patient has tongue protrusion and muscle rigidity. 3. Patient has a facial rash and periorbital edema. 4. Patient reports sensitivity to light and blurred vision.

1) Assessment: outcome a concern but not priority; can cause tachycardia 2) CORRECT-Assessment: outcome not expected and priority; extrapyramidal reactions usually dose-related; controlled by dose-reduction or antiparkinsonian medications (benztropine) 3) Assessment: outcome a concern but not priority; possible maculopapular rash 4) Assessment: outcome a concern but not priority; intolerance to light not seen; blurred vision not commonly seen

The nurse cares for a client 4 hours after admission to the hospital for treatment of an anterior wall myocardial infarction. The client suddenly reports difficulty breathing and appears very anxious. Which action should the nurse take FIRST? 1. Evaluate the client's cardiac rhythm. 2. Check for cyanosis of the hands and the toes. 3. Auscultate the client's posterior lung fields. 4. Listen to the apical heart rate.

1) Assessment: outcome desired but not priority; ABCs apply here 2) Assessment: outcome not desired; peripheral cyanosis is a late sign of hypoxemia 3) CORRECT-Assessment: outcome priority; anterior wall MI high risk for heart failure; assess client first and then equipment 4) Assessment: outcome desired but not priority; should be assessed, but ABCs apply here

The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take? 1. Check the client records to see if insulin was given prior to surgery. 2. Administer the 6 units of regular insulin subcutaneously. 3. Administer the insulin when oral fluids are tolerated. 4. Contact the healthcare provider.

1) Assessment: outcome desired but not priority; client needs insulin coverage now 2) CORRECT - Implementation: outcome desired; sliding scale-receives predetermined amount of insulin according to glucose level; surgery and infection increase insulin needs 3) Implementation: outcome not desired; needs insulin regardless of oral intake due to elevated blood glucose 4) Implementation: outcome not desired; no reason to contact healthcare provider; order is valid and appropriate for situation

A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram? 1. Observe the color of the client's fingernail beds. 2. Assess the client's blood pressure in both arms. 3. Listen to the client's breath sounds. 4. Assess for intercostal retractions.

1) Assessment: outcome desired but not priority; cyanosis is a late sign of respiratory distress; central cyanosis will occur later than peripheral cyanosis 2) Assessment: outcome not desired; priority is to assess respiratory status; blood pressure may change due to decreased arterial oxygen levels; priority is to correct underlying problem 3) CORRECT - Assessment: outcome priority; will give early and clearest indication of respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax 4) Assessment: outcome desired but not priority; late indication of respiratory distress; intercostal muscles are accessory muscles

The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse? 1. 2+ pitting pretibial edema. 2. Sodium 128 mEq/L. 3. Weight gain of 2 kg in 24 hours. 4. Urine specific gravity 1.008.

1) Assessment: outcome desired but not priority; edema not seen with SIADH even though water is retained; needs to be monitored 2) CORRECT - Assessment: outcome desired and priority; normal sodium range is 135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures 3) Asssessment: outcome desired but not priority; indicates fluid retention, not as important as hyponatremia; important to watch trends in weight 4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with SIADH, urine will have high concentration and specific gravity due to excess ADH secretion

A woman is admitted to the hospital with a diagnosis of ovarian cancer. She has been treated with surgery and chemotherapy. The client states that she has no appetite and has lost 10 lbs in the last 4 weeks. Which statement, if made by the nurse, is MOST important? 1. "Have you noticed a decrease in your energy levels lately?" 2. "Do you notice any swelling of your hands and feet?" 3. "Describe your normal daily food intake." 4. "What are your favorite foods?"

1) Assessment: outcome desired but not priority; energy level decreased with malnutrition; is also adverse effect of chemotherapy 2) Assessment: outcome desired but not priority; protein deficiency may cause peripheral edema 3) Assessment: outcome desired but not priority; more important to provide nutrition 4) CORRECT-Assessment: outcome desired and priority; offer favorite foods to deal with the "here and now"

The nurse receives a phone call from the mother of a 10-year old child taking methylphenidate (Ritalin) daily. The mother reports the child has lost 2 pounds in the last 2 weeks. Which is the MOST appropriate response by the nurse? 1. "How much does your child exercise on a daily basis?" 2. "Stop giving the Ritalin for several days to see if the appetite improves." 3. "At what time do you give your child the Ritalin medication?" 4. "What is your child's bedtime and when does he usually awaken?"

1) Assessment: outcome desired but not priority; methylphenidate has appetite suppressant effects 2) Implementation: outcome not desired; Ritalin should be tapered 3) CORRECT-Assessment: outcome desired and priority; long-acting Ritalin should be given after breakfast to decrease appetite-suppressant effects 4) Assessment: outcome not priority; more important to assess effect of medication on appetite

The nurse is called to the bathroom of a woman who delivered an 8 lb 4 oz male 12 hours ago. The nurse notes that there is blood running down the client's leg. Which statement, if made by the nurse, is BEST? 1. "Leave your perineal pad in the bathroom so I can evaluate the lochia." 2. "Why don't you go back to bed so you can rest?" 3. "Let me help you back to bed so I can check your fundus." 4. "Sit in this chair so I can check your blood pressure."

1) Assessment: outcome desired but not priority; more important to determine source of bleeding 2) Implementation: outcome not desired; need to determine source of bleeding; need to assist client 3) CORRECT- Assessment: outcome priority; determine if fundus is firm; bleeding may be caused by pooling of lochia in the vagina 4) Assessment: outcome desired but not priority; more important to determine the source of bleeding

The nurse cares for a client who returned 4 hours ago after a subtotal thyroidectomy procedure. The nurse notes that the client sounds more hoarse when speaking than he did 1 hour ago. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the gag and swallow reflex. 2. Instruct the client to chew small amounts of ice chips. 3. Notify the healthcare provider. 4. Instruct the client to cough and breathe deeply every 15 minutes.

1) Assessment: outcome desired but not priority; not best test for laryngeal damage 2) Implementation: outcome not desired; will not decrease hoarseness 3) CORRECT- Implementation: outcome priority and desired; possible laryngeal damage; further assessment and possible treatment indicated; do not assume that hoarseness is caused by endotracheal tube 4) Implementation: outcome not desired; may further damage operative site

A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is MOST appropriate? 1. Get Doppler studies to check the pulse. 2. Notify the healthcare provider. 3. Determine if the cast is dry. 4. Check the client's vital signs.

1) Assessment: outcome desired but not priority; question stem tells you that assessment has been done; changes in pulse, color, sensation should be reported immediately to the healthcare provider 2) CORRECT - Implementation: outcome priority and desired; diminished pulses indicates change in circulation 3) Assessment: outcome desired but not priority; should report changes in circulation 4) Assessment: outcome not desired; symptoms suggest changes in circulation to extremity; more important to report change in distal circulation

The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse? 1. "My wife looks at the pin sites every day." 2. "I like to bathe in the tub." 3. "I drove to the library yesterday." 4. "I drink with a straw."

1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflammation and infection 2) Implementation: outcome desired; showers increase risk of infection at pin sites 3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of injury to self and others 4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized neck

Based on the nurse's knowledge of the goal of diuretic therapy for a client with heart failure, which assessment BEST indicates that the client's condition is improving? 1. The client's weight has decreased 2 pounds. 2. The client's systolic blood pressure has decreased. 3. The client has fewer crackles heard during auscultation. 4. The client's urinary output has increased.

1) Assessment: outcome expected but not priority; could be due to changes in appetite, no time frame given in question 2) Assessment: outcome expected but not priority; could be due to other causes such as change in position 3) CORRECT- Assessment: outcome priority; reason for diuretics; diuretic reduces alveolar edema and pulmonary venous pressure 4) Assessment: outcome expected but not priority; will increase due to diuretic but may not change heart failure

The home care nurse visits a client diagnosed with Parkinson's disease. The nurse is MOST concerned if which of the following is observed? 1. The client has soft, monotonous speech. 2. The client is drooling. 3. The client rolls the left thumb against the fingers. 4. The client ambulates with a stooped posture.

1) Assessment: outcome expected, hypotonia; speech may be hard to understand 2) CORRECT-Assessment: outcome not expected; at risk for aspiration due to difficulty swallowing and the accumulation of saliva 3) Assessment: outcome expected, present at rest; may disappear with purposeful movement 4) Assessment: outcome expected, teach postural exercises to minimize this effect

The nurse cares for a client with Addison's disease who is taking 20 mg hydrocortisone (Cortef) daily. Which statement by the client requires an intervention by the nurse? 1. "I will need to have my blood sugar levels checked while on this medication." 2. "I may have episodes of low blood pressure while taking this medication." 3. "I need to weigh myself twice a week and keep a record of my weight." 4. "I should notify my health care provider if I am running a fever."

1) Assessment: outcome expected; glucocorticoids can increase serum glucose levels 2) CORRECT- Assessment: outcome not expected; hypertension due to sodium and water retention expected 3) Assessment: outcome expected; weight gain due to sodium and water retention expected 4) Implementation: outcome desired; glucocorticoids have immunosuppressant effect; client at high risk for infection

The nurse reviews health assessments completed by student nurses. Which assessment warrants further investigation? 1. An 11-year-old female who states that she has had 3 periods in the past 6 months. 2. A 13-year-old male with intermittent voice changes. 3. A 14-year-old male with bilateral breast enlargement. 4. A 15-year-old female with bilateral breast buds.

1) Assessment: outcome expected; irregular menstrual periods common during the first year or two after menarche 2) Assessment: outcome expected; age-appropriate and common 3) Assessment: outcome expected; temporary, age-appropriate phenomenon 4) CORRECT-Assessment: outcome not expected; one of the earliest changes of puberty; occurs from age 9-13

A child is admitted to the hospital with a diagnosis of status asthmaticus. The nurse is MOST concerned if which of the following is observed? 1. SaO2 91%. 2. Expiratory wheezing. 3. Intercostal retractions. 4. Arterial pH 7.25.

1) Assessment: outcome expected; minimal acceptable level 2) Assessment: outcome expected; continuous high-pitched musical sound; expected with asthma 3) Assessment: outcome expected; usually present with severe asthma 4) CORRECT- Assessment: outcome not expected; indicates severe respiratory acidosis, accumulation of CO2 is danger sign of impending respiratory failure and cardiac arrest

The nurse assesses the fetal monitor of a client in labor. Which fetal heart rate pattern requires an intervention by the nurse? 1. A baseline rate of 140-150 between contractions with moderate variability. 2. Consistent heart rate accelerations that coincide with fetal movements. 3. A heart rate that slows following the peak of the contraction and returns to baseline after the contraction ends. 4. Gradual slowing of the heart rate that begins with the onset of the contraction and returns quickly to the baseline.

1) Assessment: outcome expected; normal 2) Assessment: outcome expected; reassuring sign of fetal well-being 3) CORRECT-Assessment: outcome not expected; late deceleration; indicates fetal distress and uteroplacental insufficiency; treatment-position on left side, give O2, IVs, notify healthcare provider 4) Assessment: outcome expected; early deceleration; good fetal outcome

The nurse cares for clients in the pediatric clinic. The nurse would be MOST concerned if which of the following was observed? 1. A 3-month-old infant's back is rounded. 2. A 4-year-old has a blood pressure of 90/60. 3. A 5-year-old has a pulse of 88. 4. The hem of the skirt on a 10-year-old is longer on one side than the other.

1) Assessment: outcome expected; normal finding 2) Assessment: outcome expected; normal finding 3) Assessment: outcome expected; normal finding 4) CORRECT-Assessment: outcome not expected; symptom of scoliosis

The nurse supervises care of clients on a postoperative surgical unit. Which of the following requires an immediate intervention by the nurse? 1. The nursing assistive personnel (NAP) obtains vital signs on a client who had a bowel resection 24 hours ago. 2. The NAP assists a client who had an above-the-knee amputation apply an elastic bandage to the residual limb. 3. The NAP assists a client who had a stroke 3 days ago with feeding. 4. The NAP assists a client who had a laparoscopic cholecystectomy 6 hours ago ambulate.

1) Assessment: outcome expected; within NAP scope of practice; principles of delegation should be followed 2) Implementation: outcome desired; within NAP scope of practice 3) CORRECT-Implementation: outcome not desired; client requires assessment and evaluation; may have problems with gag and swallow reflex 4) Implementation: outcome desired; within NAP scope of practice; stable client; principles of delegation should be followed

The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if which of the by which observation? 1. The respiratory rate is 40 per minute with short periods of apnea. 2. The heart rate is 140 beats per minute with variation during sleeping and waking states. 3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows. 4. Stroking the outer sole of the infant's foot upward causes his toes to curl downward.

1) Assessment: outcome not a problem; 30-60 breaths/min with periods of apnea; normal 2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake 3) Assessment: outcome not a problem; startle reflex; normal until 4 months 4) CORRECT - Assessment: outcome not expected and is a problem; Babinski reflex; in newborn, should see dorsiflexion of big toe

The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled for a renal computed tomography scan with contrast media at 10 a.m. The nurse is MOST concerned if the client makes which statement? 1. "My blood sugar was 124 mg/dL this morning." 2. "I drank a glass of water at midnight." 3. "Sometimes I get dizzy when I first get out of bed." 4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."

1) Assessment: outcome not desired but not priority; further assessment needed 2) Implementation: outcome not a problem; NPO for 8 hours prior to scan 3) Assessment: outcome not desired but not priority; possible orthostatic hypotension; further assessment needed 4) Correct - Implementation: outcome not desired and priority; metformin should be held for 48 hours prior to tomography with contrast media; risk lactic acidosis with potential renal damage

The nurse is caring for an elderly client admitted for type 1 diabetes mellitus. The nurse notes that the client appears to have difficulty understanding what is said. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Ask the client if cotton-tipped applicators are used for ear cleaning. 2. Perform the Weber hearing test. 3. Check the client's ear canals for cerumen. 4. Use facial expressions and speak in a high frequency tone of voice.

1) Assessment: outcome not priority; most common cause is cerumen in elderly 2) Assessment: outcome not priority; cerumen most likely cause 3) CORRECT- Assessment: outcome priority; physical, ear wax becomes drier in elderly; can block ear canal and cause decreased hearing 4) Implementation: outcome not priority; nonverbal cues useful when speaking to hearing-impaired; need low tones; high frequency tones are problem for elderly

A client is scheduled for transfer to another hospital. Which observation, if made by the nurse, would require an IMMEDIATE intervention? 1. Lactated Ringer's infusing IV into the client's left forearm is 400 mL behind schedule. 2. The client's nasogastric tube is draining a moderate amount of green liquid. 3. The client's blood pressure has changed from 140/80 to 150/88 in the last hour. 4. The client's SaO2 is 88%.

1) Assessment: outcome not priority; needs to be investigated 2) Assessment: outcome not priority; no indication of a problem 3) Assessment: outcome not priority; still the same range 4) CORRECT- Assessment: outcome priority; decreased oxygenation level; needs further assessment

A 56-year-old man is scheduled for an MRI (magnetic resonance imaging). His history indicates that he suffered an injury during the Vietnam War. Which question is MOST important for the nurse to ask the client? 1. Where was your injury? 2. When were you wounded? 3. Did your injury involve shrapnel? 4. Were you exposed to chemical warfare?

1) Assessment: outcome not priority; not significant for MRI 2) Assessment: outcome not priority; not significant for MRI 3) CORRECT- Assessment: outcome desired and priority; MRI contraindicated with metal prosthesis or implanted metal 4) Assessment: outcome not priority; defoliant used in war, not significant for MRI

The nurse prioritizes the needs of a client who has been raped. Which nursing action is MOST important? 1. Observe the client for withdrawn, tearful behavior. 2. Determine if the client sustained any injuries. 3. Obtain information about events which preceded the rape. 4. Accurately document the client's comments about the rape.

1) Assessment: outcome not priority; psychosocial assessment; eliminate; address physical needs first 2) CORRECT - Assessment: outcome priority; physical needs are highest priority 3) Assessment: outcome desired but not highest priority; address physical needs first 4) Implementation: outcome not highest priority; legal documentation is not the highest priority

A client calls the healthcare provider's office reporting a rash, intermittent fever, headache, fatigue, muscle pain, and stiff neck. It is MOST important for the nurse to ask which question? 1. "Have you ever felt this way before?" 2. "Have you noticed any swollen areas on your neck?" 3. "Have you recently noticed any flea bites?" 4. "Have you noticed any tick bites recently?"

1) Assessment: outcome not priority; question too general 2) Assessment: outcome not priority; enlarged lymph glands indicate an inflammatory response or neoplastic disorder 3) Assessment: outcome not priority; causes papular urticaria, not systemic symptoms 4) CORRECT-Assessment: outcome priority; symptoms of Lyme disease; causes localized and systemic symptoms

A client is admitted to the hospital with a diagnosis of chronic bronchitis. Which action should the nurse take FIRST? 1. Weigh the client. 2. Place cardiac telemetry leads. 3. Place pulse oximetry on finger. 4. Obtain a sputum specimen

1) Assessment: outcome not priority; right heart failure and weight gain seen with chronic bronchitis; priority is to assess oxygenation 2) Assessment: outcome not priority; dysrhythmias occur due to right heart failure; priority is oxygenation 3) CORRECT-Assessment: outcome desired; priority is to establish oxygenation status 4) Assessment: outcome not priority; common reason for worsening status is respiratory infection; more important to establish respiratory status first

The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate? 1. Inform the health care provider that the client is menstruating. 2. Send the urine collected prior to the onset of the client's menstruation to the lab. 3. Insert an indwelling bladder catheter during the remainder of the collection period. 4. Request a separate urine collection container from the laboratory to be used during the remainder of the urine collection period.

1) CORRECT - Implementation: outcome desired; menstruation may last several days to a week; protein and red cells may alter the results of the urinalysis 2) Implementation: outcome not desired; all urine must be collected for accuracy 3) Implementation: outcome not desired; invasive procedure should be avoided if possible 4) Implementation: outcome not desired; would change the results of the 24-hour urine sample; all urine must be collected for accuracy

A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a monogamous relationship. Which statement by the nurse is BEST? 1. "You will need to wear a condom when having sexual intercourse for 6 weeks following the vasectomy." 2. "No other form of birth control is necessary for you or your wife at this time." 3. "You do not need to wear a condom when having sexual intercourse for the next few weeks, but your wife should use spermicidal jelly." 4. "Always wear a condom when having sexual intercourse because not all vasectomies are successful."

1) CORRECT - Implementation: outcome desired; sperm count decreased after the vasectomy; some sperm may remain in the vas deferens 2) Implementation: outcome not desired; sperm stored in vas deferens may be ejaculated for several weeks after the vasectomy 3) Implementation: outcome not desired; not effective enough 4) Implementation: outcome not desired; considered successful after 2 negative sperm counts

A 12-year-old diagnosed boy with a fractured right femur is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse is MOST concerned by which client statement? 1. "I will experience more muscle spasms and pain while my leg is in traction." 2. "I can lift my body up while I grab the overhead trapeze and bend my left leg." 3. "The health care provider told me it is okay to move the head of my bed up and down by myself." 4. "I need to put the phone where I can reach for it without moving onto my side."

1) CORRECT - Implementation: outcome not desired; muscle spasm should decrease with traction; if muscle spasm pain increases, the amount of traction weight should be assessed 2) Implementation: outcome desired; vertical movement is allowed as long as line of pull is maintained 3) Implementation: outcome desired; balanced suspension traction not affected by movement of bed; not affected by client movement unless line of pull affected 4) Implementation: outcome desired; can move up and down only, moving side-to-side changes line of pull of traction

The nurse cares for a client 4 hours after admission to the neuroscience unit due to a closed-head injury. Which is the MOST important action for the nurse to take? 1. Assess pupil shape and reactivity. 2. Take the client's rectal temperature. 3. Assess blood pressure and apical heart rate. 4. Observe the client's oxygen saturation level.

1) CORRECT- Assessment: outcome desired and priority; change in pupil size, shape, or reactivity is an early sign of increased intracranial pressure; report to healthcare provider immediately 2) Assessment: outcome not priority; increased temperature late sign of increased intracranial pressure; temperature elevation may be due to other injuries 3) Assessment: outcome not priority; changes in vital signs are late sign of increased intracranial pressure 4) Assessment: outcome desired but not priority; increased carbon dioxide level will increase intracranial pressure

The husband of a woman at 39 weeks gestation calls the clinic nurse and states, "My wife's water just broke, and I think she's going to have the baby!" Which statement, if made by the nurse, is BEST? 1. "Look at your wife's vaginal area and tell me what you see." 2. "Time the contractions for 5 minutes." 3. "Tell your wife to pant between contractions." 4. "I will instruct you about how to deliver the baby."

1) CORRECT- Assessment: outcome desired and priority; determine if presenting part is crowning 2) Assessment: outcome desired but not priority; need to determine stage of labor first 3) Implementation: outcome not desired; need to determine stage of labor first 4) Implementation: outcome not desired; need to assess first

The home care nurse visits a client who had a traditional cholecystectomy 10 days ago. The client returned to the healthcare provider to have the T-tube removed 2 days ago. It is MOST important for the nurse to take which action? 1. Observe the color of the client's urine and stool. 2. Ask the client to describe the quality and quantity of pain she is experiencing. 3. Instruct the client to avoid fatty foods for 6 weeks. 4. Listen to bowel sounds.

1) CORRECT- Assessment: outcome priority; clay-colored stools and dark urine indicate that bile is draining into liver 2) Assessment: outcome not priority; psychosocial, not as important as assessing color of urine and stool 3) Implementation: outcome desired but not priority; should eat balanced diet and avoid high-fat foods 4) Assessment: outcome not priority; more important to assess urine and stools

A client with an 8-year history of ulcerative colitis is admitted to the hospital with severe abdominal cramping and diarrhea. The client has experienced 18 to 20 stools a day for the last 4 days. The nurse is MOST concerned by which finding? 1. The client's diastolic blood pressure decreases 20 mm when the client rises to a standing position. 2. The client's urinary specific gravity is 1.020. 3. The client has lost 3 pounds since her last admission. 4. The client appears pale and thin.

1) CORRECT- Assessment: outcome priority; indicates fluid volume deficit, check blood pressure supine, sitting and standing; other symptoms include concentrated urine and weak, rapid pulse 2) Assessment: outcome not priority; normal 1.010-1.030 3) Assessment: outcome not priority; don't know when client was last hospitalized 4) Assessment: outcome not priority; more concerned about fluid volume deficit

A 22-year-old woman at term comes to the hospital in labor. Two hours after admission, the client remains 4 centimeters dilated, and her contractions are weak. The healthcare provider orders oxytocin (Pitocin). Which finding would require an intervention by the nurse? 1. Contractions every 2 minutes, lasting 90 seconds. 2. Contractions every 3-4 minutes, lasting 60 seconds. 3. Fetal heart rate of 110 beats per minute at the peak of a contraction. 4. Fetal heart rate of 158 bpm at the end of a contraction.

1) CORRECT- Assessment: outcome priority; only 30 seconds between contractions; hypertonic labor pattern; results in fetal distress 2) Assessment: outcome not priority; normal frequency and duration 3) Assessment: outcome not priority; reassuring fetal heart tones 4) Assessment: outcome not priority; reassuring fetal heart tone

A 50-year-old woman with a history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. It would be MOST important for the nurse to obtain the answer to which question? 1. "When did you have your last drink?" 2. "How much alcohol have you consumed?" 3. "Have you ever used drinking in the morning to get rid of a hangover?" 4. "How many drinks do you need before you feel high?"

1) CORRECT- Assessment: outcome priority; withdrawal 5-35 hours after last drink; grand mal seizures 48 hours after; delirium tremens 72-96 hours after; client at high risk for seizures 2) Assessment: outcome not priority; may be included as part of the assessment 3) Assessment: outcome not priority; may be included as part of the assessment 4) Assessment: outcome not the priority; may be included but timing is more important to anticipate withdrawal.

The nurse is caring for clients in the pediatric clinic. Which of the following clients should the nurse see FIRST? 1. An 8-month-old infant who had 6 watery stools in the past 8 hours. 2. A 13-month-old infant who received the MMR immunization 8 days ago and has a temperature of 101° F (38.3° C). 3. A 2-year-old child who has swelling, pain, and tenderness of the upper arm after falling off a chair. 4. An 8-year-old discharged from the hospital 2 days ago for asthma.

1) CORRECT- Diarrhea causes dehydration and electrolyte imbalances; needs to be evaluated 2) Normal reaction to MMR; stable 3) Needs continued observation; not the priority client 4) Requires follow-up; stable at this time

Heparin 5,000 units subcutaneously is ordered every 12 hours for a client. The result of the client's most recent PTT is 55 seconds. Which action by the nurse is MOST appropriate? 1. Document the result and administer the heparin. 2. Withhold the heparin. 3. Notify the healthcare provider. 4. Have the test repeated.

1) CORRECT- Implementation: outcome desired; PTT lower limit of normal 20 - 25 seconds, upper limit of normal 32 to 39 seconds, therapeutic range 1.5 to 2 times normal, 5 seconds is within therapeutic range 2) Implementation: outcome medication should be given; PTT is in therapeutic range 3) Implementation: outcome not desired; unnecessary 4) Implementation: outcome not desired; unnecessary

The nurse teaches a client with a spinal cord injury how to perform self-catheterization at home. Which statement, if made by the client, indicates that teaching has been successful? 1. "I will keep the catheter in a plastic bag." 2. "I will catheterize myself every 2 hours." 3. "I will wear sterile gloves." 4. "I will wash the perineum with alcohol prior to catheterizing myself."

1) CORRECT- Implementation: outcome desired; after use, catheter is soaked in solution of Betadine, bleach, or hydrogen peroxide, then dried and stored in a towel or bag; clean procedure in the home 2) Implementation: outcome not desired; done every 6-8 hours 3) Implementation: outcome not desired; clean procedure in the home, less risk of contamination 4) Implementation: outcome not desired; wash with soap and water

The health care provider (HCP) provider orders hydralazine 25 mg IM on call for a client before surgery. The LPN/LVN administers hydroxyzine 25 mg IM to the client. Which of the following is the MOST appropriate action for the nurse to take? 1. Document "Hydralazine 25 mg ordered; hydroxyzine 25 mg given; HCP notified; blood pressure 130/84; pulse 86; respiration 12." 2. Document "Hydroxyzine 25 mg given; hydralazine 25 mg ordered; HCP notified; vital signs stable." 3. Document "Hydroxyzine 25 mg mistakenly given; hydralazine 25 mg ordered." 4. Document "Hydroxyzine 25 mg given; incident report completed."

1) CORRECT- Implementation: outcome desired; objective; indicates nurse has monitored client 2) Implementation: outcome not desired; not best; contains judgment 3) Implementation: outcome not desired; incomplete; subjective 4) Implementation: outcome not desired; incident report not part of legal record

A client contaminated with an unidentified hazardous material arrives by ambulance at a local hospital. Which action should the nurse take FIRST? 1. Determine the decontamination that occurred in the field. 2. Reassure the client that he will receive excellent care. 3. Identify the type of hazardous material. 4. Remove all the client's clothing.

1) CORRECT-Assessment: outcome desired; nurse needs to determine if the situation is a threat to the caregiver; important to prevent the spread of contamination; flushing with water dilutes or reduces the amount of hazardous material 2) Implementation: not a priority; attend to the physical needs of client and staff 3) Assessment: outcome not desired; will be done by other health professionals; more important to determine level of decontamination in field 4) Implementation: outcome desired but not a priority; will reduce 80 to 90% contamination; more important to determine if decontamination occurred to ensure safety of client and staff

The nurse observes a student nurse examine a client's chest. Which action requires an intervention by the nurse? 1. The student nurse auscultates heart sounds and then palpates for tactile fremitus. 2. The student nurse uses the diaphragm of the stethoscope to listen to heart sounds. 3. The student nurse places the stethoscope firmly against the skin surface. 4. The student nurse inspects the chest before performing palpation.

1) CORRECT-Assessment: outcome desired; order for physical assessment is inspection, palpation, percussion, and auscultation; tactile fremitus is vibration produced when client says "99" 2) Assessment: outcome desired; used to listen for high-pitched sounds such as vesicular breath sounds 3) Assessment: outcome desired; a tight seal increases accuracy 4) Assessment: outcome desired; the order for physical assessment is inspection, palpation, percussion, and auscultation

A woman is admitted to the hospital complaining of diarrhea and vomiting for 3 days. The blood pressure is 90/60, apical heart rate 96, and respiratory rate 22 with shallow respirations. Laboratory results include Na+ 147 mEq/L, K+ 5.6 mEq/L, hematocrit 52%, hemoglobin 14 g/dL. The client is receiving 5% dextrose in 0.45% normal saline with K+ 20 mEq at 125 mL/hr. Prior to calling the healthcare provider, it is MOST important for the nurse to take which of these actions? 1. Change IV fluids to 5% dextrose in 0.45% normal saline. 2. Increase IV flow rate to 150 mL/hour. 3. Check the hourly urine output. 4. Observe the client for muscle weakness.

1) CORRECT- Implementation: outcome desired; potassium removed due to hyperkalemia; hypotonic solution used to correct dehydration 2) Implementation: outcome not desired; will increase serum potassium 3) Assessment: outcome not priority; client is dehydrated; intervention required 4) Assessment: outcome not priority; lab values indicate hyperkalemia

In preparation for a total laryngectomy, the nurse teaches a client how to support his neck after surgery. Which of the following demonstrations by the client indicates to the nurse that teaching is successful? 1. The client raises the elbows and places the hands behind the neck. 2. The client places one hand on the forehead and the other hand on the back of the head. 3. The client covers the ears with both hands and presses firmly. 4. The client grasps the chin with one hand and places the other hand on the forehead.

1) CORRECT- Implementation: outcome desired; prevents stress on suture line; supports head; use folded towel when mobile 2) Implementation: outcome not desired; no support for neck 3) Implementation: outcome not desired; no support for neck 4) Implementation: outcome not desired

The nurse plans care for a 42-year-old man receiving disulfiram (Antabuse). Which of the following statements requires an IMMEDIATE intervention by the nurse? 1. "This medication will prevent me from drinking alcohol." 2. "I should not take cough syrup preparations while taking Antabuse." 3. "If I discontinue the Antabuse, I should not consume alcohol for 2 weeks." 4. "Even small amounts of alcohol may cause nausea, vomiting, and headache."

1) CORRECT- Implementation: outcome not desired; does not prevent drinking, unpleasant reaction may decrease frequency of drinking 2) Implementation: outcome desired; must avoid all forms of alcohol, sauces, cough syrups, external, shaving lotions, liniments, back rub preparations 3) Implementation: outcome desired; effects continue for 2 weeks 4) Implementation: outcome desired; amounts as small as 7 ounces can cause reaction

Levodopa (L-Dopa) is prescribed for a 61-year-old woman. Which statement, if made by the client to the nurse, would indicate that the client needs further instruction? 1. "While I take this medication, I should eat a high-protein diet." 2. "I should change positions slowly at first so I don't get dizzy." 3. "If I have muscle twitching, I should report it to my health care provider." 4. "I should check with my health care provider before taking any over-the-counter medications."

1) CORRECT- Implementation: outcome not desired; take with low-protein diet to decrease GI upset 2) Implementation: outcome desired; true; orthostatic hypotension is common with Parkinson's disease 3) Implementation: outcome desired; true; blepharospasms (twitching eyelid) are early signs of overdosage 4) Implementation: outcome desired; true; multivitamins can reverse actions, especially vitamin B6

The home care nurse makes an initial visit to an 80-year-old client. The client's daughter states that her mother has a history of colon cancer and has been restless and confused for about a week. It is MOST important for the nurse to obtain an answer to which question? 1. "What medication is your mother taking?" 2. "Is there a family history of diabetes?" 3. "Describe your mother's usual diet." 4. "Does your mother complain of difficulty urinating?"

1) CORRECT-Assessment: outcome desired and priority; confusion can be caused by drug toxicity and polypharmacy; decreased renal function may increase risk 2) Assessment: outcome desired but not priority; hypoglycemia may be a factor 3) Assessment: outcome desired but not priority; is a good open-ended question 4) Assessment: outcome desired but not priority; not most important; urinary tract infections cause acute confusion in elderly

On the third day after a thyroidectomy, the nurse notes that the client has developed tremors. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the client's calcium level. 2. Check the client's glucose level. 3. Check the client's potassium level. 4. Check the client's sodium level.

1) CORRECT-Assessment: outcome priority; parathyroid gland may be injured, causing hormone levels to decrease; causes decrease in blood calcium; early signs include tingling of fingers, toes, lips 2) Assessment: outcome desired but not priority; blood glucose below 50 mg/dL; symptoms include sweating, trembling, anxiety, hunger, weakness 3) Assessment: outcome desired but not priority; K+ below 3.5 mEq/L; symptoms include fatigue, vomiting, muscle weakness, dysrhythmias 4) Assessment: outcome desired but not priority; if Na+ below 135 mEq/L; symptoms include muscle cramps, lethargy, hemiparesis (paralysis of one side of body)

The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching is successful if the family makes which statement? 1. "We wear a fresh pair of clean gloves with each diaper change." 2. "We are not allowing our other children to be in the same room with the baby." 3. The grandmother wears a mask when changing the baby's diaper. 4. The mother wears an apron when changing the baby's diaper.

1) CORRECT-Implementation: outcome desired; contact precautions; Clostridium difficile infection may develop after antibiotic treatment 2) Implementation: outcome not desired; unnecessary; should use stool and enteric precautions 3) Implementation: outcome not desired; mask unnecessary; used for airborne infection 4) Implementation: outcome not desired; need to use contact precautions, gown only if soiling likely

A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take FIRST? 1. Check the patency of the catheter. 2. Assess residual urine volume using bladder ultrasonography. 3. Assess the amount of drainage in the urinary drainage bag. 4. Decrease the tension on the catheter.

1) CORRECT-Assessment: outcome priority; catheter may be blocked or client may be having bladder spasms 2) Assessment: outcome not priority; need to check patency of tubing first 3) Assessment: outcome not priority; more important to look for obstruction in tubing 4) Implementation: outcome not desired; decrease in traction against bladder neck could cause bleeding; is a healthcare provider order and should not be changed

The nurse observes a student nurse caring for a client with a tracheostomy and humidified oxygen. Which of the following actions taken by the student nurse requires an intervention by the nurse? 1. The student nurse sets the wall suction to 160 mm Hg pressure prior to suctioning. 2. The student nurse increases the oxygen level to 100% prior to suctioning. 3. The student nurse uses a catheter half the size of the tracheostomy opening. 4. The student nurse tells the client to breathe normally as the catheter is inserted.

1) CORRECT-Implementation: outcome not desired; will cause trauma to tracheobronchial mucosa; suction should be set at 80-120 mm Hg 2) Implementation: outcome desired; will decrease the risk of tissue hypoxia; is standard of care; must remember to decrease oxygen level to ordered concentration after suctioning 3) Implementation: outcome desired; a larger catheter will obstruct the lumen and increase the risk of trauma 4) Implementation: outcome desired; should breathe normally during suctioning

The husband of an elderly client who is incontinent asks the nurse whether his wife will have to wear diapers. Which response, if made by the nurse, is MOST appropriate? 1. "Let's discuss your specific concerns about your wife." 2. "Have you tried any type of incontinence pads in the past?" 3. "Let's wait and see if incontinence pads are necessary." 4. "There are many brands of adult diapers available for you to try."

1) CORRECT-Outcome desired; open-ended; client can verbalize concerns 2) Outcome not priority; need to address husband's immediate concerns; is "yes/no" answer 3) Outcome not desired; need to deal with the "here and now" 4) Outcome not desired; non-therapeutic; dismisses concerns

A 50-year-old man scheduled for a vasectomy asks the nurse if he will be able to have sexual intercourse when he recovers from the surgery. Which statement, if made by the nurse, would be MOST accurate? 1. "My understanding is that each case is different after this procedure." 2. "There will be a short period of time during which you will be unable to sustain an erection." 3. "Most couples find that their sexual activity is more spontaneous after a vasectomy." 4. "This surgery should have no permanent effect on your sexual functioning."

1) Dismisses concerns 2) Provides incorrect information 3) Provides false reassurance 4) CORRECT- Provides factual answer

The home health nurse is planning client visits for the day. Which of the following clients should the nurse see FIRST? 1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week. 2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft surgery (CABG). 3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours. 4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain medication.

1) Follow-up required, but not priority; see second 2) Will require assessment and teaching, but no immediate care indicated; see third 3) CORRECT-Rapid weight gain indicates fluid retention, which could exacerbate CHF; see first 4) Stable client; pain control will be addressed but not first; see last

A 60-year-old male client awakens frightened and agitated. He climbs out of bed, removes his indwelling urinary drainage catheter, and runs down the hall screaming. Which of the following is the FIRST action the nurse should take? 1. Notify the healthcare provider. 2. Restrain the client. 3. Replace the urinary catheter. 4. Check for injuries.

1) Implementation: outcome desired but not priority; assessment needed 2) Implementation: outcome not desired; restraint is last resort; needs reorientation 3) Implementation: outcome desired but not priority 4) CORRECT- Assessment: outcome desired and priority; will guide further assessment and interventions; will gather needed information to tell health care provider

A 39-year-old man is admitted with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS). His lab results are hemoglobin 9.3 g/dL, hematocrit 25%, platelets 50,000/mm3, white cell count 1,500/mm3. Which order will should the nurse implement FIRST? 1. "Infuse 2 units of packed red cells." 2. "High-protein, high-carbohydrate diet as tolerated." 3. "Administer 2 units platelets." 4. "Place the client on neutropenic precautions."

1) Implementation: outcome desired but not priority; given when hemoglobin is down to 8 g/dL 2) Implementation: outcome desired but lower priority 3) Implementation: outcome desired but lower priority; risk of spontaneous bleeding when platelets 20,000/mm3 or below 4) CORRECT- Implementation: outcome desired and high priority; at risk for acquiring life-threatening infection due to leukopenia

The nurse enters a client's room and discovers the client is having difficulty breathing because the tracheostomy tube has become dislodged. Which is the INITIAL action the nurse should take? 1. Perform mouth-to-stoma breathing. 2. Extend the client's neck. 3. Place the client in high-Fowler's position. 4. Administer oxygen.

1) Implementation: outcome desired but not priority; needs airway first; difficult to ventilate without neck extension 2) CORRECT- Implementation: outcome desired and priority; provides patent airway; call for help; place supine, then check breath sounds; use hemostat to open airway 3) Implementation: outcome desired but not priority; needs airway first 4) Implementation: outcome desired but not priority; needs airway first

The nurse cares for a client in the cardiac care unit who had cardiopulmonary arrest 2 hours ago and was successfully resuscitated by emergency personnel. As the nurse enters the room, the client develops ventricular fibrillation and is unresponsive to loud spoken voice. Which of the following is the INITIAL action the nurse should take? 1. Ventilate the client with a manual resuscitator bag. 2. Defibrillate the client. 3. Administer sodium bicarbonate intravenously. 4. Begin chest compressions.

1) Implementation: outcome desired but not priority; no cardiac output present during ventricular fibrillation 2) CORRECT- Implementation: outcome desired; immediate return to normal rhythm needed; fatal within 5 minutes if not corrected 3) Implementation: outcome not desired; used to correct metabolic acidosis; priority is to terminate dysrhythmia 4) Implementation: outcome not desired as initial action; defibrillation is priority

The home care nurse observes an elderly woman on a low-sodium diet eating a dill pickle that her son gave her with lunch. Which response by the nurse is MOST appropriate? 1. "Giving your mother salty food will only make her condition worse." 2. "Didn't your mother tell you she's on a low-sodium diet?" 3. "Tell me what you know about your mother's diet." 4. "Let's make an appointment for you to meet with a dietician."

1) Implementation: outcome desired but not priority; non-therapeutic; closed statement 2) Assessment: outcome not desired; "yes/no" question; non-therapeutic 3) CORRECT-Assessment: outcome desired; teaching opportunity; includes family in teaching 4) Implementation: outcome not desired; "passing the buck"

The nurse cares for a 24-year-old female client admitted to an inclient treatment unit with a diagnosis of purging-type bulimia. It is MOST important for the nurse to take which action? 1. Encourage the client to verbalize feelings about eating disorders. 2. Sit with the client in silence as she discusses her daily life and eating habits. 3. Ask the family to describe the client's eating habits prior to admission. 4. Ask the client about any emotional distress she may be experiencing.

1) Implementation: outcome desired but not priority; priority is to establish trust 2) CORRECT- Implementation: outcome desired; establishing trust relationship is first priority 3) Assessment: outcome not desired; more important to establish trust 4) Assessment: outcome desired but not priority; may be done after trust relationship established

The nurse cares for a client with suspected subarachnoid hemorrhage who had a bilateral carotid angiogram 2 hours ago. Which finding requires an intervention by the nurse? 1. The client requests a large glass of water. 2. The client lies quietly in bed with a cloth placed over the forehead and eyes. 3. The head of the bed is elevated 30° and the client's legs are bent at the knee. 4. The urine specific gravity is 1.025.

1) Implementation: outcome desired; client is NPO before the procedure; risk of dye-induced nausea and vomiting; encourage fluid to decrease risk of dye-induced nephrotoxicity after the procedure 2) Implementation: outcome desired; photophobia common after subarachnoid hemorrhage 3) CORRECT-Implementation: outcome not desired and is priority; leg should be extended and in a neutral position after femoral angiogram 4) Assessment: outcome not desired but not priority; urine is concentrated; fluids encouraged to flush dye through kidneys

An adolescent is admitted to the hospital with a diagnosis of bacterial meningitis. Which of the following actions, if observed by the nurse, would require an intervention? 1. The LPN/LVN enters the client's room and leaves the door open. 2. The nursing assistive personnel leaves the client's room with the face mask hanging from the neck. 3. The student nurse washes hands and puts on gloves. 4. The client's mother stands away from the client while talking to the client.

1) Implementation: outcome desired; droplet precautions necessary, door may be left open 2) CORRECT- Implementation: outcome not desired; used masks should be discarded inside the client's room 3) Implementation: outcome desired; standard precautions used with all clients 4) Implementation: outcome desired; maintain 3-foot separation from infected client

The nurse receives a phone call from a mother who was informed that her 10-month-old child was exposed to chickenpox at the day care center. Which statement, if made by the mother, MOST concerns the nurse? 1. "I will give my child Tylenol if a fever develops." 2. "I plan to wash the crib sheets often with a mild soap and water." 3. "I will keep the baby away from the other children right now." 4. "My 85-year-old grandmother is going to help take care of the baby while I am at work."

1) Implementation: outcome desired; increased risk of Reye's syndrome if aspirin given 2) Implementation: outcome desired; no need for stronger additives; may increase skin irritation 3) Implementation: outcome desired; should be isolated until 6 days after appearance of first vesicles 4) CORRECT- Implementation: outcome not desired; immune system in elderly depressed; increased risk of varicella infection

The nurse cares for a client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate 22 per minute. Which order should the nurse question? 1. 0.9% sodium chloride water infusion at 150 mL/hour. 2. Epinephrine (Adrenalin) 1 mg bolus intravenously. 3. Monitor urinary output hourly for 24 hours. 4. 50 mL 25% albumin (human) 50 mL intravenously.

1) Implementation: outcome desired; is isotonic; will replace lost blood volume 2) CORRECT-Implementation: outcome not desired; effect is vasoconstriction with further decrease of blood flow to vital organs; used to treat anaphylactic shock 3) Implementation: outcome desired; measuring urinary output meaures renal perfusion; appropriate activity 4) Implementation: outcome desired; is a crystalloid; will expand plasma volume rapidly; must carefully monitor response

The nurse cares for an 84-year-old man who appears disheveled, restless and confused. The nurse prepares to administer medication and observes that the client's armband is missing. Which is the MOST appropriate action for the nurse to take? 1. Ask the client's roommate to identify the client. 2. Ask the client to state his name. 3. Ask another nurse to identify the client. 4. Look in the chart at the picture of the client.

1) Implementation: outcome not desired; "passing the buck;" mental status of roommate unknown 2) Implementation: outcome not desired; client confused 3) Implementation: outcome not desired; "passing the buck"; must check identification 4) CORRECT - Implementation: outcome desired; only way to positively identify client

A 26-year-old woman comes to the emergency room for a possible ruptured ectopic pregnancy. On admission, the client's vital signs are pulse 90, blood pressure 110/70, respirations 20. A half-hour later, her vital signs are pulse 120, blood pressure 86/50, respirations 26. Which of the following is the MOST appropriate initial action for the nurse to take? 1. Administer pain medication. 2. Increase the rate of the IV fluids. 3. Ask the client to identify where she is. 4. Check the client's white cell count.

1) Implementation: outcome not desired; address ABCs first; analgesic medication may cause further decrease in blood pressure 2) CORRECT-Implementation: outcome desired and priority; increased pulse, decreased BP indicates decreased intravascular volume; symptoms of hypovolemic shock 3) Assessment: outcome desired but not priority; client in shock, implementation required 4) Assessment: outcome desired but not priority; usually won't change unless infection is causing septic shock

The nurse supervises the distribution of meal trays on a medical unit. Which tray will should be given to a client who has requested a kosher diet? 1. Cheeseburger, sliced tomato, french fries, and a milkshake. 2. Pork chops, applesauce, baked potato, and ginger ale. 3. Shrimp salad, sliced avocado, bread, and coffee. 4. Fruit salad, cottage cheese, crackers, and tea.

1) Implementation: outcome not desired; cannot eat dairy and meat at the same meal; eat dairy 6 hours after meat meal 2) Implementation: outcome not desired; cannot eat pork products (bacon, ham, animal shortening, gelatin or foods containing gelatin, e.g., marshmallows) 3) Implementation: outcome not desired; cannot eat shellfish or scavenger fish; fish must have scales 4) CORRECT- Implementation: outcome desired; kosher diet follows Jewish law; no meat or poultry at the same meal as dairy, or using the same utensils; no pork products; no scavenger fish

A man comes into the outclient rheumatology clinic for follow-up care after an episode of acute gouty arthritis. The nurse would be MOST concerned if the client made which of the following statements? 1. "I don't eat shrimp and scallops anymore." 2. "I play softball twice a week without any problem." 3. "I don't go to bars on Friday nights anymore." 4. "I have been drinking SlimFast for breakfast and lunch each day."

1) Implementation: outcome not desired; foods high in purines cause hyperuricemia 2) Implementation: outcome not desired; activity does not precipitate a gout attack 3) Implementation: outcome not desired; excessive drinking precipitates gout 4) CORRECT-Implementation: outcome desired; hyperuricemia may result from prolonged fasting; increases production of ketones, which inhibit normal excretion of uric acid

At 7 A.M., the nurse administers 10 mg glipizide (Glucotrol XL) to a 75-year-old client. At 11 A.M., the nurse notes that the client is drowsy, pale, and has cold, clammy skin. Which is the INITIAL action the nurse will take? 1. Administer 1 mg glucagon subcutaneously. 2. Give the client 1 cup of fruit juice to drink. 3. Determine if the client ate breakfast. 4. Notify the healthcare provider.

1) Implementation: outcome not desired; glucagon used with severe hypoglycemia or when client cannot take oral fluids 2) CORRECT-Implementation: outcome desired; symptoms of moderate hypoglycemia; client can drink juice 3) Assessment: outcome desired but not priority; more important to increase blood glucose level 4) Implementation: outcome desired but not priority; should take action to correct hypoglycemia first

The nurse cares for a client with suspected Neisseria meningitidis infection. Which action is MOST important for the nurse to take? 1. Wear a gown when entering the room. 2. Place the client in a negative-pressure isolation room. 3. Wear a face mask while assisting the client with activities of daily living. 4. Wash hands with soap and water for 3 to 4 minutes when exiting the room.

1) Implementation: outcome not desired; gown not required with droplet precautions unless risk contact with body fluids 2) Implementation: outcome not desired; negative-pressure isolation room used for airborne precautions 3) CORRECT- Implementation: outcome desired; place on droplet precautions because organism spread by larger droplets 4) Implementation: outcome not desired; length of hand-washing does not need to be extended

The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective? 1. Cheeseburger on a whole-wheat bun, french fries, and an apple. 2. Tomato soup, saltines, and a slice of unfrosted angel food cake. 3. Baked cod, biscuit without butter, fruit roll-up. 4. Macaroni and cheese, coleslaw, 2 macaroon cookies.

1) Implementation: outcome not desired; high-fat, high-protein, high-residue; high-residue contraindicated 2) Implementation: outcome not desired; low-fat, low-protein, low-residue 3) CORRECT - Implementation: outcome desired; low-fat, high-protein, low-residue, nonirritating, high in calories, minerals 4) Implementation: outcome not desired; high-fat, low-protein, high-residue; may cause diarrhea

A woman delivers a 6-lb and 2-oz infant. The Apgar scores at 1 and 5 minutes are 8 and 9, respectively. Which action is MOST appropriate for the nurse to take? 1. Perform nasopharyngeal suctioning. 2. Document the Apgar score. 3. Administer O2 per mask. 4. Rub the infant's back.

1) Implementation: outcome not desired; if Apgar less than 8 and infant is in respiratory distress nasopharyngeal suctioning may be indicated. 2) CORRECT-Implementation: outcome desired; Apgar score of 8 to 10 is considered to be good 3) Implementation: outcome not desired; done if respirations absent or inadequate 4) Implementation: outcome not desired; resuscitative measure, used to stimulate infant

The nurse cares for the client 3 days after a stroke. It is MOST important for the nurse to take which action? 1. Instruct the client to push with the feet while moving client up in bed. 2. Offer the client soft foods on request. 3. Auscultate the client's lungs every 4 hours. 4. Observe the client's legs for warm, reddened, and tender areas every 4 hours.

1) Implementation: outcome not desired; if client holds breath, may increase intracranial pressure 2) Implementation: outcome not desired; need to assess risk for aspiration first before any oral fluids or foods given 3) CORRECT - Assessment: outcome desired and priority; decreased oxygen levels will increase intracranial pressure, client at high risk for aspiration 4) Assessment: outcome desired but not priority; at risk for thrombophlebitis due to immobility

A unit of packed cells is ordered for a client who has an intravenous infusion of dextrose 5% in water in progress. Which of the following is the MOST important action for the nurse to take? 1. Connect the packed red blood cells to the dextrose infusion. 2. Remove the dextrose infusion and replace it with the packed red cells. 3. Start a separate infusion of normal saline and use a "Y" connector to infuse the blood. 4. Start an infusion of lactated Ringer's solution and use a "Y" connector to infuse the blood.

1) Implementation: outcome not desired; incompatible; will cause hypertonic hemolysis (clumping) 2) Implementation: outcome not desired; always start with normal saline (0.9% NaCl) 3) CORRECT- Implementation: outcome desired; isotonic solution; "Y" tubing allows for addition of saline to blood cells and provides access for saline flush if transfusion is interrupted 4) Start an infusion of lactated Ringer's solution and use a "Y" connector to infuse the blood.

The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take? 1. Insert an indwelling urinary drainage catheter. 2. Perform intermittent catheterization every 4 hours. 3. Offer the bedpan to the client every 2 hours. 4. Assist the client to a bedside commode every 2 hours.

1) Implementation: outcome not desired; increases risk of infection; catheter-related infections are most common hospital-acquired infection 2) Implementation: outcome not desired; increases chance of infection 3) Implementation: outcome appropriate but not priority; does not keep client independent and active 4) CORRECT - Implementation: outcome desired; keeps client active and independent

A client with a history of gastroesophageal reflux disease reports difficulty sleeping at night. Which of the following is a PRIORITY action for the nurse to take? 1. Instruct the client to drink 8 ounces of milk at bedtime. 2. Advise the client to use 2 pillows at night. 3. Instruct the client to limit fat intake during the day. 4. Advise the client to lie down after the evening meal.

1) Implementation: outcome not desired; increasing stomach volume at bedtime may increase symptoms 2) CORRECT- Implementation: outcome desired; gravity will prevent reflux of stomach contents into esophagus 3) Implementation: outcome not desired; caffeine and spicy foods should be limited 4) Implementation: outcome not desired; lying down will increase reflux of gastric contents

The home care nurse is visiting an alert, oriented woman living with her daughter. The client is malnourished and has multiple bruises on her body, and the situation is reported to the appropriate authority. After counseling the client and daughter, the nurse notes the situation has not improved. The client decides to remain with her daughter. Which action, if taken by the nurse, is MOST appropriate? 1. Respect the client's decision to stay in her daughter's home. 2. Insist the client move in with her other child. 3. Begin guardianship procedures. 4. Place live-in help in the home.

1) CORRECT-Implementation: outcome desired; intervention not possible without consent of the senior if person is legally competent; further assessment needed to determine cause of bruises 2) Implementation: outcome not desired; legally competent senior can choose where to live and with whom 3) Implementation: outcome not desired; appropriate if senior is legally incompetent and in immediate danger 4) Implementation: outcome not desired; must have consent of client

The nurse assesses the IV site before administering vancomycin. The nurse notes that the area around the IV infusion site is pale and feels cool. Which INITIAL action will the nurse perform? 1. Remove the intravenous catheter and elevate the arm on 1 or 2 pillows. 2. Begin the vancomycin infusion and reassess the infusion site in 15 minutes. 3. Withhold the vancomycin infusion and notify the healthcare provider. 4. Apply warm, moist compresses to the infusion site for 30 minutes and then administer the medication.

1) CORRECT-Implementation: outcome desired; possible infiltration; high risk of tissue damage and thrombophlebitis during vancomycin administration 2) Implementation: outcome not desired; priority is to discontinue infusion and prevent harm to client 3) Implementation: outcome not desired; medication should be given; no need to notify healthcare provider 4) Implementation: outcome not desired; warmth indicated for thrombophlebitis, not infiltration

The nurse cares for a client 72 hours after a right-below-knee amputation. Which is the MOST important action for the nurse to take? 1. Lay the client prone for 25 minutes every 3-4 hours. 2. Dangle the client's residual limb over the side of the bed. 3. Abduct the client's residual limb by placing pillows between the legs. 4. Elevate the client's residual limb on a pillow.

1) CORRECT-Implementation: outcome desired; prevents hip flexion contracture 2) Implementation: outcome not desired; will increase edema 3) Implementation: outcome not desired; legs should be adducted to prevent flexion contractures 4) Implementation: outcome not desired; done for the first 24 hours; increases venous return; prevents edema; promotes comfort

A nurse from the surgical floor is reassigned to the pediatric unit. Which of the following client assignment is MOST appropriate for this nurse? 1. A 5-month-old infant after a cast application on the left extremity due to club foot. 2. A 4-year-old boy with right abdominal swelling and a decreased appetite. 3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C). 4. A 10-year-old girl with newly diagnosed type 1 diabetes.

1) CORRECT-Implementation: outcome desired; stable client with predictable outcome; serial casting used to correct congenital club foot 2) Implementation: outcome unstable client; needs assessment and evaluation; possible teaching interventions needed 3) Implementation: outcome not desired; unstable client; require frequent assessment and evaluation 4) Implementation: outcome not desired; unstable client; required assessment, evaluation, teaching and judgment

78. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

The correct answer is A: Exercise doing weight bearing activities

27. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88

The correct answer is A: FHT 168 beats/min

49. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube

The correct answer is A: Hold the tube feeding and notify the provider

63. The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A) Non-steroidal anti-inflammatory drugs B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts

The correct answer is A: Non-steroidal anti inflammatory drugs

41. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Read just the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes

The correct answer is A: Notify the health care provider

83. A client with diarrhea should avoid which of the following? A) Orange juice B) Tuna C) Eggs D) Macaroni

The correct answer is A: Orange juice

70. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs

The correct answer is A: Orthostatic hypotension is a common side effect

68. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem

The correct answer is A: Protamine . Protamine binds heparin making it ineffective.

29. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2

The correct answer is A: S3 ventricular gallop

10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right with the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

The correct answer is A: Side-lying on the left with the head elevated 10 degrees

26. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation

The correct answer is A: Stay with client and observe for airway obstruction

65. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion

The correct answer is A: Stop the infusion

A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic nurse that she was exposed to rubella 2 days ago. Which statement, if made by the nurse, is MOST appropriate? 1. "You need to see the health care provider today, but come in after hours." 2. "Come in this afternoon for your regularly scheduled appointment." 3. "You will receive the rubella vaccine during your regularly scheduled appointment." 4. "Please cancel today's appointment and reschedule for next month."

1) Implementation: outcome not desired; incubation period is 14-21 days, not communicable at this time; if woman develops rubella infection during the first trimester, abortion may be considered 2) CORRECT-Implementation: outcome desired; communicability is approximately 7 days before to 5 days following onset of rash; client needs to be evaluated 3) Implementation: outcome: not desired; vaccination contraindicated for pregnant women; increased risk of fetal complications 4) Implementation: outcome not desired; needs to be seen by the healthcare provider

The nurse cares for clients in a mental health center. The nurse observes the client, formerly homeless and malnourished, diagnosed with chronic schizophrenia putting food from lunch into a plastic bag. Which statement by the nurse is MOST appropriate? 1. "We don't allow people to take food from the dining room." 2. "What are you going to do with the food?" 3. "We will be serving snacks and juice at 3 P.M." 4. "Let's go watch a movie with the others."

1) Implementation: outcome not desired; judgmental; non-therapeutic communication 2) Assessment: outcome not desired; non-therapeutic; "why" questions make client defensive, feel threatened 3) CORRECT - Implementation: outcome desired; reality orientation; talk with client in non-threatening way about her needs 4) Implementation: outcome not desired; misses opportunity to reality test; distraction used for small children and manic clients

The client with with a 5-year history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. The client is agitated and verbally abusive. Admission orders include chlordiazepoxide (Librium) 50 mg IM or PO every 4-6 hours for agitation. Which action by the nurse is MOST appropriate? 1. Place the client in chest restraints. 2. Assist the client to the bathroom every 2 hours. 3. Assign a licensed practical nurse to stay with the client. 4. Administer disulfram (Antabuse) 500 mg every 12 hours.

1) Implementation: outcome not desired; last resort unless safety is an issue 2) Implementation: outcome desired but not priority; safety is a priority 3) CORRECT - Implementation: outcome desired; nurse should delegate and give specific instructions to LPN/LVN 4) Implementation: outcome not desired; administered to assist the client to refrain from drinking first dose administered at least 12 hours after the last alcohol consumed

The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action? 1. Place the client on her back with thighs flexed on her abdomen. 2. Place the client on her left side with legs flexed. 3. Place the client supine with the head of the bed elevated 30°. 4. Place the client supine with the foot of the bed elevated.

1) Implementation: outcome not desired; lithotomy position; will not decrease pressure on umbilical cord 2) Implementation: outcome not desired; position used to remove weight of fetus from vena cava to prevent maternal hypotension; will not help with prolapsed cord 3) Implementation: outcome not desired; would aggravate prolapsed cord pressure 4) CORRECT - Implementation: outcome desired; Trendelenburg or knee chest position desired to decrease pressure on umbilical cord

A client with suspected active tuberculosis is scheduled for a chest x-ray. Which action, if taken by the nurse, is MOST appropriate? 1. Instruct the staff transporting the client to wear a gown and mask. 2. Place a face mask on the client. 3. Request that the x-ray be postponed. 4. Give the client an emesis basin and tissues.

1) Implementation: outcome not desired; mask is placed on client to prevent transmission of airborne pathogen 2) CORRECT-Implementation: outcome desired and priority; client must wear a standard isolation mask if out of room 3) Implementation: outcome not desired; no reason to postpone, place mask on client 4) Implementation: outcome desired but not priority; mask worn to prevent transmission of airborne pathogen

The nurse describes to a male client how to collect a clean-catch urine for culture and sensitivity. Which explanation, if made by the nurse, is MOST accurate? 1. "The urinary meatus is cleansed with an antiseptic solution, and then a urinary drainage catheter is inserted to obtain urine." 2. "You will be asked to empty your bladder one half-hour before the test; you will then be asked to void into a container." 3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is then voided into a sterile container; the container must not touch the penis." 4. "You must void a few drops of urine, and then stop; then void the remaining urine into a clean container which should be immediately covered."

1) Implementation: outcome not desired; unnecessary to use catheter 2) This is the procedure for a double void specimen and the question is for a clean catch specimen. 3) CORRECT-Implementation: outcome desired; a culture and sensitivity urinalysis is a sterile specimen 4) Implementation: outcome not desired; need sterile container

The nurse cares for the client diagnosed with Parkinson's. The nurse notes that the client is ambulating with short, accelerating steps. Which action is the MOST appropriate for the nurse to take? 1. Offer the client a wheelchair. 2. Provide the client a walker. 3. Suggest that the client wear comfortably fitting shoes. 4. Teach the client to walk with a broad-based gait.

1) Implementation: outcome not desired; would make the client dependent 2) Implementation: outcome not desired; client needs to alter method of walking 3) Implementation: outcome not desired 4) CORRECT- Implementation: outcome desired; concentrate on walking erect with eyes on horizon

One afternoon in the hospital day room, the nurse overhears a woman with chronic schizophrenia say to another other client, "I hate you, get away from me or I'll kill you." Which of the following responses, if made by the nurse, is MOST appropriate? 1. "I will not let that client hurt you." 2. "There is no reason for you to be angry with that client." 3. "You seem to be frightened by that client." 4. "You don't really want to kill that client."

1) Non-therapeutic; false reassurance 2) Non-therapeutic; assumes client is angry because she is feeling threatened 3) CORRECT-Therapeutic; acknowledges feelings 4) Non-therapeutic; don't argue with client

The nurse cares for clients on an acute-care surgical area. Which client should the nurse see FIRST? 1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the chest drainage system. 2. The nursing assistive personnel reports that a client who had a thyroidectomy 24 hours ago refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden). 3. The family of a client who had a small bowel resection 48 hours ago reports the client is more confused than yesterday. 4. A client who had an ileostomy 3 days ago complains of "aching legs."

1) Not priority; further assessment required; see second 2) Not priority; may be safety issue; further assessment needed; see last 3) CORRECT-Priority; may have decreased cerebral blood flow or oxygenation; see first 4) Not priority; client is at risk for thrombophlebitis; further assessment and evaluation needed; see third

The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN? 1. A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis therapy. 2. A 72-year-old client admitted yesterday with a 10-day history of oral antibiotic therapy and a 24-hour history of watery diarrhea. 3. A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago. 4. A 86-year-old client just admitted with malaise, a productive cough, and WBC 17,000 mm3.

1) Outcome not desired; requires frequent assessment of neuromuscular function and monitoring response to therapy 2) Outcome not desired; elderly clients are at risk for clostridium difficile infection due to antibiotic therapy; client would need frequent assessment and evaluation 3) CORRECT - Outcome desired; LPN/LVN can care for stable clients with expected outcomes; nothing in question indicates instability; as cerebral edema resolves, the condition will improve 4) Outcome: not desired; client requires frequent assessment and evaluation; WBC indicates possible infection

The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST? 1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test. 2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate. 4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement.

1) Outcome not priority; indicates that Rh antibodies present; needs further investigation 2) CORRECT - Outcome priority; indicates pre-eclampsia; requires immediate evaluation; is at risk for complications 3) Outcome not priority; colostrum may leak from breast during pregnancy; normal finding 4) Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in primagravidas; 20 weeks in multigravidas

The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST? 1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute, shallow respirations at 16/minute. 2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute. 3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute. 4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute.

1) Potential for hemorrhage or fatty embolism; eliminate second 2) Potential pneumothorax; see second 3) CORRECT - Real problem; vitals signs indicate significant increase in intracranial pressure; most unstable client 4) Most stable client; eliminate first

A nurse is performing triage in the emergency department. Which of the following clients should the nurse see FIRST? 1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C). 2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C). 3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C). 4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F (37.4° C).

1) See last; most stable client 2) See second; unstable client; cardiovascular; requires further assessment and antihypertensive medication 3) CORRECT-See first; unstable client; upper airway injury possibly due to inhalation injury 4) See third; vital signs consistent with dehydration, rapid respiration is Kussmaul's and expected

The client is admitted to the hospital with chest pain when taking deep breaths and peripheral edema. The health care provider's order for the client reads; "Digoxin 0.25 mg orally now. Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse, is MOST appropriate? 1. Do not administer the second dose of digoxin. 2. Call the health care provider to clarify the order. 3. Administer half the prescribed second dose of digoxin. 4. Administer the first and second dose of digoxin as ordered.

1) Implementation: outcome not desired; medication should be given; if nurse questions the order, the health care provider should be contacted 2) Implementation: outcome not desired; unnecessary; 1 milligram of digoxin is a digitalizing dose; digitalizing dose is necessary to reach therapeutic blood levels 3) Implementation: outcome not desired; nurse can never change prescribed dose 4) CORRECT-Implementation: outcome desired; loading dose to achieve therapeutic blood levels; if loading dose not given, therapeutic levels are not reached for 6 days

While playing on the floor in the hospital room, a 2-year-old has a tonic-clonic seizure. Which action should the nurse take FIRST? 1. Begin oxygen at 2 liters per minute through a nasal cannula. 2. Place a pillow under the client's head. 3. Administer diazepam (Diastat) 5 mg rectally. 4. Turn the client to the side.

1) Implementation: outcome not desired; more important to protect from injury during the seizure; no indication oxygen is needed 2) CORRECT-Implementation: outcome desired; protects client from injuries; stay with client 3) Implementation: outcome not desired; rectal diazepam used to treat status epilepticus in children; not indicated for single seizure 4) Implementation: outcome not desired; turn client to side after the seizure to reduce risk of aspiration; should protect extremities during seizure

The nurse cares for the client immediately after an ileostomy procedure. Which is the best INITIAL action for the nurse to take during client teaching? 1. Schedule the teaching demonstrations during family visits. 2. Encourage the client to discuss any concerns and to ask questions. 3. Show a video demonstrating ileostomy care. 4. Perform care for the ileostomy until the client is able to do it herself.

1) Implementation: outcome not desired; must assess client's readiness to learn first 2) CORRECT - Assessment: outcome desired; ventilate feelings and assess readiness to learn 3) Implementation: outcome not desired; needs to be ready to learn 4) Implementation: outcome not desired; won't assist in adjustment

The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST? 1. "Let's get your mother a walker." 2. "Do you think it's time to put your mother in a nursing home?" 3. "When does your mother fall?" 4. "Does your mother seem to be more confused lately?"

1) Implementation: outcome not desired; need to assess first 2) Assessment: outcome not priority; "yes/no" question; doesn't help determine the problem 3) CORRECT - Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls 4) Assessment: outcome not priority; "yes/no" question is non-therapeutic; need to assess; may be a contributing factor

A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? 1. Place the client flat on her back. 2. Elevate the head of the bed 30 degrees. 3. Place the client on her left side with her legs flexed. 4. Place the client supine with the foot of the bed elevated.

1) Implementation: outcome not desired; no increase in venous return 2) Implementation: outcome not desired; will decrease venous return 3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced 4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena cava will prevent blood return to heart

Two days after admission to an alcoholic treatment unit, a 40-year-old man brags about his binges and boasts that he has not had a steady job in 3 years. Which activity, if selected by the nurse, would be MOST appropriate for this client? 1. Ask the client to lead a group discussion on alcoholism. 2. Ask the client to orient a client to the unit. 3. Encourage the client to play table tennis with other clients. 4. Have the client assume responsibility for the cleanliness of the dining

1) Implementation: outcome not desired; not appropriate at start of treatment 2) Implementation: outcome not desired; later phase; not ready 3) Implementation: outcome not desired; not appropriate at this time in treatment. 4) CORRECT-Have the client assume responsibility for the cleanliness of the dining room.

A 52-year-old homeless woman is admitted to the psychiatric unit for treatment of chronic schizophrenia. The nursing assistive personnel reports to the nurse that when attempting to bathe the client, the client became uncooperative and demanded coffee and a snack. Which suggestion will the nurse give to the nursing assistive personnel? 1. Remind the client that too much caffeine is bad for her health. 2. Tell the client that she may have coffee and a snack when her bath is complete. 3. Remove the client from the bath and return her to bed. 4. Get help from other staff members to complete the bath.

1) Implementation: outcome not desired; not effective with this client 2) CORRECT- Implementation: outcome desired; would meet client's immediate needs; is factual answer 3) Implementation: outcome not desired; needs physical needs met; need to develop trusting relationship; action may increase distress 4) Implementation: outcome not desired; shouldn't use force; client should feel environment is safe; action may increase distress

A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her husband is coaching her during labor. During the transitional phase of labor, the client begins to scream and grab the side rails with each contraction. Which action, if taken by the nurse, is MOST effective? 1. Offer the client pain medication before her next contraction. 2. Assist the client to a side-lying position with her knees flexed and a pillow between her legs. 3. Establish eye contact with the client and breathe with her. 4. Suggest to the client that she watch television between contractions.

1) Implementation: outcome not desired; not used during transition; not effective and may interfere with mother's cooperation; may cause respiratory depression in infant 2) Implementation: outcome desired but not priority; priority action is to assist client to get control 3) CORRECT-Implementation: outcome desired and priority; slow breathing, reorient; model appropriate behaviors; this will assist client to get control and reduce muscle tension 4) Implementation: outcome desired but not priority; meet physical needs first

A 42-year-old woman has a right mastectomy for treatment of breast cancer. The client is returned to her room with a Hemovac drain. Which of the following is the MOST important action for the nurse to take? 1. Open the drain port to provide an air vent. 2. Tape the collection chamber to the client's bed. 3. Compress the evacuator completely after emptying it. 4. Empty the collection chamber every 2 hours.

1) Implementation: outcome not desired; should be closed except when emptying chamber 2) Implementation: outcome not desired; should be secured to client's dressing or clothing, not to the bed 3) CORRECT- Implementation: outcome desired; provides for negative pressure of 45 mm Hg for wound suction 4) Implementation: outcome not desired; should not open unit unnecessarily due to chance of contamination

The nurse observes a man standing with his adult children after the unexpected death of his wife. Which statement by the nurse is MOST appropriate? 1. "I'm sorry about your wife. I'm sure you will miss her." 2. "This must be a difficult time for you; I will stay with you." 3. "I know you're going to miss your wife; would you like to talk about some memories you both shared?" 4. "Is there anything I can get for you?"

1) Implementation: outcome not desired; should focus on husband, not nursing staff; assumes husband's feelings 2) CORRECT-Implementation: outcome desired; nurse stays with client; open-ended; responds to feeling tone 3) Implementation: outcome not desired; should focus on here and now; assumes husband's feelings 4) Assessment: outcome desired but not priority; "yes/no" question; does not respond to feeling tone

The healthcare provider orders furosemide (Lasix) and spironolactone (Aldactone). Prior to administering Lasix and Aldactone, the nurse determines that the client's potassium level is 3.2 mEq/L. Which is the MOST important action for the nurse to take? 1. Hold the furosemide and spironolactone. 2. Administer only the spironolactone. 3. Administer only the furosemide. 4. Administer the furosemide and spironolactone.

1) Implementation: outcome not desired; should give Aldactone, K+-sparing diuretic 2) CORRECT- Implementation: outcome desired; K+-sparing diuretic; should contact health care provider about serum potassium 3) Implementation: outcome not desired; will lose more potassium 4) Implementation: outcome not desired; will lose more potassium

The nurse performs dietary teaching for a client taking lithium carbonate (Lithonate). Which snack, if selected by the client, indicates that teaching is effective? 1. Four carrot sticks. 2. 8 oz of ice tea. 3. A whole banana. 4. 12 oz of lemonade.

1) Implementation: outcome not desired; should provide increased fluid intake 2) Implementation: outcome not desired; contains caffeine, which is a natural diuretic and stimulant; should avoid fluids containing caffeine 3) Implementation: outcome not desired; should provide increased fluid intake 4) CORRECT-Implementation: outcome desired; provides for increased fluid intake; lithium can cause nephrogenic diabetes insipidus; those on lithium experience thirst and polyuria; need 2,500-3,000 mL/day with adequate salt intake

The nurse teaches a client who had an above-knee amputation (AKA) 2 days ago about how to care for the residual limb. Which statement, if made by the client, indicates to the nurse that the teaching is effective? 1. "I shall apply cream to the residual limb to soften the skin." 2. "I should rewrap my residual limb with elastic bandages 3 times a day." 3. "I will not be able to sleep on my stomach from now on." 4. "I will no longer be able to sit in straight back chairs at home."

1) Implementation: outcome not desired; skin needs to be toughened if prosthesis is going to be used; no lotions, creams, or powders should be used unless prescribed 2) CORRECT-Implementation: outcome desired; bandages may be loose; expose to air 20 min/day; inspect residual limb for redness, irritation 3) Implementation: outcome not desired; the prone position will decrease the risk of flexion contractures 4) Implementation: outcome not desired; client can sit in straight back chair; time should be restricted to 1 hour or less

The nurse monitors the activities of a 9-year-old girl with juvenile rheumatoid arthritis (JA). Which activity is MOST appropriate? 1. The girl is jumping rope. 2. The girl is skipping. 3. The girl jumps off the end of a slide. 4. The girl participates on a swim team.

1) Implementation: outcome not desired; too traumatic to the joints 2) Implementation: outcome not desired; too traumatic to the joints 3) Implementation: outcome not desired; too traumatic to the joints 4) CORRECT-Implementation: outcome desired; good moving and stretching activity; also, throwing or kicking a ball, riding a bicycle, swimming

The healthcare provider has ordered a fenestrated tracheostomy tube to be capped. Which is the MOST important action for the nurse to take before the tracheostomy tube is plugged? 1. Administer 100% oxygen. 2. Deflate the cuff of the tracheostomy tube. 3. Suction the tracheostomy tube. 4. Administer humidified oxygen.

1) Implementation: outcome not desired; unnecessary in this situation; done before suctioning 2) CORRECT- Implementation: outcome desired; allows for an airway 3) Implementation: outcome not desired; perform only as needed for congestion 4) Implementation: outcome not desired; when O2 is administered, it should be humidified, though O2 is not required in this situation

CPR priority order

1. Establish unresponsiveness. 2. Call for help. 3. Assess patent airway. 4. Assess pt carotid pulses.

Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication?Select all that apply. 1. Volume of urine output 2. Strength of peripheral pulses 3. Ability to move the extremities 4. Frequency of bowel movements 5. Color, motion, and sensation of extremities

1. Volume of urine output 4. Frequency of bowel movements

The health care provider's prescription for an adult client reads, "Potassium chloride 15 mEq by mouth." The label on the medication bottle reads, "20 mEq potassium chloride/15 mL." How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round to the nearest whole number.)

1.11

The health care provider's prescription reads, "Clindamycin phosphate 0.3 g in 50 mL NS, to be administered IV over 30 minutes." The medication label reads, "Clindamycin phosphate 150 mg/mL." How many milliliters of medication does the nurse prepare to ensure that the correct dose is administered?

1.2

The health care provider prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.21

The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.21

The health care provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.31

The health care provider prescribes 1000 mL of 5% dextrose in water, to be infused over 24 hours. The drop factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.42

Mg+

1.5-2.5

crawls

10 months

walks

10-12 months

BUN

10-20

Glycosylated Hemoglobin (Hgb A1c)

4-6% ideal, <7.5% = Ok (120 days)

A1c

4-6% is ideal

Cholesterol

< 200

Glasgow Coma Scale

< 8 = coma

Prostate Cancer

> 40 = Age PSA elevation DRE Mets to spine, hips, legs Elevated PAP (prostate acid phosphatase) TRUS = Transurethral US Post Op...monitor of hemorrhage and cardiovascular complication

A Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety.

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

A Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication.

A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control.

B Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed.

A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.

B Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair.

The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition?

A Hypothermia,decreased cardiac output, and decreased respiratory functioning

Following a precipitous labor, a client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that the client's symptoms may indicate which condition?

A cervical laceration

A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?

A client attached to a ventilator

D Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client.

A Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void.

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill.

C Rationale: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Option A, B, or D may then be implemented, if warranted.

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

A nurse is assigned to care for four clients. in planning client rounds, which client would the nurse assess first?

A client receiving oxygen via nasal cannula who had difficult breathing during the previous shift.

A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse (LPN) and a nursing assistant on the team and is planning the client assignments for the day. The RN most appropriately assigns which of the following clients to the LPN?

A client who needs to be suctioned prn

D Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings.

C Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing.

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990

7. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B)This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D)The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

The correct answer is A: Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.

99. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens

The correct answer is A: Wash hands thoroughly before and after client contact

51. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip

The correct answer is A: administer the medication in 2 separate injections

48. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap."

The correct answer is B: "I am allergic to shrimp."

28. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on."

The correct answer is B: "I have been coughing up foul tasting, brown, thick sputum."

59. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) "We will call the health care provider if the child develops acne." B) "Our child should brush and floss carefully after every meal." C) "We will skip the next dose if vomiting or fever occur." D) "When our child is seizure-free for 6 months, we can stop the medication."

The correct answer is B: "Our child should brush and floss carefully after every meal."

31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung."

The correct answer is B: "The tube will remove excess air from your chest."

22. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake

The correct answer is B: Administer acetaminophen as ordered as this is normal at this time

96. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin

The correct answer is B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

23. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication

The correct answer is B: Assess for dyspnea or stridor

39. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses

The correct answer is B: Assess for post operative arrhythmias

36. The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

The correct answer is B: Assist client to turn, deep breathe, and cough

72. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids

The correct answer is B: Check the client's gag reflex

81. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour

The correct answer is B: Continuously

87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids

The correct answer is B: Decreased sodium and potassium

37. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises

The correct answer is B: Deep breathing and coughing

6. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness

The correct answer is B: Fever of 103 degrees F (39.5 degrees C)

4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output

The correct answer is B: Have the client turn to the left side

67. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets

The correct answer is B: Hemoglobin and hematocrit

84. Which statement best describes the effects of immobility in children? A) Immobility prevents the progression of language and fine motor development B) Immobility in children has similar physical effects to those found in adults C) Children are more susceptible to the effects of immobility than are adults D) Children are likely to have prolonged immobility with subsequent complications

The correct answer is B: Immobility in children has similar physical effects to those found in adults

3. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? A)It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) B)It is critical to report promptly to your health care provider any findings of peptic ulcers c)Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D)With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

The correct answer is B: It is critical to report promptly to your health care provider any findings of peptic ulcers.

13. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles

The correct answer is B: Jugular vein distention

75. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight

The correct answer is B: Obtain a health and dietary history

88. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements

The correct answer is B: Oozing liquid stool

17. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160

The correct answer is B: Pale mucosa of the eyelids and lips

47. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator

The correct answer is B: Perform a quick assessment of the client''s condition

64. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin

The correct answer is B: Potassium

15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses

The correct answer is B: Pupils fixed and dilated

79. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A)Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream

The correct answer is B: Sliced turkey sandwich and canned pineapple

55. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion

The correct answer is B: Sore throat, fever

66. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended

The correct answer is B: Sudden cessation of alprazolam

30. Which of these observations made by the nurse during an excretory urogram indicate a complication? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick."

The correct answer is B: The client's entire body turns a bright red color

100. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? A) grilled chicken sandwich and skim milk B) roast beef, mashed potatoes, and green beans C) peanut butter sandwich, banana, and iced tea D) barbecue beef, baked beans, and cole slaw

The correct answer is B: roast beef, mashed potatoes, and green beans

11. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter

The correct answer is C: minimal drainage into the urinary collection bag

98. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits.

The correct answer is C: "Children are not to share hats, scarves and combs."

54. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."

The correct answer is C: "The medication must be continued so the fluid problem is controlled."

5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea

The correct answer is C: A cold, pale lower leg

89. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client's report of pain D) determine the client's status of pain

The correct answer is C: Accept the client''s report of pain

57. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time

The correct answer is C: Activated PTT

46. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again

The correct answer is C: Assist him to stand by the side of the bed to void

33. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms

The correct answer is C: Dyspnea

9. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A)It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B)In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C)Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D)Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to 2 weeks

The correct answer is C: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent

85. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently

The correct answer is C: Keep conversations short

82. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A) Glycerine suppositories B) Fiber supplements C) Laxatives D) Stool softeners

The correct answer is C: Laxatives

92. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h

The correct answer is C: Place in respiratory/secretion precautions

34. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak

The correct answer is C: Pulse oximetry of 88

42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision

The correct answer is C: Reinforce the dressing and elevate the leg

73. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence

The correct answer is C: Reposition every two hours

A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. A. "I need to follow the oxygen prescription exactly." B. "I can use my electric razor while I'm using oxygen." C. "I have to keep the oxygen concentrator out of direct sunlight." D. "I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner." E. "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the oxygen concentrator."

A. "I need to follow the oxygen prescription exactly." C. "I have to keep the oxygen concentrator out of direct sunlight." E. "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the oxygen concentrator."

A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? A. "I should put a steam vaporizer in her room." B. "I'll take her out into the cool, humid night air." C. "I can open the freezer door and encourage her to breathe in the cool air." D. "I can run the hot water in my bathroom and cuddle her in the steamy room."

A. "I should put a steam vaporizer in her room."

A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls? A. "I took the bathmat out of my tub." B. "I use a shower chair when I bathe." C. "I've placed nightlights in my hallway." D. "The railings on my stairs are sturdy and secure."

A. "I took the bathmat out of my tub."

A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which statements by the mother indicate a need for further instructions? Select all that apply. A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him." C. "If he gets a cut, I should hold pressure on it until the bleeding stops." D. "I should check the house for any household items that could fall over easily." E. "I should move furniture with sharp corners out of the way and pad the corners of the furniture."

A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him."

In planning the care of a client dying of cancer, the nurse seeks to have the client verbalize acceptance of his impending death. Which statement indicates to the nurse that this goal has been met? A. "I'd like to have my family here when I die." B. "I'll be ready to die once my daughter gets married." C. "I want to go to my family reunion; then I'll be ready to die." D. "I just want to live to see my grandchildren graduate from college."

A. "I'd like to have my family here when I die."

A client with heart failure being discharged home will be taking furosemide. Which statement by the client indicates to the nurse that the teaching has been effective? A. "I'll weigh myself every day." B. "I'll take my pulse every day." C. "I'll measure my urine output." D. "I'll check my ankles every day for swelling."

A. "I'll weigh myself every day."

A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by the client indicates to the nurse that the client is experiencing an adverse effect of the medication? A. "I'm feeling really drowsy." B. "My legs are very relaxed." C. "I can't seem to get enough to eat." D. "I urinate about the same amount as I always did."

A. "I'm feeling really drowsy."

The nurse is talking to a client whose spouse died 10 months ago. Which statement by the client indicates successful mourning? A. "I'm planning a trip to England next fall to tour the mansions and their gardens." B. "I must confess that I have taken to drinking more than I should at night, but a drink or two helps me to sleep alone in that big house." C. "My son has taken over managing my money because I got into a little mischief with my charge cards. I'm restricted to one debit card now." D. "Last night they had to treat me in the emergency department because I swallowed a few too many pills. Lately I've felt as if I can't go on alone."

A. "I'm planning a trip to England next fall to tour the mansions and their gardens."

A dying client with agoraphobia says to the nurse, "I've been unable to leave this house without tremendous effort for so long, and now it doesn't matter." Which statement by the nurse would be therapeutic? A. "It doesn't matter? Can you share your feelings with me?" B. "Your gardens are beautiful now. Would you like to stroll in them after our work?" C. "Did you go through systematic desensitization with your doctor? I understand that it works well." D. "I know what you mean. I spent more than $2,000 on a dental implant and still wound up with false teeth."

A. "It doesn't matter? Can you share your feelings with me?"

B Rationale: The nurse should first assess the client's feelings about her death and determine the extent to which this statement expresses her true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained.

A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about her feelings related to her own death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility.

A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most important? A. "Have you been having any thoughts of hurting your baby?" B. "Do you think that something physically wrong is causing your baby to cry?" C. "Do you think that your baby cries so frequently because he's not getting enough nourishment from breastfeeding?" D. "You say that he doesn't seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?"

A. "Have you been having any thoughts of hurting your baby?"

A client who was employed as a corporate manager before being laid off says to the nurse, "My wife thinks that I should work in a menial job to maintain our lifestyles until I find another job as a corporate manager, but I don't feel I should have to humiliate myself like that." Which nursing response would be therapeutic? A. "Have you shared your feelings with your wife?" B. "You seem to feel that a less prestigious job would be humiliating for you." C. "Oh, I agree with you. Let her get another job if she needs that much money." D. "How soon will you be able to find work? If this is permanent, you may need to swallow your pride."

A. "Have you shared your feelings with your wife?"

A 61-year-old client whose two sons and daughter-in-law died in a nightclub fire says to the nurse, "We were going to retire early, but now we are the only ones who can care for our two grandchildren." Which response by the nurse would be therapeutic? A. "I am sorry you've had so many losses." B. "I lost my nephew in that nightclub fire, so I understand your sorrow." C. "Your grandchildren sound as if they will give you a run for your money." D. "Don't you just want to scream at someone when such bad things happen? Do you have to work to support your grandchildren?"

A. "I am sorry you've had so many losses."

Family members awaiting the outcome of a suicide attempt are tearful. Which response by the nurse would be most therapeutic to the family at this time? A. "I can see that you are worried." B. "You have nothing to worry about." C. "You can see your loved one soon." D. "Everything possible is being done."

A. "I can see that you are worried."

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? A. "I didn't shampoo my hair." B. "I ate breakfast this morning." C. "I didn't take my anticonvulsant today." D. "It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't."

A. "I didn't shampoo my hair."

The husband of a terminally ill client says to the nurse, "My company went bankrupt, my son is a drug addict, my daughter is an alcoholic, and now this! My doctor wants me to try some stress reduction because my blood pressure is up. Whose wouldn't be? I've tried music and relaxation, but they don't work." Which statement by the nurse would be therapeutic? A. "Let's talk more about what has been helpful to you in the past." B. "Before we talk about stress management, let's discuss your children." C. "You have a lot of problems. How long does your wife have to live, and what is her relationship with your children?" D. "Can you afford to pay for therapy sessions? I see that your benefits are pretty much maxed out, and I'd hate to ask you to take on any additional burden."

A. "Let's talk more about what has been helpful to you in the past."

A home care nurse makes a visit to a new mother who delivered a 7-lb girl 72 hours ago. The mother tells the nurse that her newborn seems to sleep almost all day. The nurse most appropriately responds by making which statement to the mother? A. "Most newborns sleep about 16 hours a day" B. "We should probably have the baby checked out by the doctor." C. "If you see any other neurological alterations, call the pediatrician." D. "It's important to wake the baby every hour to provide stimulation.

A. "Most newborns sleep about 16 hours a day"

The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? A. "No, I wasn't, but I am now, thanks to you." B. "I hadn't thought of that, but I can see that you are." C. "Of course not, but there are days when I think that I should be." D. "What is suicide going to do for me except get me excommunicated from the church?"

A. "No, I wasn't, but I am now, thanks to you."

A client says to the nurse, "My doctor tells me that I need to start progressive muscle relaxation(PMR) to ease my stress, but I just can't get the hang of it." Which response by the nurse would be most helpful? A. "PMR requires training sessions. Let's check into classes that you can attend to learn the technique." B. "I want you to practice it as often as you can. Play soft, soothing music in the background when you practice your exercises." C. "For it to be effective and produce deep relaxation, the technique requires your complete receptivity to its benefit and your need for it." D. "I could never master the technique myself, so I understand your frustration. Would you like me to explain its difficulty for you to the doctor?"

A. "PMR requires training sessions. Let's check into classes that you can attend to learn the technique."

A university professor meeting with the mental health nurse for his weekly therapy session says, "I have a very intelligent student who keeps disrupting my classroom by bragging, and all I want to do is say, 'OK, you're great and you know it all! Now shut up!' But I just don't want to be rude." Which statement by the nurse is therapeutic? A. "Sounds like you feel pretty helpless, yet you are the professor here." B. "Just say, 'Gee where did you earn your doctorate?' and move on with your lecture." C. "Just smile and say nothing. Go on with your lecture and then talk with the student after class." D. "You're having a pretty strong reaction to this student, aren't you? Why not ask the student to leave the room and use the time to write down his or her thoughts so you can give the others your complete attention?"

A. "Sounds like you feel pretty helpless, yet you are the professor here."

An acutely ill schizophrenic client says to the nurse, "He keeps saying that he likes you, and I keep telling him you're married, but he won't listen, and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement? A. "Try not to listen to the voices right now so that I can talk with you." B. "I think that you can help him stop his behavior if you concentrate." C. "Tell him I said to mind his p's and q's or I'll call the police on him." D. "I think that you're trying to share your own feelings toward me, but you're shy."

A. "Try not to listen to the voices right now so that I can talk with you."

The nurse is talking to a client with depression when the client says, "I don't know why my son turned out like he did. I never thought that he would rob a bank! I don't know what I did wrong. I know that he didn't grow up with a father, but I gave him everything. I wish I could start over and do things differently." Which response by the nurse would be therapeutic? A. "You seem to be feeling regret." B. "Don't blame yourself. Some people just turn out bad no matter what." C. "All we can do is give our children love and do our very best. The rest is up to them." D. "Do I hear you saying that you feel that your son's behavior was caused by his upbringing?"

A. "You seem to be feeling regret."

The nurse is caring for a 39-year-old client who has experienced a mild brain attack (stroke). The client is recently widowed, is very active physically, and has two young sons. The client says to the nurse, "I don't know what my sons will do if anything permanent happens to me. We have no other relatives, even on my late wife's side." Which of the following nursing responses would be therapeutic? A. "You seem to be feeling very troubled." B. "You are working to get better, but you're worrying about things that aren't going to happen." C. "You seem to be feeling very powerless right now, yet you're getting better, so why worry about what won't happen?" D. "I am troubled that you are worried over the worst possible things that could happen rather than worrying about the efforts needed to strengthen your family situation."

A. "You seem to be feeling very troubled."

An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad told me he had to marry Mom because she got pregnant." Which response by the nurse would be therapeutic? A. "You're feeling that your folks didn't want you, but they chose to marry and have you." B. "You feel that you were a burden and not wanted? Let's talk with your parents to see whether you're right." C. "Let's speak with your parents about what you've just told me. Let's ask whether you were truly unwanted." D. "Sounds like your father was very inappropriate, but I'm certain that he didn't mean that you were a burden to him."

A. "You're feeling that your folks didn't want you, but they chose to marry and have you."

A 25-year-old client says to the nurse, "I got my degree in criminal justice. I graduated first in my class from the police academy and had just started as a patrolman when my partner and I responded to a domestic violence call in the most rural part of our patrol area. Someone started shooting at us, and I'm terrified. Maybe I'm not right for this job." Which statement by the nurse would be therapeutic? A. "You're saying that because you felt afraid in a violent situation, you may not be right for the job?" B. "Did you really think that you wouldn't be frightened? You're fortunate if this is the first time you've ever been afraid." C. "You seem to be surprised that you were frightened by the violence. Have you talked with your co-workers about their experiences?" D. "My earlier work as a nurse involved trips through our local crack houses. Wait until you've had some experience working narcotics and then tell me how you feel."

A. "You're saying that because you felt afraid in a violent situation, you may not be right for the job?"

A client who recently lost his hand in a workplace accident says to the nurse, "I don't know how I'm going to support my family with a plastic hand. I might as well be dead." Which nursing response would be therapeutic? A. "You're saying that you feel useless without your hand?" B. "Perhaps you need to focus on being happy that you survived." C. "Don't worry about all of that at this point. You're going to be fine." D. "You'll never need to worry about work again, because your employer will cover all of your expenses and make a settlement that will support you for life."

A. "You're saying that you feel useless without your hand?"

A client who is a health care provider says to the nurse, after receiving a diagnosis of terminal lung cancer, "All my life I took care of my clients, and now my family is taking care of me." Which statement is a therapeutic nursing response? A. "Your family is caring for you now." B. "Well, you'd expect them to care for you, wouldn't you?" C. "It is an honor for all of us to care for you. We want to help you." D. "You can look back on so many wonderful people you saved and cared for."

A. "Your family is caring for you now."

A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the health care provider before administering the dose? A. 3.0 mEq/L (3.0 mmol/L) B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 5.2 mEq/L (5.2 mmol/L)

A. 3.0 mEq/L (3.0 mmol/L)

A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L)

A. 3.1 mEq/L (3.1 mmol/L)

A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member? A. A client with a solid sealed cervical radiation implant B. A client with diarrhea for whom enteric precautions are in effect C. A client with metastatic cancer who is receiving a continuous infusion of intravenous morphine sulfate D. A client for whom contact precautions have been implemented and who requires frequent wound irrigations

A. A client with a solid sealed cervical radiation implant

The nurse is assigned to care for four clients. Which client does the nurse expect is likely to experience chronic pain? A. A client with osteoarthritis B. A client with angina pectoris C. A client who has undergone appendectomy D. A client with a leg fracture who is in skeletal traction

A. A client with osteoarthritis

A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply. A. A client with pancreatitis B. A client with severe sepsis C. A client with renal calculi D. A client who has undergone repair of a hiatal hernia E. A client with a severe exacerbation of ulcerative colitis

A. A client with pancreatitis B. A client with severe sepsis E. A client with a severe exacerbation of ulcerative colitis

A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, which should the nurse ensure? A. A female health care provider examines the woman B. The woman's husband remains in the examining room at all times C. The woman is examined without any other people in the examining room D. Written permission is obtained from the woman to obtain subjective health data

A. A female health care provider examines the woman

A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. How should the nurse interpret this finding? A. A reassuring sign B. A nonreassuring sign C. An indication of fetal distress D. An indication of the need to contact the health care provider

A. A reassuring sign

An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? Select all that apply. A. A victim with a limb amputation Correct B. A victim who is alert but complaining of loss of vision Correct C. A victim who is bleeding profusely from a head laceration Correct D. A victim who is dazed and staggering around the other victims E. A victim who has sustained minor bruising of an arm and the lower legs

A. A victim with a limb amputation B. A victim who is alert but complaining of loss of vision C. A victim who is bleeding profusely from a head laceration

A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. A. A victim with respiratory distress B. A victim with a fractured humerus C. A victim with partial amputation of the foot D. A victim with a forehead laceration that is not bleeding E. A victim with multiple nonbleeding bruises of the arms and legs

A. A victim with respiratory distress C. A victim with partial amputation of the foot

A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm

A. Activating the agency disaster plan

A nurse in a postanesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first? A. Airway patency B. Active bowel sounds C. Adequate urine output D. Orientation to surroundings

A. Airway patency

A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? A. Akathisia B. Pelvic thrusts C. Athetoid limbs D. Protruding tongue

A. Akathisia

A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states to eliminate which from the diet? A. Alcohol B. Diet cola C. Bran flakes D. Chicken livers

A. Alcohol

Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application? A. An older client B. A client with renal calculi C. A client with osteoporosis D. A client with rheumatoid arthritis

A. An older client

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which intervention does the nurse prepare the client? A. An ultrasound examination B. Internal fetal monitoring C. Administration of oxytocin (Pitocin) D. A manual (digital) pelvic examination

A. An ultrasound examination

A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. How should the nurse document this finding? A. Anasarca B. Ecchymosis C. Unilateral edema D. Increased vascularity of the skin tissue

A. Anasarca

A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate? A. Applying an ice pack to the perineum B. Contacting the nurse-midwife or health care provider C. Administering an intravenous (IV) opioid analgesic D. Assisting the woman in taking a warm sitz bath

A. Applying an ice pack to the perineum

A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately: A. Asks the LPN to complete and file an incident report B. Asks the LPN to check the client in 30 minutes to see whether the nausea has subsided C. Tells the LPN that she made a sound judgment in administering the medication by way of the rectal route D. Instructs the LPN to write "pr" (per rectum) on the medication record next to the time at which the medication was administered

A. Asks the LPN to complete and file an incident report

A 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy. The nurse who is interviewing the client should first: A. Assess the client's knowledge of available birth control methods B. Inform the client that birth control methods cannot be discussed unless the client's boyfriend is present C. Tell the client that for her age and lifestyle, birth control pills would be the easiest method of contraception D. Give the client written material about various birth control methods and ask her to read them and to call if she has any questions

A. Assess the client's knowledge of available birth control methods

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? A. Assess the patency of the airway B. Check tubes and drains for patency C. Check the dressing for bleeding D. Assess the vital signs to compare them with preoperative measurements

A. Assess the patency of the airway

A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? A. Assessing the client's vision B. Placing ice on the eye C. Removing the sand particles D. Irrigating the eye with sterile saline solution

A. Assessing the client's vision

A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client's safety risk? Select all that apply. A. Assessing the client's visual acuity B. Observing the client's gait and posture C. Evaluating the client's muscle strength D. Looking for any hazards in the home environment E. Asking a family member to move in with the client until her recovery is complete F. Requesting that the client transfer to an assisted living environment for at least 1 month

A. Assessing the client's visual acuity B. Observing the client's gait and posture C. Evaluating the client's muscle strength D. Looking for any hazards in the home environment

A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by: A. Assessing visual acuity B. Inspecting the eyelids for ptosis C. Assessing pupil constriction D. Assessing ocular movements

A. Assessing visual acuity

A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant? A. Assisting a client with dysphagia in eating B. Providing hygiene to a client with dementia C. Ambulating a client with Parkinson's disease D. Assisting a client with an above-the-knee amputation in showering

A. Assisting a client with dysphagia in eating

A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which food does the nurse suggest that the client eliminate from the diet, knowing that it is most likely to taste bitter to the client? A. Beef B. Custard C. Potatoes D. Cantaloupe

A. Beef

A nurse performing an abdominal assessment is preparing to auscultate for bowel sounds. The nurse: A. Begins in the right lower quadrant B. Uses the bell end of the stethoscope C. Holds the stethoscope firmly and deeply against the skin D. Listens for at least 1 minute before deciding that bowel sounds are absent

A. Begins in the right lower quadrant

A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which toy is most appropriate for these activities? A. Blocks and push-pull toys B. Finger paints and card games C. Simple board games and puzzles D. Videos and cutting-and-pasting toys

A. Blocks and push-pull toys

A nurse discontinues an infusion of a unit of blood after the client experiences a transfusion reaction. Once the incident has been documented appropriately, where does the nurse send the blood transfusion bag? A. Blood bank B. Risk management C. Microbiology laboratory D. Infection-control department

A. Blood bank

A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is which? A. Body image B. Obtaining adequate nutrition C. Keeping up with schoolwork D. Obtaining adequate rest and sleep

A. Body image

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food that just arrived on the client's meal tray should the nurse discourage the client from eating? A. Bran B. Pasta C. Boiled rice D. Low-fat cheese

A. Bran

Calcitriol is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium absorption, instruct the client to limit in the diet? Select all that apply. A. Bran B. Milk C. Clams D. Spinach E. Orange juice

A. Bran D. Spinach

The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: A. Call a poison control center B. Administer an excessive amount of fluids to induce vomiting C. Call an ambulance to bring the child to the emergency department D. Leave a message at the physician answering service about the incident

A. Call a poison control center

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client's temperature orally before hanging the blood transfusion and notes that it is 100.0° F (37.7 C). What should the nurse do next? A. Call the health care provider B. Begin the transfusion as prescribed C. Administer an antihistamine and begin the transfusion D. Administer 2 tablets of acetaminophen and begin the transfusion

A. Call the health care provider

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which instruction does the nurse plan to include? A. Call the health care provider if the infant is lethargic. B. Expect increased urine output with the shunt. C. Call the health care provider if the anterior fontanel bulges when the infant cries. D. Position the infant on the side of the shunt for sleep.

A. Call the health care provider if the infant is lethargic.

The nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? A. Calling the health care provider who gave the telephone prescription to clarify the prescription B. Calling the nursing supervisor for assistance in determining the route of administration C. Administering the medication intravenously, because this route is generally used for clients with CHF D. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department

A. Calling the health care provider who gave the telephone prescription to clarify the prescription

A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. A. Chills B. Pallor C. Headache D. Chest and back pain E. Nausea and vomiting F. Subnormal temperature

A. Chills C. Headache D. Chest and back pain E. Nausea and vomiting

A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. Which action should the nurse take? A. Clamp the enema bag tubing B. Remove the enema tube and allow the client to rest C. Stop the instillation and allow the client to expel the solution D. Raise the enema bag to quickly finish instillation of the solution

A. Clamp the enema bag tubing

A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? A. Coffee B. A tuning fork C. A wisp of cotton D. An ophthalmoscope

A. Coffee

The nurse provides instructions to a client who is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when the client states to limit consumption of which items? A. Coffee, cola, and chocolate B. Oysters, lobster, and shrimp C. Apples, oranges, and pineapple D. Cottage cheese, cream cheese, and dairy creamers

A. Coffee, cola, and chocolate

A 24-year-old schizophrenic client says, "I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester." Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client's return to college? A. Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle B. Telling all friends about the illness so that they support the client's avoidance of alcohol and drugs and help the client maintain a balanced lifestyle C. Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization D. Compliance with treatment, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and socialization with one supportive friend

A. Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply. A. Conducting client rounds before taking the break B. Taking the break in the staff lounge located on the nursing unit C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens D. Asking the nursing assistant to monitor a client's tube feeding and to contact the nurse when the feeding bag is empty E. Asking the nursing assistant to contact the health care provider during the nurse's break if a client's pain medication is not effective F. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby

A. Conducting client rounds before taking the break B. Taking the break in the staff lounge located on the nursing unit

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first? A. Contacting the health care provider B. Reassessing the client in 30 minutes C. Checking to see whether it is time for more pain medication D. Encouraging the client to continue active range of motion exercises of the left arm

A. Contacting the health care provider

A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate? A. Contacting the health care provider B. Continuing to monitor the client C. Increasing the flow rate of the intravenous (IV) solution D. Placing pressure on the bladder to aid expulsion of any additional clots

A. Contacting the health care provider

The nurse notes that a health care provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take? A. Contacting the health care provider B. Administering the medication C. Drawing up the medication in a syringe D. Planning to have the nurse on the next shift administer the medication

A. Contacting the health care provider

A health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take? A. Contacting the nursing supervisor B. Continuing to transcribe the prescription C. Asking the nurse assigned to care for the client to administer the medication D. Verifying the prescribed dose with the client before administering the medication

A. Contacting the nursing supervisor

A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse most appropriately: A. Contacts the client's health care provider B. Tells the client to avoid lying flat C. Instructs the client to eat a small portion of food every 2 to 3 hours D. Administers an antacid to the client and tell her to take a dose every 6 hours

A. Contacts the client's health care provider

A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate this procedure? A. Darken the examining room B. Administer a local anesthetic C. Obtain a signed informed consent D. Shave the skin and scrub it with povidone-iodine (Betadine)

A. Darken the examining room

A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should the nurse perform to prepare for this diagnostic test? A. Darken the room B. Obtain informed consent from the client C. Obtain a scalpel and a slide for diagnostic evaluation D. Obtain medication to anesthetize the skin area before proceeding with the examination

A. Darken the room

A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client's husband tells the nurse that the client is taking donepezil hydrochloride. The nurse should ask the husband about the client's history of which disorder? A. Dementia B. Seizure disorder C. Diabetes mellitus D. Posttraumatic stress disorder

A. Dementia

A client who has been admitted to a surgical unit with a diagnosis of cancer is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, "I'm not having surgery — you must have the wrong person! My test results were negative. I'll be going home tomorrow." Which defense mechanism should the nurse recognize that the client is using? A. Denial B. Psychosis C. Delusions D. Displacement

A. Denial

An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which? A. Determination of fetal lung maturity B. Checking the amniotic fluid for intrauterine infection C. Checking the fetal cells for chromosomal abnormalities D. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid

A. Determination of fetal lung maturity

A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action should the nurse take? A. Discarding the package B. Using the gauze pads, because the tear was small C. Examining the gauze pads and using them as long as they appear untouched D. Discarding the gauze pad closest to the outside of the package and using the others

A. Discarding the package

A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is "uncooperative and a real pain to care for." The nurse leader would most appropriately manage this issue by: A. Discouraging the judgmental comments B. Ignoring the comments made about the client C. Reporting the nurses' comments to administration D. Leaving articles about judgmental opinions in the nurses' report room

A. Discouraging the judgmental comments

The nurse is providing information to a group of nursing staff members about caring for suicidal clients. What should the nurse tell the group? A. Discussing suicide with a client is not harmful B. Those clients who talk about suicide never actually try it C. Depressed clients are the only people who commit suicide D. When a person makes suicide threats, the only thing the person wants is attention

A. Discussing suicide with a client is not harmful

A client with a history of lung disease is at risk for respiratory acidosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

A. Disorientation and dyspnea

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take? A. Document the findings B. Notify the health care provider of the finding C. Wait 15 minutes and then recheck the FHR D. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time

A. Document the findings

A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. Based on this finding, which action should the nurse take? A. Document the findings B. Notify the health care provider immediately C. Obtain a prescription for a muscle relaxant D. Ask the health care provider about referring the client to a neurological specialist

A. Document the findings

A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding? A. Document the findings. B. Check the client's temperature. C. Report the findings to the nurse-midwife. D. Obtain a sample of the amniotic fluid for laboratory analysis.

A. Document the findings.

The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL. On the basis of this result, the nurse should take which action initially? A. Document the normal value on the chart B. Call the health care provider immediately C. Call the rapid response team to help with the emergency D. Call the pharmacy to alert the pharmacist regarding the client's theophylline level

A. Document the normal value on the chart

A nurse administers a tap water enema to an adult client who is constipated. The client defecates a scant amount of brown fecal matter, which the nurse interprets as a poor result. The nurse should take which action? A. Document the results B. Administer a second tap water enema C. Add soap suds to the enema bag and repeat the enema D. Administer a Fleet enema, then a tap water irrigation

A. Document the results

A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. Based on this finding, which action by the nurse is most appropriate? A. Documenting the finding B. Helping the woman get out of bed and walk C. Performing active and passive range-of-motion exercises D. Reporting the finding to the nurse-midwife or health care provider immediately

A. Documenting the finding

A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. Based on this finding, what is the most appropriate action for the nurse to take? A. Documenting the findings B. Contacting the pediatrician C. Placing the infant in an oxygen tent D. Wrapping an extra blanket around the infant

A. Documenting the findings

A nurse performing a genital examination of a male client notes that the skin of the penis and scrotum is wrinkled. On the basis of this finding, the nurse: A. Documents the normal finding B. Checks for penile discharge, because this finding indicates infection C. Palpates for a mass in the scrotum, because wrinkling indicates the presence of one D. Obtains additional subjective data from the client, focusing on the scrotal abnormality

A. Documents the normal finding

Which action exemplifies the use of evidence-based practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her health care provider D. Taking a rectal temperature from a client for whom bleeding precautions have been instituted

A. Donning sterile gloves to change an abdominal wound dressing

A nurse performing a neurological assessment is inspecting the client's eyelids for ptosis. The nurse checks the client for: A. Drooping B. Pupil dilation C. Pupil constriction D. Deviation of ocular movements

A. Drooping

A nurse is attending an inservice program on disaster preparedness. Which of the following events is described as an example of a natural disaster? A. Drought B. Bus accident C. Terrorist attack D. Toxic waste spill

A. Drought

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expects to note if the bladder is full? A. Dull sounds B. Hyperresonance sounds C. Hypoactive bowel sounds D. An absence of bowel sounds

A. Dull sounds

The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note?Select all that apply. A. Dyspnea B. Dependent edema C. Neck vein distention D. Abdominal distention E. Crackles on auscultation of the lungs

A. Dyspnea

A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time? A. Ensuring that the client has voided B. Administering all daily medications C. Practicing postoperative breathing exercises D. Verifying that the client has not eaten for the last 24 hours

A. Ensuring that the client has voided

A clinic nurse about to meet a new client and plans to gather subjective data regarding the client's health history. Which actions should the nurse take to help ensure the success of the interview? Select all that apply. A. Ensuring that the room is private B. Seeing that distracting objects are removed from the room C. Having the client sit across a desk or table to give the client some personal space D. Maintaining a distance of 2 feet or closer between the nurse and client E. Switching on a dim light that will make the room cozier and help the client relax

A. Ensuring that the room is private B. Seeing that distracting objects are removed from the room

The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse's new role? Select all that apply. A. Evaluating and updating the plan of care as needed B. Prescribing treatments specific to the client's needs C. Assessing the client's needs for home supplies and equipment D. Coordinating consultations and referrals to facilitate discharge E. Establishing a safe and cost-effective plan of care with the client

A. Evaluating and updating the plan of care as needed C. Assessing the client's needs for home supplies and equipment D. Coordinating consultations and referrals to facilitate discharge E. Establishing a safe and cost-effective plan of care with the client

A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes

A. Every 2 hours

A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of his: A. Expert power B. Reward power C. Referent power D. Coercive power

A. Expert power

Metoprolol has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client?Select all that apply. A. Fatigue B. Dry eyes C. Weakness D. Impotence E. Nightmares

A. Fatigue C. Weakness D. Impotence

Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side/adverse effects does the nurse instruct the client to report to the health care provider? Select all that apply. A. Fever B. Nausea C. Headache D. Sore throat E. Mouth sores

A. Fever D. Sore throat E. Mouth sores

A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal? A. Firm pressure B. Pain behind the eyes C. Pain during palpation D. Pressure producing an acute headache

A. Firm pressure

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? A. Flat B. Semi-Fowler C. Side-lying, with the head of the bed elevated D. Sitting up in a recliner with the feet elevated

A. Flat

An unlicensed assistive personnel (UAP) is providing morning care to a client with a fractured leg who is in skeletal traction. The nurse determines that the UAP needs instruction regarding the guidelines for client bathing if the UAP is implementing which action? A. Giving the client a complete bed bath B. Pulling the room curtains around the bathing area C. Turning up the thermostat in the client's room for the bath D. Keeping the side rails (per agency policy)up while away from the client

A. Giving the client a complete bed bath

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply. A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and symptoms C. Telling the client to rest as much as possible during the next 24 hours D. Instructing the client to enclose the monitor in plastic wrap before taking a bath E. Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless

A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and symptoms

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), what does the nurse determine? A. Gravida 6, para 2 B. Gravida 2, para 6 C. Gravida 2, para 2 D. Gravida 3, para 6

A. Gravida 6, para 2

A nurse performing a physical examination is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note? A. Gurgling sounds B. Hypoactive sounds C. Low-pitched sounds D. An absence of sounds

A. Gurgling sounds

Which of the following actions are in keeping with the principles of standard precautions? Select all that apply. A. Handwashing between client contacts B. Cleaning of blood spills with soap and warm water C. Discarding needles in puncture-resistant containers D. Handwashing before removal of a pair of soiled gloves E. Wearing a face shield as a part of the protective garb during a wound irrigation F. Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

A. Handwashing between client contacts C. Discarding needles in puncture-resistant containers E. Wearing a face shield as a part of the protective garb during a wound irrigation F. Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply. A. Hematocrit 30% (0.30) B. Sodium 141 mEq/L (141 mmol/L) C. Hemoglobin 8.9 g/dL (89 g/L) D. Platelets 210× 103/μL (210 × 109/L) E. Serum creatinine 0.8 mg/dL (70 μmol/L)

A. Hematocrit 30% (0.30)

A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral? A. Home care B. Social services C. Physical therapy D. Occupational therapy

A. Home care

A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note? A. Hypertension B. Low serum potassium C. Increased creatinine level D. Cloudy yellow urine

A. Hypertension

A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side/adverse effect of the medication does the nurse monitor the client's laboratory results? A. Hypokalemia B. Hypocalcemia C. Hypernatremia D. Hypermagnesemia

A. Hypokalemia

A nurse is preparing a plan of care for a client who will be receiving meperidine hydrochloride. Which side/adverse effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. A. Hypotension B. Constipation C. Bradycardia D. Urine retention E. Respiratory depression

A. Hypotension B. Constipation D. Urine retention E. Respiratory depression

A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis? A. Increased calcium level B. Decreased blood urea nitrogen (BUN) C. Increased white blood cell (WBC) count D. Decreased number of plasma cells in the bone marrow

A. Increased calcium level

A nurse is providing instructions to a client regarding the use of crutches. Which information should the nurse include in the teaching plan? Select all that apply. A. It is not safe to use someone else's crutches. B. Rubber crutch tips will not slip, even when wet. C. The client should use both crutches when navigating stairs. D. Lean into the crutches as needed to support the body's weight. E. Crutch tips are made of a material that will not wear down.

A. It is not safe to use someone else's crutches. C. The client should use both crutches when navigating stairs.

Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply. A. Keeping bedside table surfaces clean and dry B. Placing tissues and soiled dressings in paper bags C. Changing dressings that become wet or soiled Correct D. Placing capped needles and syringes in puncture-resistant containers E. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin F. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

A. Keeping bedside table surfaces clean and dry C. Changing dressings that become wet or soiled E. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin F. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client? A. Keeping the door to the client's room closed B. Using a surgical mask when entering the client's room C. Placing the client in a semiprivate room with a cohort client D. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times

A. Keeping the door to the client's room closed

A client with right-sided weakness must learn how to use a cane. The nurse tells the client to position the cane by holding it in which way? A. Left hand, 6 inches lateral to the left foot B. Right hand, 6 inches lateral to the right foot C. Left hand, placing the cane in front of the left foot D. Right hand, placing the cane in front of the right foot

A. Left hand, 6 inches lateral to the left foot

A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position? A. Left side with the head lower than the feet B. Left side with the head higher than the feet C. Right side with the head lower than the feet D. Right side with the head higher than the feet

A. Left side with the head lower than the feet

A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the client? Select all that apply. A. Lentils B. Raisins C. Pineapple D. Egg whites E. Kidney beans F. Refined white bread

A. Lentils B. Raisins E. Kidney beans

A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? A. Lethargy B. Bradycardia C. Hyperactivity D. Reddened cheeks

A. Lethargy

A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to: A. Limit sodium in the diet B. Increase fluid intake to at least 3000 mL/day C. Lie down when vertigo occurs and keep a light on in the room D. Move the head from the right to the left when vertigo occurs to determine the extent of its effects

A. Limit sodium in the diet

A client with tuberculosis is being started on isoniazid and the nurse stresses the importance of returning to the clinic for follow-up blood testing. Which blood test will be performed? A. Liver enzymes B. Serum creatinine C. Blood urea nitrogen D. Red blood cell count

A. Liver enzymes

A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications? Select all that apply. A. Lying down after eating B. Eating high-protein foods C. Drinking liquids with meals D. Eating six small meals per day E. Eating concentrated sweets during the day

A. Lying down after eating B. Eating high-protein foods D. Eating six small meals per day

The nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially? A. Making a "no suicide" contract with the client B. Telling the client that anger should be suppressed C. Providing a peaceful place for the client to meditate D. Helping the client control expression of his feelings

A. Making a "no suicide" contract with the client

A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child? A. Mastering useful skills and tools B. Gaining independence from parents C. Developing a sense of trust in the world D. Developing a sense of control over self and body functions

A. Mastering useful skills and tools

A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL (34.4 mmol/L). After the nurse calls the health care provider to report the finding and monitors the client closely for which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B . What should the nurse do while the medication is being administered? A. Monitor the client's urine output B. Monitor the client for hypothermia C. Check the client's neurological status D. Check the client's blood glucose level

A. Monitor the client's urine output

A nurse is developing a plan of care for a client, hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate daily. Which intervention does the nurse identify as a priority in the plan? A. Monitoring intake and output Correct B. Monitoring the client's pupillary response C. Placing the client in a right side-lying position D. Checking the client's hemoglobin level daily

A. Monitoring intake and output

A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the health care provider has documented that the client is experiencing signs of akathisia. On the basis of the health care provider's note, which clinical manifestation would the nurse expect to find during assessment of the client? A. Motor restlessness B. Puffing of the cheeks C. Puckering of the mouth D. Protrusion of the tongue

A. Motor restlessness

A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The nurse plans care knowing that this condition is referring to which? A. Mutism B. Verbigeration C. Pressured speech D. Poverty of speech

A. Mutism

A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x-ray. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? A. No fluctuation in the water seal chamber B. Continuous bubbling in the water seal chamber C. Increased drainage in the collection chamber D. Continuous gentle suction in the suction control chamber

A. No fluctuation in the water seal chamber

The health care provider (HCP) prescribes "enemas until clear" for a client. The nurse has administered three enemas to the client, but the client is still passing brown stool and fluid. Which action should the nurse take? A. Notify the HCP B. Continue administering enemas until the fluid returns clear C. Administer a glycerin suppository and then administer one more enema D. Allow the client to rest for 1 hour and then continue with another enema

A. Notify the HCP

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? A. Notify the surgeon B. Continue the assessment C. Check the client's blood pressure D. Obtain a flashlight, gauze, and a curved hemostat

A. Notify the surgeon

A nurse is assisting the physician in performing transillumination of a client's scrotum. The nurse prepares for this procedure by: A. Obtaining a flashlight and darkening the room B. Instructing the client to drink three glasses of water C. Instructing the client to take several deep breaths and bear down D. Telling the client that the procedure is very uncomfortable but that the discomfort will only last for a few moments

A. Obtaining a flashlight and darkening the room

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? A. Obtaining new IV tubing B. Obtaining a new IV solution bag C. Scrubbing the tubing port with an alcohol swab D. Wiping the tubing port with povidone-iodine solution (Betadine)

A. Obtaining new IV tubing

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? A. One low in protein B. One high in fluids C. One high in carbohydrates D. One with a moderate amount of fat

A. One low in protein

A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client's meal tray? A. Peas B. Scrambled eggs C. Cheese casserole D. Mashed potatoes

A. Peas

The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which foods are allowed in the diet of the client taking phenelzine? Select all that apply. A. Peas B. Broccoli C. Potatoes D. Red wine E. Avocados F. Cereal with raisins

A. Peas B. Broccoli C. Potatoes

A nurse is discussing birth control methods with a client who is trying to decide which method to use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus? A. Personal preference B. Family planning goals C. Work and home schedules D. Desire to have children in the future

A. Personal preference

Phenelzine sulfate is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which medication should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis? A. Phentolamine B. Acetylcysteine C. Protamine sulfate D. Calcium gluconate

A. Phentolamine

A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should use which for repositioning? A. Pillow to keep the right leg abducted while turning the client B. Rolled bath blanket to prevent abduction while turning the client C. Trochanter roll to keep the right leg adducted while turning the client D. Rolled bath blanket to prevent external rotation while turning the client

A. Pillow to keep the right leg abducted while turning the client

A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by: A. Placing a tape measure around the widest point of the lower leg B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point

A. Placing a tape measure around the widest point of the lower leg

A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client? A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed B. Discard the residual volume properly and record it as output on the client's fluid balance record C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger

A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed

Which of the following actions are means of maintaining medical asepsis to reduce and prevent the spread of microorganisms? Select all that apply. A. Practicing hand hygiene B. Reapplying a sterile dressing C. Sterilizing contaminated items D. Applying a sterile gown and gloves E. Routinely cleaning the hospital environment F. Wearing clean gloves to prevent direct contact with blood or body fluids

A. Practicing hand hygiene E. Routinely cleaning the hospital environment F. Wearing clean gloves to prevent direct contact with blood or body fluids

A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then: A. Prepares for reintubation B. Restrains the client's wrists C. Calls the rapid response team (RRT) D. Administers an antianxiety medication to the client

A. Prepares for reintubation

The nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client? A. Providing authority and action B. Displaying an attitude of detachment and efficiency C. Providing hope and reassurance that the crisis is temporary D. Demonstrating confidence in the client's ability to deal with the crisis

A. Providing authority and action

A nurse is developing a bowel-training program for a client after a stroke. Which interventions are appropriate for inclusion in the plan? Select all that apply. A. Providing privacy and time for defecation B. Assisting the client into a sitting position C. Limiting the amount of fiber in the client's diet D. Providing a cool drink before defecation time E. Initiating defecation measures every day at the same time F. Administering a cathartic suppository a half-hour before defecation time

A. Providing privacy and time for defecation B. Assisting the client into a sitting position E. Initiating defecation measures every day at the same time F. Administering a cathartic suppository a half-hour before defecation time

A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope? A. Pulling the pinna up and back B. Pulling the pinna down and forward C. Tipping the client's head down and toward the examiner D. Tipping the client's head down and away from the examiner

A. Pulling the pinna up and back

A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs if it occurs? Select all that apply. A. Rash B. Chills C. Fatigue D. Backache E.Tiredness

A. Rash B. Chills D. Backache

A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first? A. Realigning the client B. Asking the client to wiggle her toes C. Removing some of the traction weights D. Medicating the client with the prescribed analgesic

A. Realigning the client

A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately: A. Records the findings B. Massages the fundus C. Contacts the health care provider D. Helps the mother void

A. Records the findings

The wife of a dying man is ignoring his rapid physiological decline and imminent death. She continues with her usual activities, exhibits inability to remember what others have just told her, and misses important appointments. Which therapeutic statement should the nurse make to the wife? A. "It isn't unusual for family to suffer from anticipatory grief when a loved one is dying." B. "I cannot emphasize how much your husband needs you to be there for him right now. He is in the stage of denial." C. "You will need to concentrate on getting to these appointments on time and write down what everyone says so you will remember." D. "Can you talk about what's happening to you right now? Your behavior is not appropriate at this stage of your husband's illness. You seem to be having sympathy pains for him, like men during their wives' pregnancies."

A. "It isn't unusual for family to suffer from anticipatory grief when a loved one is dying."

The nurse is caring for a bereaved man with acquired immunodeficiency syndrome who lost his twin brother in a rock-climbing accident a month ago. Which statement by the client should cause the nurse to be concerned? A. "Lately I've been feeling that life isn't that great." B. "You'd have thought that I would be the one to die first." C. "I should have made him stay home. He was always clumsy." D. "I miss him so much. We were close and talked almost daily."

A. "Lately I've been feeling that life isn't that great."

A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time? A. Reflecting back to the client that he appears upset B. Letting the client have some time alone to grieve the impending loss of the limb C. Reminding the client that the injury was a result of alcohol abuse and referring him for counseling D. Informing the health care provider of the client's depression and requesting medication to assist the client in coping with the diagnosis

A. Reflecting back to the client that he appears upset

A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? A. Rely on the fact that their needs will be met B. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality C. Must have needs ignored for short periods to develop a healthy personality D. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs

A. Rely on the fact that their needs will be met

A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. What is the priority nursing intervention? A. Remain with the client at all times B. Request that a family member remain with the client at all times C. Remove the client's clothing and dress the client in a hospital gown D. Place the client in a seclusion room from which all potentially dangerous articles have been removed

A. Remain with the client at all times

A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse dofirst? A. Remove the IV B. Apply a warm compress C. Check for blood return D. Measure the area of infiltration

A. Remove the IV

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first? A. Remove the IV catheter B. Slow the rate of infusion C. Notify the health care provider D. Check for loose catheter connections

A. Remove the IV catheter

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions? A. Roast turkey with a baked potato B. Fruit plate with fresh whipped cream C. Fried chicken with macaroni and cheese D. Barbecued spare ribs with buttered noodles

A. Roast turkey with a baked potato

The charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriateaction for the charge nurse to take? A. Send the staff member home B. Ask the staff member how much alcohol she has consumed C. Tell the staff member that she is not allowed to administer medications D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off

A. Send the staff member home

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct? A. Setting the room temperature at a comfortable level B. Placing a chair for the client across from the nurse's desk C. Providing seating for the client so that the client faces a strong light D. Setting up seating so that the client and nurse are not at eye level

A. Setting the room temperature at a comfortable level

A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. The RN would conclude that the nursing assistant is performing the procedure incorrectly after observing that the nursing assistant: A. Stands behind the client B. Stands on the right side of the client C. Positions the free hand on the client's shoulder D. Grasps the security belt in the midspine area of the small of the client's back

A. Stands behind the client

A client brought to the emergency department by the police after being mugged is extremely agitated, trembling and hyperventilating. What is the appropriate initial nursing action? A. Staying with the client B. Teaching the client how to relax C. Asking the client questions about the mugging D. Allowing the client to be alone in a room at the end of the emergency department corridor, where it is quiet

A. Staying with the client

A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first? A. Stopping the oxytocin infusion B. Notifying the nurse-midwife or health care provider C. Checking the woman's blood pressure and pulse D. Increasing the intravenous (IV) rate of the nonadditive solution

A. Stopping the oxytocin infusion

A nurse conducting an interview with a client collects subjective data. During the interview, which action should the nurse take? A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors B. Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying C. Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort D. Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable

A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors

A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? A. Taking the client's vital signs B. Giving the client a drink of water C. Monitoring the client for a sore throat D. Being alert to complaints of heartburn

A. Taking the client's vital signs

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. Which action should the nurse take? A. Tell the mother that the infant's weight is increasing as expected B. Tell the mother to decrease the daily number of feedings because the weight gain is excessive C. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes D. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate

A. Tell the mother that the infant's weight is increasing as expected

A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond? A. Telling the health care provider that "slow codes" are not acceptable B. Telling the health care provider that the client would probably want to die in peace C. Telling the health care provider that all of the nurses on the unit agree with this plan D. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken

A. Telling the health care provider that "slow codes" are not acceptable

A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, "I don't want a bath. I've been up all night, and I'm clean enough." The student reports the client's refusal to the nurse in charge. Which action by the nurse in charge is appropriate? A. Telling the nursing student to allow the client to rest B. Telling the nursing student to give the client the bath anyway C. Telling the client that the health care provider will be informed of the refusal of care D. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it

A. Telling the nursing student to allow the client to rest

A nurse is preparing to screen a client's vision with the use of a Snellen chart. Which action should the nurse take? A. Tests the right eye, then tests the left eye, and finally tests both eyes together B. Assesses both eyes together, then assesses the right and left eyes separately C. Asks the client to stand 40 feet from the chart and read the largest line on the chart D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision

A. Tests the right eye, then tests the left eye, and finally tests both eyes together

A man who is visiting his wife in a long-term care facility for people with Alzheimer's disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital health care provider that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember? A. That a DNR order may be written by a client's health care provider B. That everything possible must be done if the client stops breathing C. That medications only may be given to the client if the client stops breathing D. That life support measures will have to be implemented if the client stops breathing

A. That a DNR order may be written by a client's health care provider

A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. A. That informed consent is required Correct B. That the test takes about 4 hours to complete C. That no premedication for sedation will be necessary D. That food and fluids will be withheld before the procedure Correct Correct E. That multiple position changes may be necessary to pass the tube

A. That informed consent is required D. That food and fluids will be withheld before the procedure E. That multiple position changes may be necessary to pass the tube

The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. What should the nurse tell the parents? A. That this is normal behavior for an adolescent B. To restrict any social privileges until the behavior stops C. That this type of behavior is usually the result of parents' spoiling a child D. That their daughter will need to see a child psychologist if the behavior continues

A. That this is normal behavior for an adolescent

A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing mustard-yellow stools. What should the nurse tell the mother? A. That this is normal for breastfed infants B. To decrease the number of feedings by two per day C. That the stools should be solid and pale yellow to light brown D. To monitor the infant for infection and, if a fever develops, to contact the pediatrician

A. That this is normal for breastfed infants

A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment? A. The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home. B. The LPN is assigned to provide discharge teaching about dressing changes and medications to a 35-year-old man. C. The LPN is assigned to care for a client with newly diagnosed diabetes mellitus who will need to be taught how to self-administer insulin. D. The RN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications.

A. The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home.

A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply. A. The client becomes cyanotic. B. Secretions are becoming bloody. C. The client gags during the procedure. D. Clear to opaque secretions are removed. E. The heart rate varies from 80 to 82 beats/min.

A. The client becomes cyanotic. B. Secretions are becoming bloody.

The nurse reviews the nursing care plan of a client being seen in the mental health clinic and notes that the client is experiencing dysfunctional grieving after losing his spouse. Which is the appropriate outcome for the treatment plan for this client? A. The client plans to attend a community grief group. B. The client reports that he is trying to use coping strategies. C. The client verbalizes an absolute need to spend time with friends. D. The client verbalizes the relationship between significant loss and depression.

A. The client plans to attend a community grief group.

A nurse is reading the history and physical examination findings of an older client who has just been admitted to the hospital. Which findings documented in the history indicate an increased risk for accidents? Select all that apply. A. The client's range of motion is limited. B. Transmission of hot impulses is delayed. C. The client's peripheral vision is decreased. D. The client complaints of frequent nocturia. E. High-frequency hearing tones are perceptible. F. Voluntary and autonomic reflexes are slowed.

A. The client's range of motion is limited. B. Transmission of hot impulses is delayed. C. The client's peripheral vision is decreased D. The client complaints of frequent nocturia. F. Voluntary and autonomic reflexes are slowed.

A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide (Lasix) through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action? A. Verifying the physician's prescription B. Sitting and talking to the client to alleviate his concern C. Explaining to the client that the oral route will not permit the medication to exert an adequate effect D. Letting the client know that most medications are administered by way of the IV route when a client is hospitalized

A. Verifying the physician's prescription

A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? A. Visitors must be limited to one half-hour per day. B. Visitors must remain at least 2 feet from the client. C. A dosimeter badge must be placed on the client's bedside stand. D. The client may be maintained in a semiprivate room as long as the client uses a commode.

A. Visitors must be limited to one half-hour per day.

A client with diabetes mellitus is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test? A. Water Correct B.Tea without any sugar C. Coffee without any milk D. Clear liquids such as apple juice

A. Water

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. A. Wear a lead shield when in the client's room. Correct B. Limit visits from family to 60 minutes per day. C. Wear a dosimeter film badge when in the client's room. D. Allow children to visit the client as long as they are at least 12 years old. E. Keep all bed linens and dressings in the client's room until the implant is removed.

A. Wear a lead shield when in the client's room. C. Wear a dosimeter film badge when in the client's room. E. Keep all bed linens and dressings in the client's room until the implant is removed

A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client's plan of care? A. Wearing gloves when emptying the client's bedpan B. Allowing the client to ambulate in the hall only once a day C. Placing the client in a semiprivate room at the end of a hallway D. Placing used linen in double bags and sending a bag to the laundry room every evening

A. Wearing gloves when emptying the client's bedpan

A nurse performs an evaluation to determine whether a client's home is electrically safe. Which finding indicates the need for further investigation and intervention? A. Wiring for the television runs under the carpet. B. Electrical cords are free of frayed and damaged wires. C. Electrical kitchen appliances are located away from the sink. D. A safety-type extension cord is secured to the floor with electrical tape.

A. Wiring for the television runs under the carpet.

- A registered nurse (RN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the LPN?

ANS - 1. A client with a decubitus ulcer that requires a wound irrigation and dressing change.

A client is to receive cimetidine (Tagamet) 300mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr. should the infusion pump be set to deliver the secondary infusion?

ANS - 150ml/hr. This is calculated as ratio proportion problem: i.e. 50ml/20min : xml/60 min. Multiply extremes and means 50 x 60/20x 1=3000/20 = 150

The head nurse of the emergency department (ED) is assigning duties to volunteer nurses to care for a group of clients injured in a mass casualty situation. Which assignments are appropriate in this situation. Select all that apply. a. The general staff nurse should organize nursing services. b. The trauma nurse manager should organize ancillary services. c. The medical-surgical nurse should recommend clients for discharge. d. The ED nurse leader should direct the ancillary departments to deliver supplies. e. The hospital nurse leader should identify clients who can be transferred out of the unit.

ANS - 2, 3, 4 - The trauma nurse manager should organize ancillary services. The medical-surgical nurse should recommend clients for discharge. The ED nurse leader should direct the ancillary departments to deliver supplies.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

ANS - A - Assist the ambulating patient back to bed. An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize demands.

The health care provider prescribes 1000mL of total parenteral nutrition to be administered in 12 hours. Based on this prescription, how many milliliters of solution should be administered per hour? a. 83mL/hr b. 100mL/hr c. 108mL/hr d. 125mL/hr.

ANS - A 83mL/hr.

A client is undergoing peritoneal dialysis. After several fluid exchanges, the abdomen is distended, blood pressure is elevated, and 6,500 ml were infused while 5,500 ml were drained. In response to this finding, what action should the nurse take? a. irrigate the drainage tube with normal saline. b. Instruct the client to cough. c. Turn the client from side to side. d. Lower the head of the bed.

ANS - A Irrigate the drainage tube with normal saline.

Which statement should the nurse include when providing anticipatory guidance to the parents of a 3 year old client? a. It is important to set limits with your child. b. Your child may being to have more nightmares. c. It is important to enroll your child in swimming lessons. d. Your child may being to exhibit more aggressive behavior.

ANS - A It is important to set limits with your child. Anticipatory guidance for the 3 year old client is educating the parents on the importance of setting limit with the child.

The school nurse is implementing standards to manage students and provide a safe and healthy school setting. Which action is most important for the nurse to implement? A- Maintain student immunization records B- Develop an emergency plan for the school C- Ensure that medical supplies are available D- Conduct annual student health assessments

ANS - A Maintain student immunization records

The nurse is preparing to administer 1,000ml of dextrose 25% TPN to a client with ulcerative colitis. Which intervention is most important for the nurse to implement? a. Review the client's intake and output. b. Assess vital signs prior to administration c. Administer TP through Central Line. d. Evaluate the client's nutritional history.

ANS - Administer TPN through central line.

17. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? • Document the client's request in the medical record. • Ask the client if this decision has been discussed with his healthcare provider. • Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. • Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

ANS - Ask the client if this decision has been discussed with his healthcare provider. Rationale - Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action.

22. A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? • Help the client to accept the final stage of life. • Assist and support the client in establishing short-term goals. • Encourage the client to make future plans, even if they are unrealistic. • Instruct the client's family to focus on positive aspects of the client's life.

ANS - Assist and support the client in establishing short-term goals. Rationale - Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B).

The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

ANS - B - Reassess the client's blood pressure using a larger cuff. The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B).

A neonate is born with exstrophy of the bladder, and the parents are visibly upset. They are told that corrective surgery will be performed as soon as possible. How can the nurse best assist the parents at this time? a. Teaching the parents about preoperative and postoperative care b. Caring for the newborn in the same manner as any other newborn. c. Keeping the newborn as clean as possible to decrease the odor of urine. d. Reassuring the parents that after surgery their newborn will grow and develop without any after effects.

ANS - B Caring for the newborn in the same manner as any other newborn.

The nurse is reinforcing home care instructions with a client who is being discharged following transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the clients discharge instructions? A- Avoid strenuous activity for 6 weeks B- Report fresh blood in the urine C- Take acetaminophen for fever 101 D- Consume 6 to 8 glasses of water daily

ANS - B Report fresh blood in the urine.

An adolescent female suffering from severe cystic acne is placed on isotretinoin. What important facts should the nurse tell the client about isotretinoin. Select all that apply. a. Inform the client to use vinyl helmet straps. b. Inform the client about the risk of teratogenicity. c. Inform the client that skin improvement may take time. d. Inform the client to scrub vigorously to remove blackheads. e. Inform the client to use abrasive cleaners to remove blackheads.

ANS - B, C - Inform the client about the risk of teratogenicity. Inform the client that skin improvement may take time. Even is a adolescent is not sexually inactive, the nurse should discuss viable birth control options with the client due to the risk of teratogenicity with isotretinoin.

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)? a. A client with pancreatic cancer is experiencing intractable pain. b. An older client who fell yesterday and is now complaining of diplopia. c. An older client post-stroke who is aphasic with right-sided hemiplegia. d. An adult newly diagnosed with Type 1 diabetes and high cholestrol.

ANS - C An older client post-stroke who is asphasic with right-sided hemiplegia.

A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances? a. Restrict family visits b. Withhold analgesic medications c. Plan for maximum periods of rest d. Keep the room light on most of the time.

ANS - C Plan for maximum periods of rest. Sleep deprivation alone can cause these disturbances because of the interruption in rapid eye movement REM sleep. Lack of contract with significant others increases anxiety and feelings of isolation, which can lead to disturbances in rest. Pain limits or interrupts periods of sleep and rest.

A pt with possible pneumonia come to the hospital and the nurse need to do an assessment but the family don't want to leave the room, what the nurse need to do first? A -Call the security B- Put the family out of the room C- Put a pneumonia droplet sign in the door D - Continue with the assessment and put mask to the family

ANS - C Put a pneumonia droplet sign in the door.

A young woman is diagnosed as having genetically related amenorrhea. What is the primary nursing intervention at this time? a. Supporting her physical abilities b. Discussing her altered body image c. Trying to meet her emotional needs d. Exploring other reproductive options with her.

ANS - C Trying to meet her emotional needs.

A public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Case management and screening for clients with HIV. B. Regional relocation center for earthquake victims. C. Vitamin supplements for high-risk pregnant women. D. Lead screening for children in low-income housing.

ANS - C Vitamin supplements for high-risk pregnant women

A 4 month old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? a. Decreased tremors b. Increased hours of sleep c. Weight loss during next 2 days d. More rapid heart rate within 2 days.

ANS - C Weight loss during next 2 days. Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failure.

A nurse teaches a client about limiting the discomfort associated with a hiatal hernia. Which statement from the client indicates teaching by the nurse is effective? a. After meals I will take a 10 minute walk b. After meals I will drink 8oz (240ml) of water c. After meals I will rest in a sitting position for one hour. d. After meals I will lie down in bed for at least 20 minutes.

ANS - C after meals I will rest in a sitting position for one hour. Gravity (Sitting up after meals) facilitates digestion and prevents reflux of stomach contents into the esophagus.

While assessing a client, the nurse finds redness and swelling of the scrotum. The client reports fever and pus in the urine. Which treatment strategies would be beneficial? Select all that apply. a. Radiotherapy b. Chemotherapy c. Analgesic therapy d. Antibiotic therapy e. Hormone therapy

ANS - C, D - Pus in the urine of the client indicates pyuria. Redness and swelling of the scrotum associated with fever and pyuria indicate epididymitis. The treatment of epididymis includes analgesic therapy and antibiotic therapy.

A confused older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? a. Apply adult diapers after each attempt to void. b. Check residual urine volume using an indwelling urinary catheter. c. Assist the client to the bedside commode every two hours. d. Instruct the client to use the call button when a bedpan is needed.

ANS - C. Assist the client to bedside commode every two hours.

8. What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? • Check capillary refill of toes on lower extremity with Unna's paste boot. • Apply dressing to wound area before applying the Unna's paste boot. • Wrap the leg from the knee down towards the foot. • Remove the Unna's paste boot q8h to assess wound healing.

ANS - Check capillary refill of toes on lower extremity with Unna's paste boot. Rationale - The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D).

13. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first? • Page the unit manager to address the situation. • Close the demographic screen on the computer. • Instruct the UAP to end the phone call immediately. • Send a UAP into the client's room to relieve the nurse.

ANS - Close the demographic screen on the computer. Rationale - The greatest priority is for the charge nurse to close the computer screen (B), because health information stored in computerized systems is considered to be Protected Health Information (PHI) under HIPAA (Health Insurance Portability and Accountability Act). (A, C, and D) may be indicated, but are of less priority than (B). Category: Fundamentals

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A postoperative client preparing for discharge with a new medication. b. A client requiring daily dressing changes of a recent surgical incision. c. A client scheduled for a chest x-ray after insertion of a nasogastric tube. d. A client with asthma who requested a breathing treatment during the previous shift.

ANS - D A client with asthma who requested a breathing treatment during the previous shift.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? a. A client complaining of muscle aches, a headache, and history of seizures. b. A client who twisted her ankle when rollerblading and is requesting medication for pain. c. A client with a minor laceration on the index finger sustain while cutting an eggplant. d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

ANS - D A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? a. Kidney dysfunction. b. Cardiovascular disease c. Eye problems, such as glaucoma d. Accidents, including their prevention

ANS - D Accidents, including their prevention Accidents are common during young adulthood because of immature judgement and impulsivity associated with this stage of development.

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? a. Ingestion of shellfish or fish oil capsules daily. b. Length and frequency of the client's tobacco use. c. Genetically inherited disorders of family members. d. Frequency of laxative use for chronic constipation.

ANS - D Frequency of laxative use for chronic constipation.

A client is undergoing treatment for schizophrenia with antipsychotic drugs. During a client assessment, the primary healthcare provider noticed an increase in body temperature and unstable blood pressure. Which adverse effect of the antipsychotic drug caused this condition in the client? a. Akathisia b. Tardive dyskinesia c. Extrapyramidal symptoms d. Neuroleptic malignant syndrome

ANS - D Neuroleptic malignant syndrome Neuroleptic malignant syndrome is the adverse effect caused by antipsychotic drugs. The symptoms are fever and unstable blood pressure. Akathisia is thee one of the symptoms of pseudoparkinsonism. Tardive dyskinesia is one the adverse effects of antipsychotic drugs. The symptoms of this adverse effect are characterized by involuntary contractions of oral and facial muscles. Extrapyramidal symptoms is one the adverse effects of antipsychotic drugs. The symptoms of this adverse effect are involuntary motor symptoms.

A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continous positive airway pressure (CPAP). His vital signs are temp 98.8F, heart rate 118 beat/minute, respirations 46 breaths/minute, blood presure 176/92. While completing the pulmonary assessment, his oxygen reading is 78% and he is difficult to arouse. Which action should the nurse implement? a. Administer PRN nebulizer treatment b. Increase oxygen delivery by 10% c. complete neurological assessment d. Prepare for rapid sequence intubation

ANS - D Prepare for rapid sequence intubation.

The nurse is feeding a client who was admitted this morning wiht syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement? a. Elevate head of bed for 30 minutes after meals. b. Perform oral care before meals. c. Allow small amount of liquids with meals. d. Provide nectar thickened liquids

ANS - D Provide nectar thickened liquids

The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate intervention by the nurse? a. Paresthesia of fingers due to carpal tunnel syndrome. b. Stinging pain related to Plantar fascitis c. Burning pain due to a Morton's neuroma. d. Sharp pain related to a crushed femur.

ANS - D Sharp pain related to a crushed femur.

Which condition should be reported immediately to the primary healthcare provider? a. Pelvic pain immediately after colposcopy b. Light vaginal bleeding for 1 to 2 days following a hysterosalpingogram. c. Rectal bleeding for 2 days after prostate biopsy d. Body Temp 102 F with vaginal discharge 48 hours after cervical biopsy.

ANS - D The client with cervical biopsy should immediately report to the primary healthcare provider if experiencing a body temperature of 102F with vaginal discharge. This is because fever and vaginal discharge that develops 48 hours after cervical biopsy may be signs of infection related to the procedure.

The nurse would expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit what initial symptoms? a. Dull, left lower cramping pain and low grade fever. b. Change in bowel habits, blood in stool and unexplained anemia. c. Rigid board-like abdomen and elevated while blood cell count. d. Diarrhea, abdominal pain, and weight loss.

ANS - Diarrhea, abdominal pain, and weight loss.

11. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? • Use disposable plates and utensils. • Stay in a room with the door closed. • Dispose of soiled dressings in plastic bags that are securely closed. Correct • Others who are in the same room with the client should wear a mask.

ANS - Dispose of soiled dressings in plastic bags that are securely closed. Rationale - Contact precautions require the use of a barrier that prevents contact with wound secretions on soiled dressings, which are best disposed of in tightly closed plastic bags (C). (A) is not necessary with contact precautions. (B and D) should be implemented for airborne, droplet precautions, or protective environments. Category: Fundamentals

16. When making the bed of a client who needs a bed cradle, which action should the nurse include? • Teach the client to call for help before getting out of bed. • Keep both the upper and lower side rails in a raised position. • Keep the bed in the lowest position while changing the sheets. • Drape the top sheet and covers loosely over the bed cradle.

ANS - Drape the top sheet and covers loosely over the bed cradle. Rationale - A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics.

5. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? • Empty the client's urinary drainage bag. • Draw up the irrigating solution into the syringe. • Secure the client's catheter to the drainage tubing. • Use aseptic technique to instill the irrigating solution.

ANS - Draw up the irrigating solution into the syringe. To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time.

18. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? • Take measures to promote as much comfort as possible. • Report any signs of drug addiction to the nurse immediately. • Wait until the client's pain is gone before assisting with personal care. This client's pain will be difficult to manage, since the cause is unknown

ANS - ake measures to promote as much comfort as possible. Correct Rationale - Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause.

15. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? • Encourage the student to associate with non-smokers only while attempting to stop smoking. • Tell the student that he is still young and should continue to try various smoking cessation methods. • Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. • Provide the student with the latest research data describing the long-term effects of tobacco use.

ANS - • Encourage the student to associate with non-smokers only while attempting to stop smoking. Rationale - It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers, so (A) is the most important intervention for the nurse to implement. (B) is not likely to be helpful and offers no concrete suggestions for smoking cessation. (C) is condescending. Risks associated with smoking must already be known to this adolescent who is already attempting to stop the habit (D). Category: Fundamentals

21. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? • Use an electronic sphygmomanometer to take the BP every 30 minutes. • Retake the blood pressure in the same arm, deflating the cuff slowly. • Ask another nurse to recheck the blood pressure to compare results. • Obtain another blood pressure cuff and retake the blood pressure.

ANS = Retake the blood pressure in the same arm, deflating the cuff slowly. Rationale = The nurse should first retake the blood pressure in the right arm, deflating the cuff more slowly (B), because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. There is no indication that the BP needs to be taken frequently (A). If the blood pressure remains low, further assessment is needed, which may include (C). If deflating the cuff slowly does not resolve the discrepancy, the nurse may then need to implement (D). Category: Fundamentals

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin.

ANS A - Observe the appearance of the skin under the ice pack. The first action taken by the nurse should be to assess the skin for any possible thermal injury (A)

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

ANS A - The client voluntarily signed the form. The nurse signs the consent form to witness that the client voluntarily signs the consent. {A) that the client's signature is authentic, and that the client is otherwise competent to give consent.

The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

ANS B - Continue asking the mother questions about the child. Eye contact is a culturally-influenced form of non-verbal communication. In some non-western cultures, such as Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child.

A nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? a. Clamp the tube for 20 minutes b. Flush the tube with water. c. Administer the medications. d. Crush the tablets and dissolve in sterile water.

ANS B - Flush the tube with water. The NGT tube should be flushed before, after and in between each medication administered. (B). Once all medications are administered, the NGT should be clamped for 20 minutes.

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

ANS B - Initiate an alternate site for the IV infusion of the medication. cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated. (b) before issuing the next dose.

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

ANS B - Localized red rash comprised of flat areas, pinpoint to 0.5cm in diameter.

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications". What initial action is most important for the nurse to take? a. Ask about any past history of drug abuse or addiction. b. Measure the pulse volume and capillary refill distal to the infiltration. c. Compress the infiltrated tissue to measure the degree of edema. d. Evaluate the extent of ecchymosis over the forearm area.

ANS B - Measure the pulse volume and capillary refill distal to the infiltration. Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity.

During resuscitation of a critically injured client in a bomb blast, the nurse finds the client is breathing spontaneously. Which nursing intervention would the nurse perform in this situation? a. Inserting an endotracheal tube b. Providing non-rebreather mask c. Providing mechanical ventilation d. Providing bag-valve-mask (BVM) ventilation

ANS B - Providing non-rebreather mask. A non-rebreather mask is used in spontaneously breathing clients. Providing an endotracheal tube and mechanical ventilation is beneficial in clients with significantly impaired consciousness.

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

ANS C - Examining a chest x-ray obtained after the tubing was inserted.

8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A)Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. * C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over.

The correct answer is C: The flow of life is believed to flow through major pathways or nerve clusters in your body.

53. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure

The correct answer is C: improved respiratory status and increased urinary output

91. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors

The correct answer is C:Visitors should wash their hands before and after touching the client

69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well."

The correct answer is D: "I always make sure to shake the NPH bottle hard to mix it well."

16. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A)"I knew this would happen. I've been eating too much red meat lately." B)"I really enjoyed my fishing trip yesterday. I caught 2 fish." C)"I have really been working hard practicing with the debate team at school." D)"I went to the health care provider last week for a cold and I have gotten worse."

The correct answer is D: "I went to the doctor last week for a cold and I have gotten worse."

86. After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

19. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

The correct answer is D: A preschooler with intermittent episodes of alertness

93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia

The correct answer is D: Altered patterns of urinary elimination related to nocturia

62. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides

The correct answer is D: Application of pediculicides

38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene

The correct answer is D: Assist with oral hygiene

71. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato

The correct answer is D: Baked potato.

80. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall

The correct answer is D: Bed in lowest position, wheels locked, place bed against wall

44. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage

The correct answer is D: Continue to monitor the rate of drainage

25. A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.

The correct answer is D: Fibroids that cause no problems still need to be taken out.

58. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube Skip

The correct answer is D: Flush adequately with water before and after using the tube

21. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

The correct answer is D: Hair loss

95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces

The correct answer is D: Have gloves on while handling bedpans with feces

24. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

The correct answer is D: I went to the bathroom and my urine looked very red and it didn't hurt when I went.

1. Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

The correct answer is D: Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

56. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days Skip

The correct answer is D: No bowel movement for 3 days

60. Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding

The correct answer is D: Occult bleeding

18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

The correct answer is D: Pupil responses

32. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L

The correct answer is D: Serum potassium 6 mEq/L

52. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation

The correct answer is D: prevent the drug from tissue irritation

35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

The correct answer is D: restlessness

2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight

The correct answer is D: weekly weight

A nurse on the day shift is assigned to care for four clients. List the clients in order of priority for nurse.

The correct order is: A client with asthma who had shortness of breath during the night A client scheduled to have a chest x-ray at 9 am A client scheduled for an echocardiogram at 10 am A client with pneumonia who is scheduled for discharge home

The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. The nurse should perform these actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

The correct order is: Documenting the findings Obtaining vital signs/oxygen saturation Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate Notifying the health care provider Stopping the infusion of blood

A nurse hears someone calling, "Help! My bed is on fire!" On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take:

The correct order is: Removing the client from the room Pulling the nearest fire alarm Closing the door to the room Running to get the nearest fire extinguisher

Place in order of priority the actions that the nurse should take to perform hand-washing procedure.

The correct order is: Wet the hands and wrists, keeping the hands lower than the elbows. Obtain 3 to 5 mL of soap from the dispenser. Wash all surfaces for 15 to 30 seconds. Rinse the hands and wrists. Dry the hands. Turn off the water faucet.

B Rationale: Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

D Rationale: The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender or age, even when not using the client's name.

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.

B Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns

D Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be threatening to an older client and will not determine his ability. Option C is not as effective as direct observation by the nurse.

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted.

C Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication.

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication.

D Rationale: The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following.

C Rationale: A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"

.A Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement.

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider

B Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

A, D Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.

B Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity

B Rationale: His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her.

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.

C Rationale: The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.

A Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications.

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.

A clieint is brought to the emergency room following a burn injury. On assessment the nurse notes that the client's eyebrow and nasal hairs are singed. The nurse would identify this type of burn as:

Thermal

A-fib and A-flutter

Thrombus formation

A nurse provides instructions to the client who received cryosurgery for a local stage 0 cervical tumor. The nurse tells the client.

To avoid tub baths.

Stroke

Tongue points toward side of lesion (paralysis) Uvula deviates away from the side of lesion (paralysis)

TB

Treatment with multidrug regimen for 9 months; Rifampin reduces the effectiveness of OC's and turn pee orange. Isoniazide (INH) increases Dilantin blood levels

Pulmonary air embolism prevention

Trendelenburg (HOB down); place on left side (to trap air in right side of heart)

Cardiac enzymes

Troponin (1hr), CKMB (2-4hrs), Myoglobin (1-4hrs), LDH1 (12-24hrs)

NG tube

Turn off NG suction for 30 minutes after PO meds

Demyelination

Tx with ACTH corticosteroids, Cytoxan and other immunosuppressants

MI (Myocardioinfarction)

Tx: Nitro = Yes, No Digoxin, Betablockers, Atropine

BPH

Tx: TURP (Transurethral Resection of Prostate); some blood for 4 days and burning for 7 days post TURP

Bloody diarrhea

Ulcerative colitis

Thoracocentesis (thoracentesis)

Unaffected side, HOB 30-45 degrees

Defibulator patches

Under the left breast and on top of the right breast

Contact precautions

Universal + goggles; Mask and gown No infection patients with immunosuppressed patients

S. Blakemore tube ( Sengstaken-Blakemore tube)

Usually for esophageal varices; sudden respiratory distress-cut inflation tube and remove

The healthcare provider prescribes oxytocin synthetic (Pitocin) 10 units via IV drip to augment a client's labor because she is experiencing a prolonged active phase. Because the client is receiving Pitocin, the nurse should closely monitor for which complication?

Uterine tetany (extremely prolonged contractions)

Post-op Monitoring

VS and BP every 15 min the first hour, every 30 min next 2 hours, every hour the next 4 hours, then every 4 hours prn

Inevitable miscarriage

Vaginal bleeding without passage of tissue yet, open cervix *often has ROM

Removing chest tube

Valsalvas, or deep breath and hold

Dysarthria

Verbal enunciation/articulation

The practical nurse LPN reports the patterns of urinary frequency and volume for several clients. Which finding necessitates assessment by the RN?

Voiding 50ml of cloudy urine a day

Brain tumor

Vomiting not associated with nausea

Precautions & room assignments/Universal precautions...HIV initiated

Wash hands Wear gloves Gown for splashes Mask and eye protection for splashes and droplets Don't recap needles Mouthpiece or ambu-bag for resuscitation Refrain from giving care if you have skin lesions

Potassium sparing diuretic: Aldactone (Spironolactone)

Watch for hyperkalemia with this ACE inhibitor

Opiate (Heroin, Morphine, etc.) withdrawal

Watery eyes, runny nose, dilated pupils, NVD, cramps

Gullain-Barre Syndrome

Weakness progresses from legs upward/resp arrest

Myesthenia Gravis: Myesthenic crisis

Weakness with change in vitals (give more meds)

Cholinergic crisis

Weakness with no change in vitals (reduce meds)

B Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall.

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

C Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive.

When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised.

A Rationale: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.

D Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.

C Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

D Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it.

When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

B Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.

B Rationale: Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client's primary language, so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching. Family members should not be used to translate instructions because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter to ensure that the nurse's instructions are understood accurately by the client.

Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions.

A Rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

Which client is most likely to be at risk for spiritual distress? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement

C Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour.

D Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.

A Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.

Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair.

A Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications.

A Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."

A nurse providing preoperative information to a client scheduled for a laser trabecloplasty for the treatment of primary open-angle glaucoma. Which information would the nurse provide to the client?

You may return to work 1 to 2 days following procedure.

A client receives an IV heparin infusion at 22 mL/hr through an infusion pump. The IV bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. How many units of heparin is the client receiving during an 8-hour shift? Calculate and record the answer in the box.

Your Response: Correct Response: 8800 units 50 units heparin/1 mL 50 units x 22 = 1100 units per hour 1100 units x 8 = 8800 units heparin

D Rationale: The client's recognition of a "new" pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client's feelings C should be acknowledged, but observation of the five rights of medication administration is most essential.

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."

B Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B.

The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months

D Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.

A Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level

B Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings.

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28

B Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."

B Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake

A Rationale: Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.

PT

(Coumadin/Warfarin) 11-12.5 sec (INR and PT TR= 1.5-2 times normal)

The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? 1. "I have been sleeping 6 hours at night." 2. "I have lost 2 lbs in the past week." 3. "Lately, I have trouble watching television." 4. "I have much less muscle tension now."

1) CORRECT - Assessment: outcome desired; clients with depression may have increased or decreased sleep time 2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression 3) Assessment: outcome not desired; lack of concentration is sign of depression 4) Assessment: outcome not desired; is a sign of anxiety

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inflated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.

1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement 2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection 3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures 4) Implementation: outcome not desired; increases the risk of trauma to lower airways

The nurse teaches a client about foods and beverages that may be consumed on a low- sodium diet. Which beverage, if selected by the client, indicates an understanding of the instructions? 1. Lemonade. 2. Skim milk. 3. Ginger ale. 4. Tomato juice.

1) CORRECT- Implementation: outcome desired; 1 cup = 2 mg Na+ 2) Implementation: outcome not desired; 1 cup = 125 mg; high Na+ in milk products 3) Implementation: outcome not desired; 1 cup = 60 mg; high Na+ in carbonated beverages 4) Implementation: outcome not desired; 1 cup = 500 mg; extremely high Na+

A woman with a diagnosis of Alzheimer's disease is admitted to the hospital for treatment of an upper respiratory tract infection. On admission, she is incontinent of urine. When assigning the client to a room on the nursing unit, which location would be BEST? 1. A semi-private room near the nurse's station. 2. A private room near the nurse's station. 3. A private room away from the nurse's station. 4. A semi-private room away from the nurse's station.

1) CORRECT-Implementation: outcome desired and priority; stimulation helps with orientation; allows for frequent assessment 2) Implementation: outcome not desired; meets safety needs but lacks environmental stimulation 3) Implementation: outcome not desired; client should be frequently assessed and needs stimulation 4) Implementation: outcome not desired; does provide environmental stimulation but client should be frequently assessed

The nurse teaches a client who is lactose-intolerant about some alternative ways to maintain an adequate diet. The nurse will suggest the client include which food items in the diet? 1. Tofu and green leafy vegetables. 2. Beef and tomato salad. 3. Cottage cheese and yogurt. 4. Custard and mashed potatoes.

1) CORRECT-Implementation: outcome desired; good sources of calcium 2) Implementation: outcome not desired; contain no calcium 3) Implementation: outcome not desired; contain lactose 4) Implementation: outcome not desired; made with milk; contain lactose

The nurse reviews room assignments for 4 clients admitted to the unit. The nurse should question which room assignment? 1. A child with chickenpox placed in a private room at the end of the hall. 2. A child with meningitis placed in a private room across from the nurses' station. 3. A client with cellulitis of the right leg placed in a semi-private room with a client diagnosed with type 1 diabetes. 4. A client with essential hypertension placed in a semi-private room with a client who has pancreatitis.

1) Implementation: outcome desired; communicable disease, appropriate room placemen 2) Implementation: outcome desired; communicable disease, requires frequent assessment; client at risk for seizures 3) CORRECT- Implementation: outcome not desired; don't put a client with infection (cellulitis) with a client who is at risk for infection 4) Implementation: outcome desired; appropriate placement, no cross-contamination

The nurse instructs a client on 100 mg losartan (Cozaar) and 25 mg hydrochlorothiazide (Hyzaar 100-25) tablets to be taken once daily. Which statement requires an intervention by the nurse? 1. "I will eat more fresh fruits while taking this medication." 2. "I should call my health care provider if I develop swelling of my lips." 3. "I can take this medication with or without food." 4. "I understand that I may develop a dry cough while taking this medication."

1) Implementation: outcome desired; hydrochlorothiazide is potassium-wasting diuretic 2) Implementation: outcome desired; angiotensin receptor blockers (ARBs) may cause angioedema 3) Implementation: outcome desired; may be taken with or without food 4) CORRECT- Implementation: outcome not expected; dry, nonproductive cough may occur with angiotensin-converting enzyme inhibitors (ACE inhibitors), not ARBs

A mother brings her 15-month-old infant to the pediatric clinic for immunizations. The mother tells the nurse that the infant has been diagnosed with cancer and is being treated with chemotherapy. The nurse should question the administration of immunization? 1. Hepatitis B (HB). 2. Measles/mumps/rubella (MMR). 3. Inactivated polio (IPV). 4. Diphtheria, tetanus toxoid, and acellular pertussis (DTaP).

1) Implementation: outcome desired; no contraindication 2) CORRECT- Implementation: outcome not desired; live virus, not given to immunosuppressed clients 3) Implementation: outcome desired; no contraindication 4) Implementation: outcome desired; contraindication includes encephalopathy within 7 days

The nurse teaches elderly residents of an assisted-living facility about wellness and health promotion. The nurse is MOST concerned about which statement by one of the residents? 1. "My health care provider tells me I may need the chickenpox vaccine." 2. "I get my flu shot every year in November at a local pharmacy." 3. "I got a pneumonia vaccine about 10 years ago." 4. "The last time I got an injection in my arm, it felt hot and swollen for a day."

1) Implementation: outcome may be desired but is not priority; varicella vaccine recommended for adults who are not immune to varicella or who are immunocompromised; need further assessment 2) Implementation: outcome desired but not priority; should be given earlier in the winter; yearly influenza vaccine recommended for older adults 3) CORRECT- Implementation: outcome not desired and is problem; vaccine 6 years ago or more needs to be repeated; elderly at great risk for streptococcal pneumonia 4) Implementation: outcome: needs follow-up but not of MOST concern.

A mother brings her 2-month-old infant to the emergency room. The mother states that her daughter has an elevated temperature and "hasn't kept anything down since yesterday." Which nursing action is MOST appropriate? 1. Administer 0.9% NaCl at 30 mL/hour. 2. Inquire if the child was delivered prematurely. 3. Offer the infant 4 oz of oral rehydration solution (ORS). 4. Ask if the child's older siblings have been ill.

1) Implementation: outcome not desired at this time; offer oral rehydration therapy first; continue to assess fluid and electrolyte balance; may use if severe dehydration or shock noted 2) Assessment: outcome not priority; need to meet physical needs for fluids to prevent or treat dehydration 3) CORRECT- Implementation: outcome desired; offer oral rehydration therapy first with moderate dehydration 4) Assessment: outcome not priority

The home care nurse instructs the daughter of a client diagnosed with congestive heart failure. The daughter states her father is taking digoxin (Lanoxin) 0.25 mg and the healthcare provider just prescribed furosemide (Lasix) 40 mg. Which statement, if made by the daughter to the nurse, indicates teaching is successful? 1. "I'm glad that Dad doesn't have to change his diet." 2. "Dad is going to have to eat more cottage cheese and add some more salt to his diet." 3. "Dad must increase his intake of cheese and yogurt." 4. "I should encourage Dad to eat more fresh fruits and vegetables."

1) Implementation: outcome not desired; Lasix is a potassium-wasting diuretic, hypokalemia may precipitate digitalis toxicity 2) Implementation: outcome not desired; high in sodium, would increase fluid retention 3) Implementation: outcome not desired; high in calcium, no indication to increase calcium in the diet; dairy products are high in sodium 4) CORRECT-Implementation: outcome desired; good source of potassium, decreased potassium can predispose to digitalis toxicity

The nursing team consists of two RNs, one LPN/LVN, and one nursing assistive personnel. The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which task? 1. Ambulate a client 8 hours after a thoracotomy. 2. Give an enema to a client prior to a colonoscopy. 3. Complete a bed bath for a client with burns on the arms and legs. 4. Perform a dressing change on a client 3 days after a cholecystectomy.

1) Implementation: outcome not desired; RN needs to frequently assess and evaluate 2) Implementation: outcome not desired; standard, unchanging procedure, assign to assistive personnel 3) Implementation: outcome not desired: high risk of infection and sepsis, RN can do thorough assessment during bath 4) CORRECT- Implementation: outcome desired; stable client with an expected outcome

A client is admitted to a medical unit with a diagnosis of pneunocystis jiroveci pneumonia. A nurse from another client care area asks the nurse caring for this client about the client's condition. Which is the MOST appropriate statement for the nurse to make? 1. "I will give a brief report on the client's condition in private." 2. "You can get an update by reading the client's chart." 3. "I cannot discuss this client's condition with you." 4. "Why do you want to know about this client's condition?"

1) Implementation: outcome not desired; breaks confidentiality 2) Implementation: outcome not desired; breaks confidentiality 3) CORRECT- Implementation: outcome desired; keep information confidential 4) Assessment: outcome not priority; no need to ask this

The nurse feeds the client in a chair when the client suddenly begins to choke on food. The client is conscious but unable to speak. Which action is MOST appropriate for the nurse to take? 1. Encourage the client to cough and breathe deeply. 2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind. 3. Return the client to the bed and apply vigorous abdominal or chest thrusts while straddling the client's thighs. 4. Apply several vigorous back blows until the food dislodges.

1) Implementation: outcome not desired; can't inhale, can't exert enough pressure 2) CORRECT-Implementation: outcome desired; abdominal thrust maneuver appropriate when client not moving air 3) Implementation: outcome not desired; no time to do this 4) Implementation: outcome not desired; could cause increased problems; food could migrate further into respiratory tract

The nurse observes a peer self-administering fentanyl (Sublimaze) after removing it from the narcotic cabinet. Which is the MOST appropriate action for the nurse to take? 1. Tell the nurse what was observed. 2. Report the observation to the supervisor. 3. Complete an incident report. 4. Discuss the incident with another nurse.

1) Implementation: outcome not desired; inappropriate; is confrontational 2) CORRECT- Implementation: outcome desired; use chain of command 3) Implementation: outcome not desired; not appropriate for situation 4) Implementation: outcome not desired; inappropriate; confidential information

The nurse cares for a client after a lumbar laminectomy. Which action by the nurse is MOST important? 1. Elevate the head of the bed 30° and then turn the client. 2. Place a pillow between the client's legs and then turn the client. 3. Have the client grasp the side rail on the opposite side of the bed and then assist the client to turn. 4. Instruct the client to bend the knees and then assist the client to turn.

1) Implementation: outcome not desired; must stay flat to maintain alignment 2) CORRECT-Implementation: outcome desired; log roll repositioning maintains proper alignment of spine 3) Implementation: outcome not desired; no twisting allowed 4) Implementation: outcome not desired; no twisting allowed

A nurse is presented with a group of clients in the emergency room. The nurse knows that which of the following clients needs immediate attention? 1. A child who is bleeding from a facial injury. 2. A middle-aged client with midsternal chest pain. 3. A middle-aged client in respiratory distress. 4. An infant who has been vomiting for 8 hours.

1) Not usually life-threatening 2) Could be angina; see second 3) CORRECT-Most unstable client; check airway, breathing (ABCs) 4) Potential for dehydration; needs further assessment; should not see first

Specific gravity

1.005-1.030

The health care provider's prescription reads, "Phenytoin 0.1 g by mouth twice daily." The medication label indicates that the bottle contains 100-mg capsules. How many capsules does the nurse prepare for administration of one dose?

1.1

Magnesium

1.5-2.5

Quickening

14-20 weeks

Platelets

150-400k

throws ball overhand

18 months

Burn degrees

1st Degree - Red and Painful 2nd Degree - Blisters 3rd Degree - No Pain because of blocked and burned nerves

2-3 word sentences

2 years

50% of adult height

2 years

Intermediate stage

2-24 hours post-op

uses scissors

4 years

WBC's

4.5-11k

ties shoes

5 years

Turns over

5-6 months

ANS - An adult client with renal insufficiency has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietician and then plans to allow the client to have how many mL of fluid from 7:00 a.m. to 3:00 p.m.?

600ml

hand to hand transfer

7 months

Glucose

70-100

sits unsupported

8 months

Ca++

9-10.5

few words

9-12 months

Cl-

96-106

A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? A. 7% B. 9% C. 10% D. 15%

A. 7%

A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first? A. Beginning chest compressions B. Checking the client's pulse oximetry reading C. Placing an oxygen mask on the client D. Counting the client's carotid pulse for 15 seconds

A. Beginning chest compressions

A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? A. Bleeding B. Renal colic C. Infection at the site D. Increased temperature

A. Bleeding

A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine? Select all that apply. A. Plums B. Prunes C. Apples D. Broccoli E. Cabbage F. Cranberries

A. Plums B. Prunes F. Cranberries

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply. A. Removing the IV catheter at that site B. Applying warm, moist compresses to the IV site C. Notifying the health care provider about the finding D. Encouraging the client to scrub the site while in the shower E. Starting a new IV line in a proximal portion of the same vein

A. Removing the IV catheter at that site B. Applying warm, moist compresses to the IV site C. Notifying the health care provider about the finding

A nurse provides dietary instructions to the mother of a child with celiac disease. Which food does the nurse tell the mother to include in the child's diet? A. Rice B. Wheat cereal C. Rye crackers D. Oatmeal biscuits

A. Rice

A nurse is providing dietary instructions to a client taking spironolactone. Which foods does the nurse instruct the client are acceptable to consume?Select all that apply. A. Rice B. Cereal C. Carrots D. Bananas E.Citrus fruits

A. Rice B. Cereal C. Carrots

Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. A. Saving vomitus for laboratory analysis B. Placing the client in the supine position C. Determining the type and amount of substance ingested D. Removing any visible materials from the nose and mouth E. Inducing vomiting if a household cleaner has been ingested F. Assessing the client's airway patency, breathing, and circulation

A. Saving vomitus for laboratory analysis C. Determining the type and amount of substance ingested D. Removing any visible materials from the nose and mouth F. Assessing the client's airway patency, breathing, and circulation

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. A. Setting the suction pressure to 60 mm Hg B. Applying suction throughout the procedure C. Assessing breath sounds before suctioning D. Placing the client in a supine position before the procedure E. Hyperoxygenating the client with 100% oxygen before suctioning

A. Setting the suction pressure to 60 mm Hg B. Applying suction throughout the procedure D. Placing the client in a supine position before the procedure

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse tells the client that: A. She will need to sign an informed consent form B. Her mother or father will need to be contacted for permission to treat her C. Anyone over the age of 18 years may sign a consent form for her treatment D. A consent form is not needed if the problem is a sexually transmitted infection

A. She will need to sign an informed consent form

The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply. A. Spaghetti with fresh tomatoes B. Boiled lobster with baked potato C. Grilled chicken with turnip greens D. Instant hot cereal with bacon E. Tomato soup with a ham sandwich

A. Spaghetti with fresh tomatoes C. Grilled chicken with turnip greens

A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? A. Xerosis B. Pruritus C. Seborrhea D. Actinic keratoses

A. Xerosis

A elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgement? a. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. b. The nurse assigned to care for the client who was at lunch at the time of the fall. c. The nurse who transferred the client to the chair when the fall occurred. d. The charge nurse who completed round 30 minutes before the fall occurred.

ANS - C. The nurse who transferred the client to the chair when the fall occurred. The four elements of malpractice are: 1. breach of duty owed. 2. Failure to adhere to the recognized standard of care. 3. Direct causation of injury, and 4. evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring" C implies that duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B and D).

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

ANS - D - gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface.

6. Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? • Removing the empty food tray from a client with a urinary catheter. • Washing and combing the hair of a client with a fractured leg in traction. • Administering oral medications to a cooperative client with a wound infection. • Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Correct

ANS - Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Rationale - possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves.

20. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? • Use distraction techniques during times of spiritual stress and crisis. • Reassure the client that his faith will be regained with time and support. • Consult with the staff chaplain and ask that the chaplain visit with the client. • Use reflective listening techniques when the client expresses spiritual doubts.

ANS - Use reflective listening techniques when the client expresses spiritual doubts. Rationale - The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C).

12. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? • Fiber. • Folate. • Ascorbic acid. • Vitamin B12

ANS - Vitamin B12 Rationale - Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegetables and fruits.

The nurse leader suffers from headaches, hypertension, and gastrointestinal problems. Which affirmative statement by the leader reflects an appropriate way to manage the stress? a. I will avoid protein b. I will plan a vacation c. I will get enough sleep d. I will participate in support groups.

ANS C - I will get enough sleep Headache, hypertension and gastrointestinal problems indicate physical stress in the leader. Stress can be managed by getting enough sleep. The leader should consume protein in moderate amounts. Planning a vacation would help in managing mental stress. Participating in support groups would help to manage this type of stress.

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

ANS D - 500mL/5mg x 1mg/1000mcg x 30mcp/1min x 60 min/hr. = 180mL/hr.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

ANS D - Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distension.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

ANS D - Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D)

The nurse performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? a. Encourage the client to cough to help loosen secretions. b. Advise the client to increase the intake of oral fluids. c. Rotate the suction catheter to obtain any remaining secretions. d. Re-oxygenate the client before attempting to suction again.

ANS D - Re-oxygenate the client before attempting to suction again. Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. (D) may be performed after the client is re-oxygenated and additional suctioning is performed.

Nurses Lab Q4: What question would be most important to ask a male client who is in for a digital rectal examination? A. "Have you noticed a change in the force of the urinary system?" B. "Have you noticed a change in tolerance of certain foods in your diet?" C. "Do you notice polyuria in the AM?" D. "Do you notice any burning with urination or any odor to the urine?"

ANSWER: A. "Have you noticed a change in the force of the urinary system?" RATIONALE: This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy.

Nurses Lab Q19: Which of these statements, when made by the nurse, is most effective when communicating with a 4-year-old? A. "Tell me where you hurt." B. "Other children like having their blood pressure taken." C. "This will be like having a little stick in your arm." D. "Anything you tell me is confidential."

ANSWER: A. "Tell me where you hurt." RATIONALE: Four-year-olds are egocentric and interested in having the focus on themselves. They will not be interested in what it feels like to other children. Preschoolers are concrete thinkers and would literally interpret any analogies so they are not helpful in explaining procedures. Assurance of confidential communication is most appropriate for the adolescent. In addition, confidentiality is not maintained if the child plans to harm themselves, harm someone else, or discloses abuse.

Nurses Lab Q13: The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? A. Formula or breast milk B. Dilute nonfat dry milk C. Warmed fruit juice D. Fluoridated tap water

ANSWER: A. Formula or breast milk RATIONALE: Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.

Nurses Lab Q8: While performing a physical examination on a newborn, which assessment should be reported to the physician? A. Head circumference of 40 cm B. Chest circumference of 32 cm C. Acrocyanosis and edema of the scalp D. Heart rate of 160 and respirations of 40

ANSWER: A. Head circumference of 40 cm RATIONALE: Average circumference of the head for a neonate ranges between 32 to 36 cm. An increase in size may indicate hydrocephaly or increased intracranial pressure.

Nurses Lab Q15: The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A. Hold a rattle B. Bang two blocks C. Drink from a cup D. Wave "bye-bye"

ANSWER: A. Hold a rattle RATIONALE: The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.

Nurses Lab Q9: Which action by the mother of a preschooler would indicate a disturbed family interaction? A. Tells her child that if he does not sit down and shut up she will leave him there. B. Explains that the injection will burn like a bee sting. C. Tells her child that the injection can be given while he's in her lap. D. Reassures child that it is acceptable to cry

ANSWER: A. Tells her child that if he does not sit down and shut up she will leave him there. RATIONALE: Threatening a child with abandonment will destroy the child's trust in his family.

Nurses Lab Q5: The nurse assesses a prolonged late deceleration of the fetal heart rate while the client is receiving oxytocin (Pitocin) IV to stimulate labor. The priority nursing intervention would be to: A. Turn off the infusion B. Turn the client to the left C. Change the fluid to Ringer's Lactate D. Increase mainline IV rate

ANSWER: A. Turn off the infusion RATIONALE: Stopping the infusion will decrease contractions and possibly remove uterine pressure on the fetus, which is a possible cause of the deceleration.

Nurses Lab Q25: A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to A. increase her fluid intake to three liters/day. B. request a prescription for a laxative from her physician. C. stop taking iron supplements. D. take two tablespoons of mineral oil daily.

ANSWER: A. increase her fluid intake to three liters/day. RATIONALE: In pregnancy, constipation results from decreased gastric motility and increased water reabsorption in the colon caused by increased levels of progesterone. Increasing fluid intake to three liters a day will help prevent constipation. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Iron supplements are necessary during pregnancy, as ordered, and should not be discontinued. The client should increase fluid intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are not recommended because of the possible development of laxative dependence or abdominal cramping. Mineral oil is especially bad to use as a laxative because it decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near mealtimes.

Nurses Lab Q6: Which nursing approach would be most appropriate to use while administering an oral medication to a 4 month old? A. Place medication in 45cc of formula B. Place medication in an empty nipple C. Place medication in a full bottle of formula D. Place in supine position. Administer medication using a plastic syringe

ANSWER: B. Place medication in an empty nipple RATIONALE: This is a convenient method for administering medications to an infant. Option D is partially correct however, the infant is never placed in a reclining position during a procedure due to a potential aspiration.

Nurses Lab Q16: The nurse should recognize that all of the following physical changes of the head and face are associated with the aging client except: A. pronounced wrinkles on the face. B. decreased size of the nose and ears. C. increased growth of facial hair. D neck wrinkles.

ANSWER: B. decreased size of the nose and ears. RATIONALE: The nose and ears of the aging client actually become longer and broader. The chin line is also altered. Wrinkles on the face become more pronounced and tend to take on the general mood of the client over the years. For example laugh or frown wrinkles about the eyebrows, lips, cheeks, and outer edges of the eye orbit. The change in the androgen-estrogen ratio causes an increase in growth of facial hair in most older adults. The aging process shortens the platysma muscle, which contributes to neck wrinkles.

Nurses Lab Q20: A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? A. Explain to the client that the dentures must come out as they may get lost or broken in the operating room B. Ask the client if there are second thoughts about having the procedure C. Notify the anesthesia department and the surgeon of the client's refusal D. Ask the client if the preference would be to remove the dentures in the operating room receiving area

ANSWER: D. Ask the client if the preference would be to remove the dentures in the operating room receiving area RATIONALE: Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.

Nurses Lab Q21: The nurse is assessing a client who states her last menstrual period was March 17, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? A. November 8 B. May 15 C. February 21 D. December 24

ANSWER: D. December 24 RATIONALE: Naegele's rule: add 7 days and subtract 3 months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

Nurses Lab Q12: When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? A. Competitive board games with older children B. Playing with their own toys along side with other children C. Playing alone with hand held computer games D. Playing cooperatively with other preschoolers

ANSWER: D. Playing cooperatively with other preschoolers RATIONALE: Playing cooperatively with other preschoolers. Cooperative play is typical of the late preschool period.

Nurses Lab Q2: Which technique would be best in caring for a client following receiving a diagnosis of a state IV tumor in the brain? A. Offering the client pamphlets on support groups for brain cancer B. Asking the client if there is anything he or his family needs C. Reminding the client that advances in technology are occurring everyday D. Providing accurate information about the disease and treatment options

ANSWER: D. Providing accurate information about the disease and treatment options RATIONALE: Providing information for the client is the best technique for a new diagnosis.

A client is taking lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. The nurse evaluates that the client best understands the disorder and medication regime if the client states that he or she should take which of the following products for pain?

Acetaminophen (Tylenol) Zollinger-Ellison syndrome - is a complex condition in which one or more tumors form in your pancreas or the upper part of your small intestine (duodenum). These tumors, called gastrinomas, secrete large amounts of the hormone gastrin, which causes your stomach to produce too much acid. The excess acid, in turn, leads to peptic ulcers.

Post Strep URI diseases and conditions:

Acute glomerulonephritis (triggered by immunologic mechanism), rheumatic fever (valve disease), Scarlet fever

Ca++ channel blockers

Avoid grapefruit juice

A dying client says to the nurse, "How do I tell my parents that I am dying of AIDS ?" Which statement by the nurse would be therapeutic? A. "Well, isn't it better that they learn from you than for them to learn on their own?" B. "Sounds as if you're thinking that it's time for you to tell your parents about your disease." C. "I've worked with this illness for many years now, and there just doesn't seem to be an easy way to do this." D. "Are you saying that your parents don't know about your illness?"

B. "Sounds as if you're thinking that it's time for you to tell your parents about your disease."

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem worth it anymore. Why shouldn't I just end it all?" Which statement should the nurse use to gather additional data from the client? A. "Did you sleep at all last night?" B. "Tell me what you mean by that." C. "I know you've had a stressful night." D. "I'm sure that your family is worried about you."

B. "Tell me what you mean by that."

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply. A. "Accountability can be delegated." B. "You are responsible for your own actions." C. "It carries legal implications for task performance." D. "You must answer for the care that you ask others to complete." E. "It refers to the process of answering or being responsible for what occurs."

B. "You are responsible for your own actions." C. "It carries legal implications for task performance." D. "You must answer for the care that you ask others to complete." E. "It refers to the process of answering or being responsible for what occurs."

A client says to the nurse, "I don't do anything right. I'm such a loser." What is the appropriate response? A. "Everything will get better." B. "You don't do anything right?" C. "You do things right all the time." D. "You are not a loser; you are sick.

B. "You don't do anything right?"

A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request? A. "Short walks are OK." B. "You need to stay in your room for now." C. "Yes, it's fine to take a walk around the nursing unit." D. "Do you think that a walk around the unit will tire you out?"

B. "You need to stay in your room for now."

A nurse is performing an admission assessment on an older client who will be seen by a health care provider in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. What is the next action the nurse should take? A. Report the client's concern to the health care provider B. Ask the client about medications he is taking C. Document the client's concern in the medical record D. Tell the client that sexual dysfunction is a normal age-related change

B. Ask the client about medications he is taking

The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure

B. Ask the client for permission to lock the necklace in the hospital safe

The nurse developing a plan of care for a client whose spouse recently died determines the client has a problem with dysfunctional grieving. Which priority intervention does the nurse incorporate into the plan? A. Monitoring the client's sleep pattern B. Assessing the client's risk for violence toward self and others health care provider C. Obtaining a health care provider's prescription for an antidepressant D. Assisting the client in resolving the grief through emotional, cognitive, and behavioral means

B. Assessing the client's risk for violence toward self and others health care provider

A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? A. Fulfilling the physician's request B. Discussing the situation with the nurse manager C. Reporting the health care provider to the chief of medicine at the hospital D. Stating to the physician, "I don't really care whether you report me. I am not writing your prescriptions."

B. Discussing the situation with the nurse manager

A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on the data, which action should the nurse take? A. Report the findings to the health care provider B. Document the findings in the medical record C. Ask the health care provider for a prescription for a nighttime sedative D. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours

B. Document the findings in the medical record

A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse should provide the client with which information about the insulin? A. Keep insulin refrigerated at all times B. Draw the regular insulin into the syringe first C. Shake the NPH insulin bottle before mixing the two types D. Remove all of the air from the bottle before mixing the two types

B. Draw the regular insulin into the syringe first

During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing? A. Vagus B. Facial C. Abducens D. Oculomotor

B. Facial

The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first: A. Aiming at the base of the fire B. Pulling the pin on the fire extinguisher C. Squeezing the handle of the extinguisher D. Sweeping from the top to the bottom of the fire with the extinguisher

B. Pulling the pin on the fire extinguisher

A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse? A. Hanging the IV solution as prescribed B. Questioning the health care provider about the prescription C. Diluting the solution with sterile water to half-strength D. Hanging the IV solution but setting the infusion at just half the prescribed rate

B. Questioning the health care provider about the prescription

The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client's record? A. An incident report was completed and filed. B. Ramipril (Altace) 2.5 mg was administered at 9 am. C. Twice the amount of the prescribed ramipril was administered at 9 am. D. Client's blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril.

B. Ramipril (Altace) 2.5 mg was administered at 9 am.

A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related factors does the nurse recognize as increasing blood flow to the kidneys? A. Physiological stress B. Release of dopamine C. Release of norepinephrine D. Sympathetic nervous system stimulation

B. Release of dopamine

For which vitamin deficiency should the nurse monitor the client who is on a vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E

B. Vitamin B12

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat which kind of words? A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the client B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested C. Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested D. Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client

B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested

The nurse employed in a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided? A. Day shift B. Weekdays C. Weekends D. 7 to 10 a.m.

C. Weekends

Bladder infection

Common cause of death (try to keep urine acidic)

(Y )A nurse administers the morning dose of digoxin (Lanoxin) to the client. When the nurse charts the medication, the nurse discovers that a dose of 0.25 mg was administered rather than the prescribed dose of 0.125 mg. The nurse should take which appropriate action?

Complete an incident report

Spinal shock

Complete loss of all reflex, motor, sensory and autonomic activity below the lesion; medical emergency

Neuropathic pain meds

Conanalgesic or adjuvant drugs (anticonvulsants, antidepressants)

Western Blot test

Confirmatory test for HIV infection; + CD4 >200=AIDS

A nurse manager has implemented a change in the method of documenting nursing care. A license practical nurse (LPN) is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following would be the best approach in dealing with the LPN?

Confront the LPN and encourage verbalization of feelings regarding the change.

A nurse manager is implementing a change in the documentation system in the nursing unit. The documentation regarding client care will be made on a computer system rather than in a narrative form. A nurse who is resistant to the change is not taking an active part in facilitating the process of change. Which of the following would be the best initial approach in dealing with the resistance from the nurse?

Confront the nurse about his or her behavior regarding the change.

(Y) A nurse is preparing to administer medications to an assigned client and notes that the order for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the physician to clarify the order and asks the physician to prescribe a dosage within the recommended range. The physician refuses to change the order and instructs the nurse to administer the dose as prescribed. Which of the following actions would the nurse take?

Contact the nurse supervisor

CABG

Coronary Artery Bypass Graft

A home care nurse visits a client who lives in a small apartment to perform an admission assessment. During the home safety assessment, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse? A. "A space heater should never be used in an apartment." B. "A space heater can be used as long as it is kept at a low setting at all times." C. "A space heater can be used as long as it is kept in the bedroom at night in case a fire occurs." D. "A space heater can be used as long as it's placed at least 3 feet from anything that may ignite."

D. "A space heater can be used as long as it's placed at least 3 feet from anything that may ignite."

A 45-year-old client says to the nurse, "Since I left my wife and children, I can hardly make ends meet between child support and trying to support myself. I don't know why I bother going to work when my wife and kids take just about everything I make." Which nursing statement would be therapeutic? A. "I wonder why you left your wife and children." B. "What would you expect your wife and children to do? They didn't leave you." C. "You seem to be very angry about carrying out your responsibility to your children." D. "Do you feel that child support is designed to help children, not punish spouses who leave?"

D. "Do you feel that child support is designed to help children, not punish spouses who leave?"

A client with rheumatoid arthritis is taking high doses of acetylsalicylic acid. While assessing the client for aspirin toxicity, which question should the nurse ask the client? A. "Are you constipated?" B. "Are you having any diarrhea?" C. "Do you have any double vision?" D. "Do you have any ringing in the ears?"

D. "Do you have any ringing in the ears?"

During a nursing interview, a client says, "My daughter was murdered in her apartment, and her estranged husband called to tell me. I can't stop myself from wondering whether he killed her, but the police have ruled him out as a suspect." Which response by the nurse would be therapeutic? A. "Sounds like it." B. "It feels terrible to lose a daughter." C. "I agree. What do you want to bet he did it?" D. "Have you shared your concerns with the police?"

D. "Have you shared your concerns with the police?"

A 16-year-old client says, "My dad thinks I'm evil, but we get into fights because I let things build up. He never has any time for me because he's always glued to the TV. He doesn't even look at me when he talks." Which statement by the nurse encourages the client to use assertive behavior with his father? A. "So you're saying that you let your feelings build up and then you just explode?" B. "Have you tried standing in front of the television when your dad is watching it?" C. "What makes you feel that you have the right to fly off the handle just because you feel ignored?" D. "Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"

D. "Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"

A 12-year-old client who has been reported for drawing sexually explicit scenes in her textbooks during class says to the psychiatric nurse, "I just felt like it." Which response by the nurse would be therapeutic and aid assessment of abuse-related symptoms? A. "Well, a picture paints a thousand words." B. "You just felt like destroying your textbooks?" C. "Your parents and teachers are very concerned about your drawings." D. "I am concerned about you. Are you being or have you ever been abused?"

D. "I am concerned about you. Are you being or have you ever been abused?"

The family of a client who is being discharged after trying to kill himself with one of his father's guns asks for a family meeting with the nurse to discuss their son's situation. Which statement by the nurse would be the most therapeutic start to the meeting? A. "I must begin by saying that I am uncomfortable meeting without your son here to talk for himself." B. "Let's start by introducing ourselves and talking about what is most troubling to each of you about having your son home." C. "Why don't we all introduce ourselves and say what our relationship is to your son? I'll begin, because I'm the nurse who'll be seeing him after he comes home." D. "I am going to begin by talking in general terms about your son's return home and some of the things that might happen. I can suggest measures that might be helpful, and then you can ask questions."

D. "I am going to begin by talking in general terms about your son's return home and some of the things that might happen. I can suggest measures that might be helpful, and then you can ask questions."

A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates theneed for further instruction? A. "I may feel cool while the cast is drying." B. "I shouldn't use anything to scratch underneath the cast." C. "If I smell any odor from the cast, I should call the doctor." D. "I can dry the cast faster if I use a hairdryer on the hot setting."

D. "I can dry the cast faster if I use a hairdryer on the hot setting."

A recently widowed client says, "I lived my whole life for my husband and children. Now he's dead and my daughter and son have each married and moved across the country. They hardly ever call or visit. It's just that there's really nothing much for me to do." Which response by the nurse to the client is appropriate? A. "Your children seem very distant. They hardly ever call?" B. "Are you thinking of hurting yourself just because you're alone?" C. "You're feeling pretty useless right now, but I wonder if you've taken enough time to grieve?" D. "You seem to be identifying some issues in your life that are troubling, and you sound very down right now."

D. "You seem to be identifying some issues in your life that are troubling, and you sound very down right now."

A young woman who has been divorced twice says to the nurse, "I've decided not to date men ever again! It never works out for me. Now I'm left with two children to bring up." Which nursing response would be therapeutic? A. "Oh, me too. I always pick the worst kind of men, so I know just how you feel." B. "Divorce is more difficult for children. Maybe you should focus on them for now." C. "You've been unfortunate, but you seem to be focusing on yourself and what you have to do." D. "You talk about how the divorces affected you. Tell me how your children are dealing with the loss."

D. "You talk about how the divorces affected you. Tell me how your children are dealing with the loss."

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! I'm the one who's dying." Which response by the nurse would be most therapeutic? A. "Have you shared your feelings with your family?" B. "Well, it sounds like you're being pretty pessimistic." C. "I think we should talk more about your anger with your family." D. "You're feeling angry that your family continues to hope for you to be cured."

D. "You're feeling angry that your family continues to hope for you to be cured."

A 45-year-old fireman says to the nurse, "I've worked at some fires recently that were just devastating, but last week was the worst. I carried this little girl from a fire — she was badly burned and lived just a few minutes after I brought her out, and she said to me, 'Tell my mom and Rudy I love them both very much.' Her mom told me that Rudy is their dog, and he just mopes around the house since the little girl died. I keep thinking about her and just don't know if I can go on." Which response by the nurse would be therapeutic? A. "Maybe you could help the mother find a home for Rudy, and then your troubling thoughts would go away." B. "Would you listen to yourself? You've seen firemen stress out before. What is your responsibility in all this?" C. "You've helped victims of some horrific fires lately, and yet you question your calling. Do you feel the need to resign?" D. "You're questioning your job because you're upset about the little girl you tried to save. Work stress can be treated and help you cope better. It is so important for you to seek treatment."

D. "You're questioning your job because you're upset about the little girl you tried to save. Work stress can be treated and help you cope better. It is so important for you to seek treatment."

A client with major depression says to the nurse, "I should have died. I've always been a failure." Which response by the nurse is therapeutic? A. "I see a lot of positive things in you." B. "You still have a great deal to live for." C. "Feeling like a failure is part of your illness." D. "You've been feeling like a failure for some time now?"

D. "You've been feeling like a failure for some time now?"

The slightly overweight mother of a morbidly obese 11-year-old girl says, "My family health care provider is wild over my daughter's weight gain. He says she's not eating correctly and is too sedentary, and now she's at risk for diabetes. He says the sugar in her blood was up this month. It's all my fault because I eat the wrong things, too, and I never get off the couch." Which statement by the nurse would be therapeutic in easing the client's self-blame? A. "Well, it seems very bleak to you, but your daughter is responsible for her eating and exercising, too." B. "What about her father? Isn't it partly his fault, too? I want to meet with you, him, and your daughter tomorrow." C. "It's all this fast food and TV-watching these days. If our kids aren't watching television, they're playing with their computers." D. "Your daughter has a serious problem, but there are many successful programs that you can join with her to lose weight and improve your overall lifestyle."

D. "Your daughter has a serious problem, but there are many successful programs that you can join with her to lose weight and improve your overall lifestyle."

A client with depression says to a nurse, "Why is my family meeting with you? Are you telling them about me?" Which response by the nurse would be therapeutic? A. "Have you talked with your family? What have they said to you about the meetings?" B. "I am committed to keeping everything you say to me confidential, so it is troubling when you accuse me of talking to your family." C. "You sound concerned that I would tell your family something about you even though you know that what we talk about is confidential." D. "Your family is learning about depression and how best to help you so that they can be supportive of you. We do not talk about you or anything confidential about you."

D. "Your family is learning about depression and how best to help you so that they can be supportive of you. We do not talk about you or anything confidential about you."

A client says to the nurse, "I'm worried about my husband. He's talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose — but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is appropriate? A. "Yes, he's too intelligent to end it all." B. "I'm not sure. I don't know him that well." C. "Most people who talk about ending it all are just looking for attention." D. "Your husband is displaying behaviors that indicate a risk for self-harm."

D. "Your husband is displaying behaviors that indicate a risk for self-harm."

The parents of a 20-year-old who was killed while driving drunk say to the nurse, "We're so devastated, but we are also angry that she would drink and drive when we told her over and over not to." Which statement by the nurse would be therapeutic? A. "Young people don't always obey their parents." B. "Everyone feels guilt or anger when they lose a loved one." C. "Does anyone in the family have a drinking or drug problem?" D. "Your sadness over losing your daughter is mixed with anger at her driving while intoxicated."

D. "Your sadness over losing your daughter is mixed with anger at her driving while intoxicated."

A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be administered? A. 250 mL B. 500 mL C. 750 mL D. 1000 mL

D. 1000 mL

A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? A. 6 weeks B. 8 weeks C. 12 weeks D. 16 weeks

D. 16 weeks

A nurse is administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag? A. 4 inches B. 8 inches C. 10 inches D. 18 inches

D. 18 inches

A nurse provides information to a client about the importance of consuming fluids every day. If the client has no renal or cardiac disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client consume each day? A. 500 to 1000 mL B. 1000 to 1500 mL C. 1500 to 2000 mL D. 2000 to 2500 mL

D. 2000 to 2500 mL

The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct? A. 15:1 B. 15:2 C. 20:2 D. 30:2

D. 30:2

A nurse is working in the emergency department. Which client should be assessed first? A. A client with new-onset dizziness B. A client admitted with a recent ear injury C. A client who has been experiencing nausea and vomiting for 12 hours D. A client with new-onset atrial fibrillation with a rate of 118 beats/min

D. A client with new-onset atrial fibrillation with a rate of 118 beats/min

A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (unlicensed assistive personnel)? A. A client scheduled for a cardiac stress test B. A client who had a mastectomy 2 days ago C. A client scheduled for a laparoscopic cholecystectomy D. A client with renal calculi whose urine must be strained

D. A client with renal calculi whose urine must be strained

A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line-related sepsis is diagnosed. The nurse interprets this finding as meaning that this infection is: A. An iatrogenic infection B. A result of bacterial colonization C. A community-acquired infection D. A healthcare-associated infection

D. A healthcare-associated infection

A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse should select an activity that will assist is developing which psychosocial stage? A. Initiative B. Autonomy C.A sense of trust D. A sense of industry

D. A sense of industry

A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy. Which laboratory finding prompts the nurse to initiate neutropenic precautions? A. A clotting time of 10 minutes B. An ammonia level of 20 mcg N/dL (14.6 μmol N/L) C. A platelet count of 100 × 103/μL (100× 109/L). D. A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

D. A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

A nurse is preparing a list of measures that will help promote sleep. Which measures that would be included on the list? Select all that apply. A. Exercise just before bedtime. B. Drink a glass of wine at bedtime. C. Drink a cup of black tea before bedtime. D. Adjust the room temperature to a comfortable level. E. Eliminate lights, noise, and other environmental distractions. F. Get up at the same time each day and avoid naps during the day.

D. Adjust the room temperature to a comfortable level. E. Eliminate lights, noise, and other environmental distractions. F. Get up at the same time each day and avoid naps during the day.

An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A. Inserting a Foley catheter B. Initiating an intravenous (IV) line C. Cleansing the burn wound D. Administering 100% humidified oxygen

D. Administering 100% humidified oxygen

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client's deltoid muscle. The RN determines that the LPN is performing the procedure correctly if the LPN: A. Administers the injection in the thigh B. Places the client in the Sims position C. Positions the client in a prone toe-in position D. Administers the injection 2 inches below the acromion process

D. Administers the injection 2 inches below the acromion process

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive? A. Belt B. Wrist C. Elbow D. Ambularm

D. Ambularm

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse provides instruction regarding foods to avoid. Which menu choice by the client indicates to the nurse that the client needs further instruction? A. Fish B. Spinach C. Rhubarb D. American cheese

D. American cheese

A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse? A. Neck B. Wrist C. Behind the knee D. Antecubital fossa of the arm

D. Antecubital fossa of the arm

Performing an abdominal assessment, a nurse notes tenderness while lightly palpating a client's right lower quadrant. The nurse determines that this finding is most likely associated with which of the following anatomic structures? A. Liver B. Spleen C. Pancreas D. Appendix

D. Appendix

A nurse is assessing a newborn infant for jaundice. Which action should the nurse take to assess the infant for its presence? A. Squeeze the infant's nail beds B. Squeeze the infant's brachial area C. Apply pressure with a finger over the umbilical area D. Apply pressure with a finger on the infant's forehead

D. Apply pressure with a finger on the infant's forehead

A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee? A. Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg B. Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is sitting C. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. D. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

D. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? A. Call the client's health care provider B. Document the error in the client's chart C. Report the nurse who changed the IV solution D. Ask the nurse whether she intends to report the error

D. Ask the nurse whether she intends to report the error

A nurse performing a neurological examination is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve? A. Asking the client to raise his or her eyebrows and looking for symmetry B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face D. Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear

D. Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear

A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? A. Placing the tube in warm water B. Hyperextending the head while inserting the tube C. Removing the tube if any resistance to insertion is met D. Asking the client to swallow as the tube is being advanced

D. Asking the client to swallow as the tube is being advanced

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure? A. Keeping the specimen at room temperature B. Saving the first urine specimen collected at the start time C. Discarding the last voided specimen at the end of the collection time D. Asking the client to void, discarding the specimen, and noting the start time

D. Asking the client to void, discarding the specimen, and noting the start time

The nurse instructs a unlicensed assistive personnel (UAP) that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the UAP doing which? A. Washing the client's feet B. Washing the client's chest C. Giving the client a back rub D. Asking the client to wash his arms

D. Asking the client to wash his arms

A nurse is performing sterile wound irrigation for an assigned client. A nursing assistant enters the client's room and tells the nurse that a physician has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse? A. Asking the nursing assistant to take a message B. Covering the client and answering the telephone call C. Finishing the wound irrigation while the physician waits on the telephone D. Asking the nursing assistant to obtain a telephone number from the physician so that the nurse may return the call after the wound irrigation is complete

D. Asking the nursing assistant to obtain a telephone number from the physician so that the nurse may return the call after the wound irrigation is complete

A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members should the nurse ask the client? A.Spouse and spouse's parents B. Foster children and their parents C. Spouse's children from a previous marriage D. Aunts, uncles, grandparents, and cousins

D. Aunts, uncles, grandparents, and cousins

A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? A. Prone B. Supine C. Standing D. Hands and knees

D. Hands and knees

A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client? A. Supine B. Standing C. Lithotomy D. Left lateral

D. Left lateral

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? A. Imposing nothing-by-mouth (NPO) status for 4 hours B. Asking the client to sign an informed consent form C. Asking the client about a history of allergy to iodine or shellfish D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? A. That mammography takes about 1 hour B. Not to eat or drink on the morning of the test C. That there is no discomfort associated with the procedure D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test

D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test

A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client: A. To maintain strict bedrest for 48 hours B. To expect bloody drainage on the eye dressing C. That vision will be perfectly clear immediately after surgery D. That redness and swelling of the eyelids and conjunctiva are expected

D. That redness and swelling of the eyelids and conjunctiva are expected

A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. What should the nurse tell the client? A. The procedure takes about 2 hours B. She will be positioned on her back for the procedure C. A probe coated with gel will be inserted into the vagina D. That she may need to drink fluids before the test and may not void until the test has been completed

D. That she may need to drink fluids before the test and may not void until the test has been completed

IV fluids given

Due to fluid shift to interstitial spaces and resultant shock

D Rationale: School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment

Early deceleration

Head compression

Elevated ICP

Increased BP, widened pulse pressure, increased Temp

- Oral lactulose (Chronulac) is prescribed for a client with a hepatic disorder, and the home care nurse provides instructions to the client regarding the medication. The nurse determines that the client needs additional instructions if the client states to:

Notify the physician if nausea occurs.

A one day old neonate is awaiting surgical correction of a myelomeningocele. During the preoperative period !hat is the priority nursing intervention?

Observe for CNS infection related to sac trauma

Post-renal problem

Obstruction in UT anywhere from tubules to urethral meatus

Y)"In a client with polycystic kidney disease, a urinary tract infection (UTI) has developed, and the nurse has been discussing discharge instructions with the client. Which statement by the client indicates a need for further teaching?"

Once the symptoms of my infection go away, I can stop taking my antibiotics.

Peak and Trough

Peak draw 30-60 minutes after drug administration Trough draw ~30 minutes before scheduled administration

Pericarditis

Pericardial friction rub, pain relieved by leaning forward

Harris Tube

Rt/back/Lt - to advance tube in GI

Droplet precautions

Ssspppidermmman *Sepsis *Scarlet fever *strep *parvovirus *pneumonia *pertussis *influenza *diptheria *epiglottitis *rubella *mumps *meningitis *mycoplasma *andenovirus

Decubitus (pressure) ulcer staging

Stage 1 = erythema only Stage 2 = partial thickness Stage 3 = full thickness to SQ Stage 4 = full thickness + involving mm/bone

20. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

The correct answer is D: Pale, thin arms and legs, uninterested in surroundings

Uterine atony

The most common cause of postpartum hemorrhage.

B Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL

The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL

Pregnancy induced hypertension

high blood pressure, blurred vision, headache, Proteinuria,Abdominal pain

Multiple Sclerosis

is a chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter of the brain and spinal cord. *Motor S/S: limb weakness, paralysis, slow speech *Sensory S/S: numbness, tingling, tinnitus *Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria

isotonic solutions

it's the same solute/water concentration as inside cells and the cells retain their normal size. -0.9 NS -Lactated ringers

mothers water breaks and she is at a negative station

know there is a risk of prolapsed cord.

Positioning with pneumonia

lay on the affected side to splint and reduce pain. But if you are trying to reduce congestion the sick lung goes up

During a 26 week gestation prenatal exam, a client reports occasional dizziness. What intervention is best for the nurse to recommend to this client?

lay on the right or left side when sleeping or resting

Med of choice for Vtach

lidocaine

Hyponatremia

nausea, muscle cramps, increased ICP, muscular twitching, convulsion; *osmotic diuretics

Lipitor (statins) remember

no grapefruit juice

Lasix

not a potassium sparing diuretic *give Aldactone

McBurneys point

pain in RLQ indicative of appendicitis

Murphys sign

pain with palpation of gall bladder area seen with cholecystitis

During a tet spell

put infant in knee chest position immediately

Glucose tolerance test for pregnant

result of 140 or highter needs further evaluation

CSF in meningitis

will have high protein, and low glucose

The nurse knows that which psycho-social stage should be a priority to consider while planning care for the 20 year old client?

identity vs diffusion

Hold Digoxin

if HR <60

Prior to liver biopsy

important to be aware of the lab result for prothrombin time

First sign of pyloric stenosis

in a baby is mild vomiting that progresses to projectile vomiting. Later you may be able to palpate a mass, the baby will seem hungry often, and may spit up after feedings

Dumping syndrome

increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis, wait 1 hr after meals to drink

At 25 weeks gestation, pulse

increase is normal

-Munchausen Syndrome

is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization.

Nitro

is administered up to 3 times (every 5 minutes). If chest pain does not stop go to hospital. Do not give when BP is < 90/60.

Osteomylitis

is an infectious bone dz. Give blood cultures and antibiotics, then if necessary surgery to drain abscess.

Nephrotic Syndrome

is characterized by massive proteinuria (looks dark and frothy) caused by glomerular damage.

Nine month old verify growth development

is child sitting up?

Musomyst

is the antedote to tylenol and is administered orally

Post thyroidectomy

keep trach set by bed with O2, suction and calcium gluconate

A nurse reviewing the record of a client with Meniere's disease prepares dietary instructions for the client. Which of the following dietary prescriptions would the nurse expect to be prescribed for the client?

low Sodium - Meniere's disease is a disorder of the inner ear that causes spontaneous episodes of -vertigo — a sensation of a spinning motion — along with fluctuating hearing loss, ringing in the ear (tinnitus), and sometimes a feeling of fullness or pressure in your ear. In many cases, Meniere's disease affects only one ear.

Pitocin

med used for uterine stimulation

Urine Output of 30mL/hr

minimal competency of heart and kidney function

Multiple sclerosis

myelin sheat destruction, disruption in nerve impulse conduction

Opiates antidote

narcan

Meningeal irritation S/s

nuchal rigidity, positive Brudzinski + Kernig signs and PHOTOPHOBIA too!

UAP delegations

only non-sterile procedures

While transferring a client with a chest tube from the bed to a stretcher, the chest becomes disconnected from the water seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. What action should the nurse implement next?

prepare a new water seal system and reattach the chest tube

You conduct CPR on intubated client and detects palpable pulse during 24 min cycle of chest compressions, absent breath sounds over left lung, what to do next?

prepare for the endotracheal tube to be repositioned

3. The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? • Raise the bed to a comfortable working level. • Bend the client's knee. • Move the knee toward the chest as far as it will go. • Cradle the client's heel. Correct

•Ans - Cradle the client's heel. Correct Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times.

Renal impairment

serum creatinine elevated and urine clearance decreased (85-135)

After removal of pituitary gland

you must watch for hypocortisolism and temporary diabetes insipidus.

glomerulonephritis

you should consider blood pressure to be your most important assessment parameter. * Dietary restrictions you can expect include fluids, protein, sodium, and potassium.

- (Y) A client has a diagnosis of hypoparathyroidism. The nurse assesses that the client has a positive Trousseau's sign if the client has which of the following responses when tested?

• Carpopedal spasm when a blood pressure cuff is inflated on the arm for 3 min HYPOCALCEMIA- TROUSSEAU'S SIGN Elicitation: Inflating a sphygmomanometer cuff above systolic blood pressure for several minutes Postitive response: Muscular contraction including flexion of the wrist and metacarpophalangeal joints, hyperextension of the fingers, and flexion of the thumb on the palm, suggestive of neuromuscular excitability caused by hypocalcemia

- (Y) A client being discharged from the mental health unit has a history of anxiety and command hallucinations to harm self or others. The nurse teaches the client about interventions for hallucinations and anxiety. The nurse determines that the client understands these measures when the client says:

• I call my clinical specialist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone

2. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? • Temperature increases from 98.8° to 99.0° F. • Pulse rate decreases from 78 to 52 beats/min. Correct • Respiratory rate increases from 16 to 24 breaths/min. • Blood pressure increases from 110/84 to 118/88 mm/Hg.

• Pulse rate decreases from 78 to 52 beats/min. Rationale - Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure.

A Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, option C is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.

Nurses Lab Q18: When assessing a newborn whose mother consumed alcohol during the pregnancy, the nurse would assess for which of these clinical manifestations? A. wide-spaced eyes, smooth philtrum, flattened nose B. strong tongue thrust, short palpebral fissures, simian crease C. negative Babinski sign, hyperreflexia, deafness D. shortened limbs, increased jitteriness, constant sucking

ANSWER: A. wide-spaced eyes, smooth philtrum, flattened nose RATIONALE: The nurse should anticipate that the infant may have fetal alcohol syndrome and should assess for signs and symptoms of it. These include the characteristics listed in choice A.

Nurses Lab Q11: While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following assessments is appropriate for the nurse to perform? A. Measure the length of the mass B. Auscultate the mass C. Percuss the mass D. Palpate the mass

ANSWER: B. Auscultate the mass RATIONALE: Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the provider. The mass should not be palpated because of the risk of rupture.

Nurses Lab Q22: The family of a 6-year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? A. Growth problems will occur if the fracture involves the periosteum B. Epiphyseal fractures often interrupt a child's normal growth pattern C. Children usually heal very quickly, so growth problems are rare D. Adequate blood supply to the bone prevents growth delay after fractures

ANSWER: B. Epiphyseal fractures often interrupt a child's normal growth pattern RATIONALE: Epiphyseal fractures often interrupt a child's normal growth pattern

Nurses Lab Q14: While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? A. "That's OK, its alright to skip your medication now and then." B. "I will have to call your doctor and report this." C. "Is there a reason why you don't want to take your medicine?" D. "Do you understand the consequences of refusing your prescribed treatment?"

ANSWER: C. "Is there a reason why you don't want to take your medicine?" RATIONALE: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.

Nurses Lab Q7: Which nursing intervention would be a priority during the care of a 2 month old after surgery? A. Minimize stimuli for the infant B. Restrain all extremities C. Encourage stroking of the infant D. Demonstrate to the mother how she can assist with her infant's care.

ANSWER: C. Encourage stroking of the infant RATIONALE: actile stimulation is imperative for an infant's normal emotional development. After the trauma of surgery, sensory deprivation can cause failure to thrive.

Nurses Lab Q3: An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic? A. Administer insulin B. Administer oxygen C. Feed the infant glucose water (10%) D. Place infant in a warmer

ANSWER: C. Feed the infant glucose water (10%) RATIONALE: After birth, the infant of a diabetic mother is often hypoglycemic.

Nurses Lab Q23: A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A. "Good morning. Do you remember where you are?" B. "Hello. My name is Elaine Jones and I am your nurse for today." C. "How are you today? Remember, you're in the hospital." D. "Good morning. You're in the hospital. I am your nurse Elaine Jones."

ANSWER: D. "Good morning. You're in the hospital. I am your nurse Elaine Jones." RATIONALE: As cognitive ability declines, the nurse provides a calm, predictable environment for the client. This response establishes time, location and the caregivers name.

Nurses Lab Q1: What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment? A. A cotton ball B. A penlight C. An ophthalmoscope D. A tongue depressor and flashlight

ANSWER: D. A tongue depressor and flashlight RATIONALE: Cranial nerves 9 and 10 are the glossopharyngeal and vagus nerves. The gag reflex would be evaluated.

Nurses Lab Q24: When a client wishes to improve the appearance of their eyes by removing excess skin from the face and neck, the nurse should provide teaching regarding which of the following procedures? A. Dermabrasion B. Rhinoplasty C. Blepharoplasty D. Rhytidectomy

ANSWER: D. Rhytidectomy RATIONALE: Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face lift. Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos. Rhinoplasty is done to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin. Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.

Nurses Lab Q10: During the history, which information from a 21 year old client would indicate a risk for development of testicular cancer? A. Genital Herpes B. Hydrocele C. Measles D. Undescended testicle

ANSWER: D. Undescended testicle RATIONALE: Undescended testicles make the client high risk for testicular cancer. Mumps, inguinal hernia in childhood, orchitis, and testicular cancer in the contralateral testis are other predisposing factors.

B Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.

After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately.

D Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Hyperventilation

Alkalosis = low CO2

While triaging clients after an earthquake that has caused mass casualties, the nurse notes that a client with a massive head injury does not respond to stimulation and cannot breathe independently. Which color tag would be given to the client? a. Red b. Black c. Green d. Yellow

Ans - B Black tag An incident that has caused mass casualties, a military form of triage is performed to provide the best care for the most people. In such instances, clients who may otherwise have been resuscitated are often classified as expectant. Therefore a client with a massive head injury who is unable to respond to any kind of stimulus and is unable to breathe independently would be classified with a black tag.

C Rationale: The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."

Nursing process

Assessment, Diagnosis (analysis), Planning, Implementation (treatment), Evaluation

7. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? • Maintain in a lateral position using protective wrist and vest devices. • Position prone with a small pillow below the diaphragm. • Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation

Ans - Position prone with a small pillow below the diaphragm. Rationale - The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point.

A nurse is caring for a woman in the postpartum unit. When the nurse checks the postition of the fundus, the nurse notes that the fundus is dislaced to one side. Which of the following nursing actions is appropriate?

Assist the client to empty the bladder

A client with gestational diabetes at 39 weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

Assist the client to sharply flex her thighs up against the abdomen

A male client with angina pectoris is being discharged from the hospital.What instruction should the nurse plan to indicate in this discharge teaching?

Avoid isometric activity, but walk regularlly

A client with atrial fibrillation receives a new prescription for Dabigatram. What instruction should the nurse include in this client teaching plan?

Avoid use of non-steroid anti-inflammatory drugs

4. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? • Continue gabapentin. Correct • Discontinue ibuprofen. • Add aspirin to the protocol. Add oral methadone to the protocol

Ans 1 - Continue gabapentin Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an anti-seizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Non-opioid analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests.

ANS - "At 10:00 a.m., a client complained of nausea and vomited. The nurse calls the physician and an antiemetic and a clear liquid diet are prescribed. The nurse administers the antiemetic and the client sleeps for three hours. When the client awakens, the client tells the nurse that he is hungry and would like something to eat. Which food item would be most appropriate for the nurse to give the client?"

Apple Juice

50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion

Applying suction for more than 10 seconds

A charge nurse observes a nursing assistant talking in an unusually loud voice to a client with delirium. The charge nurse takes which action?

Ascertains the client's safety, calmly asks the nursing assistant to join the nurse outside the room, and inform the nursing assistant that her voice was unusually loud

Cephalhematoma puts infant at risk for

hyperbillirubinemia *does not cross suture line

Methergine lady presented to the hospital postpartum what would alert the doctor

hypertension

A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? A. Pupil constriction B. Increased urine output C. Complaints of dry mouth D. Complaints of feeling sweaty

C. Complaints of dry mouth

Thoracentesis

*surgical puncture to remove fluid from the pleural space *Take v.s., shave area around needle insertion, position patient with arms on pillow on over bed table or lying on side, no more than 1000cc at a one time. *Post- listen for bilateral breath sounds, v.s., check leakage, sterile dressing.

TB

*treamtment regimen for 9 months *Rifamin turns pee orange *Isoniazide increases dilantin levels

Trough and Peak blood draws

*trough= 30 min before schedules med *peak=30-60 min after drug

During asthma attack

*use bronchodilator before steriod *exhale completely, inhale completely, hold for 10 sec

The nurse presents a class on herbal medications at a community health care seminar. Which statement should be included in the class? Select all that apply 1. (1.) The potency of herbal preparations varies between manufacturers. 2. (2.) The FDA tests and regulates herbal preparations. 3. (3.) Herbal preparations are classified as dietary supplements. 4. (4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure. 5. (5.) Herbal preparations are used in the treatment of immune system dysfunction.

(1.) CORRECT - read labels carefully to determine the exact amount of herbs in the preparation (2.) herbal preparations are classified as dietary supplements; adverse reactions may be reported after use (3.) CORRECT - the FDA does not research or regulate herbal preparations because they are classified as dietary supplements (4.) CORRECT - read labels carefully to determine what the herbal preparation contains (5.) label should state that the herbal preparation will "decrease inflammation or support the immune system"; label cannot say that the preparation "protects against cancer"

The nurse cares for a client with chronic renal failure who has an arteriovenous fistula in the left arm. Which of the following should be included in the care of the client? Select all that apply 1. (1.) Assess and compare blood pressure in both arms. 2. (2.) Auscultate for "whooshing" sound over the fistula. 3. (3.) Palpate for warmth and tenderness over the area of the fistula. 4. (4.) Instruct the client to avoid getting the left arm wet. 5. (5.) Instruct the client to sleep with the left arm in the dependent position. 6. (6.) Instruct the client to avoid carrying heavy objects with the left arm.

(1.) no constriction of the arm with the fistula; may damage fistula (2.) CORRECT - Bruit should be heard over the area of the fistula due to increased blood flow; if no bruit heard, notify healthcare provider (3.) CORRECT - Increased risk of infection in the fistula area; possible infection should be reported to healthcare provider (4.) fistula is internal; no risk of infection from exposure to water (5.) no weight should be placed on the extremity with the fistula (6.) CORRECT - increases the risk of fistula damage

Magnusium sulfate

*(used to halt preterm labor) *contraindicated if deep tendon reflexes are ineffective. *If patient experiences seizure during magnesium adm. Get the baby out stat (emergency).

Fundus after delivery

*5 cm below umbilicus post delivery *rises to umbilicus 6-12 hours after delivery

Fetal heartbeat

*8-12 weeks by Doppler *15-20 weeks by fetoscope

Cystic fibrosis

*An inherited life-threatening disorder that damages the lungs and digestive system. *give diet low fat, high sodium, fat soluble vitamins ADEK.

Isotonic solutions

*D5W *NS (0.9 NaCl_ *ringers lactate

Which surveillance clues are specific potential indicators of a bioterrorism attack?

*Geographic clustering of client illnesses *Unusual age distributions for a common disease.

Best time to take meds

*Growth Hormone PM *Steroids AM *Diuretics AM *Aricept AM. *Antacids after meals

Congenital megacolon

*Hirschsprung disease *suspect if no meconium in 24 hours or ribbon-like stools

The nurse is performing a surgical hand scrub prior to entering the operating room. In what order should the nurse perform the steps of this procedure?

*Scrape under the nails with a nail pick. *Rinse from the fingertips to the elbow. *Use a soapy brush to scrub the hands. *Cleanse the arm with a lathered brush *rinse the whole thing off starting from fingertips to upper arm

Hip dysplasia in infant

*breech position increases risk *positive ortholani sign -Spica cast

Croup

*bring them into steam bathroom or the cool night air *avoid cough syrups and cold medicines

Restraints

*check every 20 min *2 fingers room underneath

Hypoglycimia

*confusion *HA *iritable *nausea *sweating *tremors *hunger

COPD

*emphysema= pink puffer *Chronic bronchitis= blue bloater (right sided HF)

X-linked recessive disorders

*females are carriers, never have the disease *muscular dystrophy, hemophillia

Acute pancreatitis

*fetal position *turners sign.. bluish discoloration of flanks *cullens sign *board like abdomen with guarding

MAOIs

*for depression *PANAMA PA - parnate NA - nardil MA - marplan

Venous ulcer

*inflammation *swelling, WARM *itchy, hardened skin *scabbing or flaking *brown or black stained skin *irregular wound edges

Hypocalcemia

*muscle spasms, convulsions, cramps *Trousseaus sign *Chvosek sign

Pericarditis

*pericardial friction rub *pain relieved by leaning forward

Placenta previa and abruption

*placenta previa = there is no pain, there is bleeding. *Placenta abruption = pain, but no bleeding.

Fontanel closure

*posterior- 8 weeks *anterior- 12-18 months

Duchenne Muscular Dystrophy

*potbelly *bow legs *longer arms

Which patient is at greatest risk for cadiogenic shock?

*pt whom had a traumatic amputation from the groin down *there one of the choice a pt with gunshot wound to the chest and abdomen *HESI HINT: if cardiogenic shock exists in the presence of pulmonary edema (from pump failure), position pt to reduce venous return &high fowler's with legs down in order to reduce further venous return to the left ventricle

Arterial ulcer

*red, yellow, or black sores *deep wound *tight, hairless skin *leg pain at night *affected area is cool or cold to touch from *minimal blood circulation *leg reddens when dangled and turns pale when elevated

Renal failure

*restrict protein intake *watch for hyperkalemia *monitor body weight and I&O

A nurse is monitoring a client who has undergone pleural biopsy. Which finding causes the nurse to suspect that the client is experiencing a complication? A. Warm, dry skin B. Mild pain at the biopsy site C. Complaints of shortness of breath D. Capillary refill time of less than 3 seconds

C. Complaints of shortness of breath

The nurse cares for an 80-year-old client taking medication for the treatment of hypertension and heart failure. Which action is MOST important for the nurse to take? 1. Check the client's blood pressure and heart rate immediately after ambulation. 2. Instruct the client to use a walker at all times during ambulation. 3. Encourage the client to walk with the feet as close together as possible. 4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.

1) Assessment: outcome not desired; blood pressure and heart rate should be assessed prior to ambulation; more important to assess for shortness of breath and activity tolerance 2) Implementation: outcome not desired; avoid soft-soled shoes; remove barriers; orthostatic precautions are priority; no indication in the question that a walker is needed 3) Implementation: outcome not desired; should have wide-based gait to distribute center of gravity; may be unsafe ambulation 4) CORRECT-Implementation: outcome desired and priority; elderly have decreased cerebral perfusion; antihypertensives and medications used to treat heart failure cause vasodilation

The nurse cares for a client in active labor. The client's membranes rupture spontaneously at 6 centimeters of dilation. Which action actions should the nurse take FIRST? 1. Check the fetal monitor. 2. Place the client on her right side. 3. Auscultate fetal heart rate. 4. Check the client's heart rate and blood pressure.

1) Assessment: outcome not desired; check client, not equipment; fetal monitor may give incorrect information 2) Implementation: outcome not desired; position on left side if needed to prevent pressure on vena cava; no information in question indicates fetal hypoxia 3) CORRECT-Assessment: outcome priority; check for possible prolapsed cord; recheck in 10 minutes; fetal assessment is priority during labor 4) Assessment: outcome not priority; provides no information about baby

The home care nurse is visiting a client terminally ill with pancreatic cancer who wishes to die at home. Which question, if asked by the nurse, is MOST appropriate? 1. "Are you sure you want to die at home?" 2. "Where will you put the hospital bed?" 3. "Would you like your minister to visit you?" 4. "Who will take care of you?"

1) Assessment: outcome not desired; psychosocial, yes-no question, non-therapeutic 2) Assessment: outcome desired but not priority; important to obtain the needed equipment, but is very specific 3) Assessment: outcome not priority; passing the buck, yes-no question, non-therapeutic 4) CORRECT- Assessment: outcome desired and priority; physical need, meet basic needs first before psychosocial

The nurse is caring for an elderly client receiving total parenteral nutrition (TPN) due to malnutrition. Which observation, if made by the nurse, indicates that the client is improving? 1. The client gains 8 lbs in one week. 2. The client's edema decreases. 3. The client's hemoglobin increases. 4. The client's output is greater than the intake.

1) Assessment: outcome not expected; indicates fluid retention 2) CORRECT- Assessment: outcome expected; edema is manifestation of malnutrition; decreased serum protein levels cause fluid to move into interstitial space 3) Assessment: outcome not expected; hemoglobin may increase with increased iron levels 4) Assessment: outcome not expected; TPN can cause hyperosmolar diuresis due to hyperglycemia, complication of TPN

The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds? 1. Continuous, high-pitched musical sounds heard on expiration. 2. Soft, high-pitched interrupted sounds heard on inspiration. 3. Deep, low-pitched rumbling sounds are heard mainly on expiration. 4. Harsh, grating sounds heard best during inspiration.

1) Assessment: outcome not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles 2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF, caused by fluid in the alveoli 3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus in the airways; excessive mucous production is primary symptom 4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed pleura or pericarditis

The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?"

1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment 2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching 3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myocardial oxygen consumption; increased risk of angina and myocardial infarction 4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain dental work

The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? 1. Assess the patency of the PCA IV tubing. 2. Determine the client's understanding of the PCA pump function. 3. Obtain an order to begin a PCA infusion of fentanyl. 4. Ask the client to describe the pain.

1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated 2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiation of the pain, and relieving factors 3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first 4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation

A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis pulses. 4. Ask the client if he knows today's date.

1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose 2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest 3) Assessment: outcome not priority; most important to assess airway and breathing 4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority

An LPN/LVN informs the nurse that aspirin 325 mg was given to a client even though 80 mg aspirin had been ordered once daily. The LPN/LVN asks the nurse if it is necessary to complete a medication-error form since "no harm was done." Which statement, if made by the nurse, is BEST? 1. "What do you mean, "no harm was done"? 2. "A medication-error form must be completed whenever the wrong preparation of a medication is given." 3. "I will call the health care provider and ask what should be done to deal with this error." 4. "It is not necessary to complete an incident report with over-the-counter medications."

1) Assessment: outcome not priority; assessment of client must be done by nurse; question is not necessary 2) CORRECT-Implementation: outcome desired; contains full description of situation, error committed, condition of client, remedial steps taken; medication error form must be completed for all variances 3) Implementation: outcome not desired; it is a nursing responsibility; health care provider should be informed 4) Implementation: outcome not desired; always complete form for any medication error

A news reporter and camera person arrive on the nursing unit to videotape an interview of a client. When the nurse refuses their request, the reporter references his First Amendment rights. Which statement, if made by the nurse, is MOST appropriate? 1. "Why do you want to talk with the client?" 2. "I'll ask the client if he is ready to speak with you." 3. "I will need to call the nurse manager about your request." 4. "Does the client know that you are coming?"

1) Assessment: outcome not priority; don't ask "why" questions on the NCLEX-RN®; "why" questions are considered to be confrontational 2) Implementation: outcome not desired; confirms client presence; breaches confidentiality; report to nursing supervisor 3) CORRECT- Follows the chain of command within the facility. 4) Verified the client's admission, violates client's confidentiality.

The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to compression fractures of the 5th and 6th cervical vertebrae. The client reports a sudden onset of sweating and has a flushed face and chest. Which action should the nurse take FIRST? 1. Perform a digital rectal examination. 2. Check the color and temperature of the extremities. 3. Place the client in high-Fowler's position. 4. Administer hydralazine (Apresoline) 20 mg intravenously.

1) Assessment: outcome not priority; immediate action to decrease blood pressure is priority; rectal stimulation may increase autonomic dysreflexia 2) Assessment: outcome not priority; immediate need is to reduce blood pressure and prevent hemorrhage 3) CORRECT-Implementation: outcome desired; immediate effect; decrease venous return to heart, decrease stroke volume, and decrease in blood pressure 4) Implementation: outcome not desired as initial action; causes vasodilation; more immediate effect with position change; if cause of autonomic dysreflexia removed, sudden drop in blood pressure could occur

A 60-year-old client comes to the outclient clinic to receive the influenza vaccine. Which of the following questions, if asked by the nurse, is BEST? 1. "Have you had the flu in the past month?" 2. "Do you have any food allergies?" 3. "Has anyone in your family been sick?" 4. "Are you allergic to any medication?"

1) Assessment: outcome not priority; immunization deferred in presence of acute respiratory disease or other acute infection 2) CORRECT-Assessment: outcome priority; allergy to eggs is a contraindication to receiving flu vaccine 3) Assessment: outcome not priority; immunization deferred only if client has active infection 4) Assessment: outcome not priority; medication allergy not pertinent

The nurse teaches a wellness class to a group of women. The nurse knows that which of the following clients is MOST at risk for developing cervical cancer? 1. A woman who began menstruating at age 9. 2. A woman who used oral contraceptives for 8 years. 3. A woman diagnosed with endometriosis at age 20. 4. A woman who has had approximately 10 sexual partners.

1) Assessment: outcome not priority; increases risk of breast cancer 2) Assessment: outcome not priority; increases risk of estrogen-dependent cancers 3) Assessment: outcome not priority; not related to cervical cancer 4) CORRECT-Assessment: outcome priority; multiple sexual partners increases risk of cervical cancer

The nurse cares for the client diagnosed with schizophrenia. Which question is MOST important for the nurse to ask the client's spouse? 1. "Have you noticed loud talking and excessive restlessness lately?" 2. "Has your spouse seemed withdrawn and less responsive to you during the last few weeks?" 3. "How would you describe your spouse's daily consumption of alcohol?" 4. "Does your spouse appear to have lost weight recently?"

1) Assessment: outcome not priority; manic client (bipolar disorder); symptoms include inappropriate dress, excessive talking, lack of inhibition, inability to stop moving, disorientation 2) CORRECT - Assessment: outcome priority; may withdraw from previous relationships or regress to previous behavior levels 3) Assessment: outcome not priority; no data to support relationship 4) Assessment: outcome not priority; secondary to withdrawn behavior; common with other psychiatric problems

The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication? 1. Request a daily hemoglobin and hematocrit test. 2. Monitor the serum BUN and creatinine. 3. Request a highly-sensitive C-reactive protein (hs-CRP) test. 4. Monitor the erythrocyte sedimentation rate (ESR).

1) Assessment: outcome not priority; may cause anemia, but not usually seen 2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance 3) Assessment: outcome not priority; will be increased in inflammation and rheumatoid arthritis 4) Assessment: outcome not priority; will be increased with any inflammatory process

The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed? 1. The client has a forceful cough during repositioning. 2. The client tries to chew on the oral airway.. 3. The client tries to push the airway out with his tongue. 4. The client is able to swallow.

1) Assessment: outcome not priority; may cough due to irritation of the airway; does not reflect client responsiveness 2) CORRECT - Assessment: outcome priority; client is alert and able to maintain his own airway 3) Assessment: outcome not priority; client needs to be responsive before airway is removed; may be a reflexive action 4) Assessment: outcome not priority; client will be able to swallow before he is responsive

The home care nurse performs a health screening at the local mall. The nurse knows that which of the following clients is at HIGHEST risk for developing a stroke? 1. A 32-year-old Caucasian female who has a history of type 1 diabetes mellitus and has used oral contraceptive for 8 years. 2. A 49-year-old Caucasian male who works as an account executive at an ad agency and has a cholesterol level of 250 mg/dL. 3. A 56-year-old African-American female who consumes 1 to 2 alcoholic beverages weekly and has smoked cigarettes for 30 years. 4. A 69-year-old African-American male who has a history of hypertension and is 30 pounds overweight.

1) Assessment: outcome not priority; risk factors include diabetes and oral contraceptive use 2) Assessment: outcome not priority; risk factors include high cholesterol; no demonstrated relationship between occupation and stroke 3) Assessment: not priority; risk factors include race and smoking; daily consumption of 2 or more alcoholic beverages a day increases risk of hypertension and stroke 4) CORRECT- Assessment: priority; risk factors include age, race, hypertension, and obesity

A client had a right kidney transplant 1 week ago. Which symptom, if experienced by the client, indicates to the nurse that the client is experiencing rejection? 1. The client complains of generalized muscle weakness. 2. The client complains of diffuse pain over the right abdomen. 3. The client gets up twice each night to void. 4. The client has lost 3 pounds.

1) Assessment: outcome not priority; seen with electrolyte imbalance, not rejection 2) CORRECT-Assessment: outcome priority and expected with kidney rejection; tenderness over kidney is sign of rejection 3) Assessment: outcome not expected; oliguria is seen with rejection due to failing kidney 4) Assessment: outcome not expected; edema and weight gain are seen with rejection

A client is brought to the clinic by the spouse. The client's lab results are Na+ 156 mEq/L, Cl- 100 mEq/L, K+ 4.0 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Which is the MOST appropriate action for the nurse to take? 1. Assess for muscle weakness and dysrhythmias. 2. Assess for confusion and tachycardia. 3. Check for peripheral edema and lung crackles. 4. Determine if muscular twitching and muscle weakness are present.

1) Assessment: outcome not priority; symptoms of hypokalemia 2) CORRECT-Assessment: outcome priority; elevated Na+ and elevated BUN, other values are normal; elevated Na+ and BUN seen with dehydration 3) Assessment: outcome not priority; symptoms of fluid volume overload 4) Assessment: outcome not priority; symptoms of hyponatremia; hypernatremia seen with dehydration

During a paracentesis, 1500 mL of fluid is removed from a client. Which action should the nurse take IMMEDIATELY following the procedure? 1. Measure the client's abdominal girth. 2. Weigh the client. 3. Assess the client's level of pain. 4. Check the client's blood pressure.

1) Assessment: outcome not priority; will decrease in size 2) Assessment: outcome not priority; will lose weight 3) Assessment: outcome not priority; not most important 4) CORRECT- Assessment: outcome priority; complication of procedure is hypotension (hypovolemic shock due to fluid shift); also check for tachycardia, oliguria, pallor

The nurse plans care for a client admitted with fever, vomiting, and diarrhea. Which laboratory value demonstrates an improvement in the client's condition? 1. Specific gravity of urine 1.020 and hematocrit 42%. 2. Specific gravity of urine 1.039 and hematocrit 50%. 3. Specific gravity of urine 1.010 and hematocrit 52%. 4. Specific gravity of urine 1.030 and hematocrit 35%.

1) CORRECT - Assessment: outcome expected; normal specific gravity of urine, normal hematocrit; specific gravity and hematocrit increase with dehydration 2) Assessment: outcome not expected; increased specific gravity of urine, increased hematocrit; suggests ongoing fluid volume deficit 3) Assessment: outcome not expected; decreased specific gravity of urine, increased hematocrit; does not indicate improvement 4) Assessment: outcome not expected; increased specific gravity of urine, decreased hematocrit; does not indicate improvement

A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500 mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours. 4. Blood pressure of 100/82.

1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated 2) Assessment: outcome not priority; indicates that blood is hemoconcentrated 3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours 4) Assessment: outcome not priority; normal BP is 120/80

The nurse prepares to assign a client requiring a capillary blood glucose test to a newly hired nursing assistive personnel. Which action should the nurse take FIRST? 1. "Show me how you check a capillary glucose level." 2. "How many of these glucose checks have you done in the past?" 3. "Would you like for me to go with you when you do the glucose test?" 4. "Was this procedure covered during your nursing assistive personnel class?"

1) CORRECT - Assessment: outcome priority; must evaluate competency of the UAP; nurse is accountable for UAP's actions during delegation process 2) Assessment: outcome not priority; number of procedures done is not as important as demonstrated competency 3) Assessment: outcome not priority; nurse should be able to delegate procedure if UAP is competent 4) Assessment: outcome not priority; obtaining a capillary glucose sample is within UAP scope of practice

The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate? 1. A 38-year-old client with a diagnosis of systemic lupus erythematosus. 2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer. 3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg. 4. A 74-year-old client who has received intravenous antibiotics for 7 days.

1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious 2) Implementation: outcome not desired; possible skin damage and suppression of bone marrow with decreased white-blood-cell levels; increased risk for infection 3) Implementation: outcome not desired; generalized skin infection of deeper connective tissue; usually caused by Streptococcus or Staphylococcus; increased risk for infection 4) Implementation: outcome not desired; elderly clients receiving long-term antibiotic therapy are at risk for Clostridium difficile infection; highly contagious; increased risk for infection

The nurse counsels a woman at 36 weeks gestation who has attended childbirth class in preparation for labor and delivery. Which statement by the client requires an intervention by the nurse? 1. "I now know when to expect discomfort during labor and delivery and the things I can do to decrease the discomfort." 2. "My husband is still concerned that he is not sure what to do during the labor process." 3. "Even though I learned pain control techniques, I still may need some pain medication during labor and delivery." 4. "The breathing patterns I learned in class will decrease the amount of time I spend in labor."

1) Implementation: outcome desired; purpose of childbirth class is to eliminate fear of the unknown 2) Implementation: outcome not desired but not priority; focus of class is on fetus and mother; further assessment needed 3) Implementation: outcome desired; anxiety and pain reduction techniques included in class, but mothers are encouraged to use analgesia if needed 4) CORRECT-Implementation: outcome not desired; breathing techniques may decrease anxiety and pain but have no effect on time of labor

An elderly woman is being seen by the home care nurse following a partial gastrectomy for cancer. Which statement, if made by the client, requires further teaching? 1. "The healthcare provider told me to come in once a month for vitamin B12 injections." 2. "I eat frequently throughout the day." 3. "I do not eat concentrated sweets." 4. "I drink several glasses of iced tea with my meals."

1) Implementation: outcome desired; required monthly to prevent pernicious anemia 2) Implementation: outcome desired; small, frequent feeding prevents dumping syndrome 3) Implementation: outcome desired; prevents dumping syndrome 4) CORRECT-Implementation: outcome not desired; drinking fluids with meals causes stomach content to empty too rapidly into the jejunum

The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed? 1. "The skin around the stoma should be cleaned with warm water and thoroughly dried." 2. "The appliance should fit snugly around the ileostomy opening." 3. "I should take polyethylene glycol (MiraLax) with a large glass of water." 4. "I will continue to take a daily multi-vitamin."

1) Implementation: outcome desired; standard of care for ileostomy 2) Implementation: outcome desired; ileostomy drainage is liquid and very alkaline; great risk of skin irritation 3) CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract 4) Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy

The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1. "I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3. "I plan to use salt substitutes now that I have to limit my sodium intake." 4. "I should read food and nonprescription medication labels to check the ingredients."

1) Implementation: outcome desired; would indicate fluid retention 2) Implementation: outcome desired; symptoms of digitalis toxicity, CHF 3) CORRECT - Implementation: outcome not desired; salt substitutes contain potassium; spironolactone is a potassium-sparing diuretic 4) Implementation: outcome desired; some medications may contain sodium and potassium

The nurse cares for a client who is to receive thrombolytic therapy with tissue plasminogen activator (rtPA). The nurse is MOST concerned if the client makes which of the following statements? 1. "I take a multivitamin tablet daily for cold and flu prevention." 2. "I had major abdominal surgery a year ago." 3. "I get some stomach pain when I eat spicy foods." 4. "I hit my head and lost consciousness during a car accident 2 months ago."

1) Implementation: outcome not a problem; no interaction 2) Implementation: outcome not a problem; surgery within 3 weeks is potential contraindication 3) Implementation: outcome not a problem; active peptic ulcer disease is potential contraindication; needs further investigation 4) CORRECT-Implementation: outcome a problem; significant traumatic head injury within 3 months is an absolute contraindication for thrombolytic therapy

The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client? 1. 20 mg oral escitalopram (Celexa) in the morning. 2. 40 mg oral furosemide (Lasix) in the morning. 3. 300 mg of oral gabapentin (Neurontin) twice daily. 4. 10 mg zolpidem (Ambien) at bedtime.

1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant 2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension 3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label use for neuropathic pain 4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors

A 7-year-old boy is brought to the emergency room by his mother following a fall from his bicycle. X-ray reveals healed fractures of the ribs. The child's mother states, "My son is such a careless child; he's always having accidents or fights with his brother." Which response by the nurse would be MOST appropriate? 1. "When I document information about these injuries, it will be on your son's hospital record forever." 2. "How would you describe your son's relationship with his brothers and sisters?" 3. "What I see suggests that someone has been abusing your son." 4. "I will need to talk to the nurse manager about this situation before you leave."

1) Implementation: outcome not desired and not priority; documentation of suspected abuse should contain facts and be nonjudgmental 2) Assessment: outcome not priority; priority action is to report potential abuse to nurse manager 3) Implementation: outcome not desired; close-ended statement; confrontational 4) CORRECT-Implementation: outcome desired; follows chain of command; potential abuse situation

A man diagnosed with a stroke develops dysphagia. Before allowing the client to eat, which action should the nurse take FIRST? 1. Place client in semi-Fowler's position. 2. Auscultate bowel sounds. 3. Check client's gag reflex. 4. Offer to cut client's food.

1) Implementation: outcome not desired but not priority; should be in high-Fowler's position during and 30 minutes after eating; not first action; assessment should be done first 2) Assessment: outcome desired but not priority; should be assessed, but is not first action 3) CORRECT-Assessment: outcome desired and priority; touch tongue depressor to back of throat; first priority to determine risk of aspiration 4) Implementation: outcome not desired; should keep independent

The nurse reviews medications with a 35-year-old female. The client takes 200 mg carbamazepine (Tegretol) orally twice daily. The client asks the nurse about future pregnancies. Which statement by the nurse is MOST appropriate? 1. "If you take 5 mg folic acid daily while trying to conceive, you should be able to get pregnant." 2. "It is recommended that you take carbamazepine suspension instead of the tablets when trying to get pregnant." 3. "You should contact your health care provider and discuss your concerns about pregnancy." 4. "If you avoid drinking grapefruit juice, there should be no problem with conception."

1) Implementation: outcome not desired; carbamazepine and valproic acid increase risk of birth defects; daily folic acid decreases risk of neural tube defects if taken during pregnancy; folic acid will not increase fertility 2) Implementation: outcome not desired; possible birth defects due to action of the medication; route of administration does not matter 3) CORRECT - Implementation: outcome desired; carbamazepine may be teratogenic; the health care provider should discuss risks and benefits with client 4) Implementation: outcome not desired; grapefruit juice can increase serum levels of carbamazepine as much as 40%

During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation? 1. Administer the Ceclor as ordered; do not administer the naproxen. 2. Administer the naproxen as ordered; do not administer the Ceclor. 3. Administer both the Ceclor and naproxen as ordered; document the client's response. 4. Do not administer the Ceclor or naproxen; notify the healthcare provider.

1) Implementation: outcome not desired; cephalosporins have cross-allergies with penicillins 2) Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin allergies 3) Implementation: outcome not desired; both medications should be withheld due to allergies 4) CORRECT - Implementation: outcome desired; both medications should be withheld; risk of hypersensitivity reaction

A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram? 1. Clean and shave the catheter insertion-site area. 2. Locate and note the presence of peripheral pulses. 3. Encourage the client to increase oral fluid intake. 4. Teach coughing and deep-breathing exercises.

1) Implementation: outcome not desired; cleansing may be done according to facility policy; shaving may not be recommended due to possible abrasions and increased risk of infection 2) CORRECT - Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses 3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause possible nausea; fluid intake should be increased after procedure to clear dye and reduce risk of renal toxicity 4) Implementation: outcome desired but not highest priority; not at greatly increased risk for atelectasis

A registered nurse from a surgical floor is reassigned to a medical unit. Which of the assignment is MOST appropriate for this nurse? 1. A client with type 1 diabetes mellitus scheduled for discharge at 2 P.M. 2. A client admitted 4 hours ago with a diagnosis of myocardial infarction. 3. A client with Alzheimer's disease who requires a tube feeding. 4. A client admitted yesterday with a diagnosis of left-sided cerebral vascular accident.

1) Implementation: outcome not desired; client requires discharge instructions 2) Implementation: outcome not desired; client requires frequent assessment 3) CORRECT- Implementation: outcome desired; stable client with an expected outcome 4) Implementation: outcome not desired; client requires frequent assessment

The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action? 1. Leave the television on all day in the client's room. 2. Frequently inform the client of the room and bathroom location. 3. Provide the client with newspapers and magazines. 4. Assign a staff member to check on the client every 15 minutes.

1) Implementation: outcome not desired; does not address orientation needs; risk of overstimulation; television should be on intermittently 2) CORRECT - Implementation: outcome desired; provides for safety needs and frequent orientation 3) Implementation: outcome not priority; does not address safety needs or orientation 4) Implementation: outcome desired not priority; addresses safety but not orientation or stimulation needs

The nurse plans care for a 4-year-old girl who has been sexually abused by her grandfather. Play therapy is scheduled as part of the treatment plan. Which statement, if made by the child's parents, indicates understanding of the primary purpose of play therapy? 1. "The main goal of play therapy is for our child to deal with any anger that she has." 2. "During these play sessions, our child will be encouraged to communicate at her own level." 3. "Our child's developmental level will be evaluated by a child development specialist during these sessions." 4. "The main purpose of play therapy is to determine exactly what type of abuse occurred."

1) Implementation: outcome not desired; expression of anger may occur; main goal is communication 2) CORRECT- Implementation: outcome desired; child may not be able to express her perception of the events verbally; play with dolls will facilitate communication 3) Implementation: outcome not desired; not primary goal of play session; assessment of developmental level may occur 4) Implementation: outcome not desired; may occur, but not the primary purpose

The nurse teaches the client how to perform a colostomy irrigation. During the teaching, the client states, "I can't do this." Which response, if made by the nurse, is BEST? 1. "Sure you can do this. You just need to have more practice." 2. "I'll do it for you this time, but you must perform the irrigation the next time." 3. "You seem to be frustrated. What are your specific concerns?" 4. "Most of the other clients learn this without any difficulty. Let's try it again."

1) Implementation: outcome not desired; false reassurance; need to assess first 2) Implementation: outcome not desired; fosters dependence 3) CORRECT-Implementation: outcome not desired; reflects feelings; allows nurse to assess 4) Implementation: outcome not desired; implies deficiency in the client

The unit supervisor of an emergency department (ED) is called at home and told by an emergency department nurse who is on duty that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the unit supervisor be? A. "Has the disaster plan been activated?" B. "Call as many nursing staff as you can to come in to work." C. "Make sure all of the rooms are well stocked with supplies." D. "Be sure that the nursing staff finds as many stretchers as they can."

A. "Has the disaster plan been activated?"

The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know everything I need to know about it." Which response by the nurse is BEST? 1. "After I explain the operation to you, both of us will sign the form for legal purposes and it will be placed in your chart." 2. "Tell me what the healthcare provider told you about the risks and benefits of this operation." 3. "Can I answer any questions that you have about the procedure?" 4. "You should read all these materials to be sure that you understand everything about this procedure."

1) Implementation: outcome not desired; nurse should not explain the procedure; the health care provider doing the procedure should explain the risks and benefits 2) CORRECT - Assessment: outcome desired; nurse should determine if client understands risks and benefits of the procedure before the client and nurse sign the informed consent form 3) Implementation: outcome not desired; yes/no question non-therapeutic response 4) Implementation: outcome desired but not priority; reading materials do not ensure that client understands risks and benefits of the procedure

The nurse discusses an appropriate diet with a client diagnosed with iron-deficiency anemia. Which meal, if selected by the client, indicates to the nurse, that teaching is effective? 1. Spaghetti with a sauce of ground beef, cheese, and garlic bread. 2. Baked sausage casserole with rice and sliced tomato. 3. Frankfurter, baked beans, and chopped cabbage salad. 4. Lamb chop, baked potato, and tossed green salad.

1) Implementation: outcome not desired; only beef is a good source 2) Implementation: outcome not desired; only sausage is good source 3) Implementation: outcome not desired; low in iron 4) CORRECT-Implementation: outcome desired; contains 24-30 mg; vitamin C from potato and salad enhance iron availability

The school nurse teaches accident-prevention to the parents of school-aged children. Which statement, if made by a parent to the nurse, indicates teaching is effective? 1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his bike." 2. "I keep my guns and ammunition in a locked cabinet in the basement." 3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the monkey bars." 4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."

1) Implementation: outcome not desired; only bicycle helmet is recommended; additional protective gear with skateboarding or rollerblading 2) Implementation: outcome not desired; guns and ammunition should be kept in separate locked areas 3) CORRECT-Implementation: outcome desired; injury prevention facilitated by age-appropriate safety education 4) Implementation: outcome not desired; school-aged children are developmentally ready for less supervision; parents should encourage interaction with peers

The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements? 1. "Your parents are going to leave a half hour before the surgery." 2. "You're going to talk with some other children who had this surgery." 3. "If you have this surgery, your parents will buy you a new toy." 4. "Take this doll and show me where the operation will be done."

1) Implementation: outcome not desired; parents are encouraged to remain with child 2) Implementation: outcome not desired; appropriate only for school-aged and adolescent children 3) Implementation: outcome not desired; not appropriate 4) CORRECT - Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment

The nurse cares for a client being maintained on a ventilator. The client suddenly becomes distressed and agitated. Which of the following is the MOST appropriate action for the nurse to take? 1. Obtain an order for a tranquilizer. 2. Restrain the client. 3. Check the last arterial blood gas result. 4. Assess the client's breathing pattern in relation to the ventilator.

1) Implementation: outcome not desired; priority is to determine cause of distress 2) Implementation: outcome not desired; physical restraints are a last resort 3) Incorrect. A current ABG is needed to make any type of decision. 4) CORRECT-Assessment: outcome desired and priority; is client "fighting" the ventilator; symptoms of respiratory distress include restlessness, agitation, apprehension, irritability, pallor, use of accessory muscles, increased pulse; check airway, vital signs, and ABGs

The parents of a newborn boy ask the nurse whether they should have their son circumcised. Which response by the nurse is MOST appropriate? 1. "The benefits of the procedure usually outweigh the risks of bleeding and infection." 2. "You should ask your obstetrician or pediatrician to advise you." 3. "It is not mandatory that your son have a circumcision. What are your concerns?" 4. "Some parents worry about the pain associated with circumcision, but there is actually very little discomfort."

1) Implementation: outcome not desired; program of good hygiene provides advantages without risks of circumcision 2) Implementation: outcome not desired; passing the buck 3) CORRECT-Assessment: outcome priority; open communication; initial assessment: acknowledges parents' feelings 4) Implementation: outcome not desired; closed communication; nurse assumes that pain is the issue

The nurse teaches reality orientation to the husband of a woman with Alzheimer's disease and a moderate hearing loss. Which statement, if made by the client's husband, indicates that he understands this technique? 1. "I should ask my wife about current events we have discussed." 2. "I should reminisce with my wife about past events." 3. "I should frequently ask my wife for the date and time." 4. "I should place a calendar and clock in an obvious place."

1) Implementation: outcome not desired; short-term memory affected; unable to remember 2) Implementation: outcome not desired; will not reorient 3) Implementation: outcome not desired; can cause confusion, anxiety 4) CORRECT-Implementation: outcome desired and priority; use of memory aids and cues to help orientation; gives sense of security

A client is brought to the mental health center reporting severe headaches, insomnia, and poor appetite. Each time a question is asked, the client provides a lengthy, detailed description of events. Which of the following is the MOST important action for the nurse to take? 1. Remind the client of the time. 2. Tell the client that people are there to take care of her. 3. Sit and listen to the client. 4. Ask the client to be brief.

1) Implementation: outcome not desired; should allow client the time to express needs; non-therapeutic response 2) Implementation: outcome not desired; false reassurance; blocks communication 3) CORRECT- Implementation: outcome desired; assess first to meet client needs, allow client to express needs 4) Implementation: outcome not desired; non-therapeutic; nurse is controlling the interview

Bilirubin New Born

1-12

Billirubin newborn

1-12

Extended stage

1-4 days post-op

Immediate stage

1-4 hours post-op

A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? A. Use water and a cotton swab and rub the teeth B. Use diluted fluoride and rub the teeth with a soft washcloth C. Use a small amount of toothpaste and a soft-bristle toothbrush D. Dip the infant's pacifier in maple syrup so that the infant will suck

A. Use water and a cotton swab and rub the teeth

A nurse is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the nurse: A. Uses a tuning fork B. Asks the client to puff out the cheeks C. Tests taste perception on the client's tongue D. Checks the client's ability to clench the teeth

A. Uses a tuning fork

RBCs

4.2-6.1

- (Y) The clinic nurse is reviewing the laboratory results of an adult client seen in the health care clinic. The nurse determines that the white blood cell count (WBC) is normal if which of the following is noted on the laboratory results?

8400mcg/L

A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. A. Using tongs to collect any broken glass B. Wearing gloves for the cleanup procedure C. Placing the pieces of broken glass in a plastic bag D. Blotting up the spill with a face cloth or cloth towel E. Disinfecting the area of the blood spill with a dilute bleach solution

A. Using tongs to collect any broken glass B. Wearing gloves for the cleanup procedure E. Disinfecting the area of the blood spill with a dilute bleach solution

C Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? A. Uterine tenderness B. Lack of uterine activity C. Painless vaginal bleeding D. Constipation

A. Uterine tenderness

A client with heart failure and hypertension who has been admitted to the hospital is unable to make own selections from the menu. Which meal does the nurse select for the client's supper on the day of admission? A. Smoked ham, fresh carrots, boiled potato B. Hot dog in a bun, sauerkraut, baked beans C Turkey, baked potato, salad with oil and vinegar D. Shrimp, baked potato, salad with blue cheese dressing

C Turkey, baked potato, salad with oil and vinegar

A 74-year-old widower of 3 months says to the nurse, "When my wife died, I lost my love and my best friend. Everyone I cared about is dead. We both were only children, and we had no kids. I'm more than ready to go when the time comes." Which nursing response should the nurse make? A. "Are you thinking of ending your life because your time has come?" B. "Did you know that many people live happier lives without children?" C. "It must seem very lonely to you. I can't believe that you never had any children." D. "When my dad died, my mother said some of the things you're saying now, and she had three kids."

A. "Are you thinking of ending your life because your time has come?"

A female victim of incest says to the nurse, "I've had tons of therapy but still can't let my fiancé get too close. He knows I've been sexually abused by my dad and older brother, but I'm wondering whether I'll ever be able to lead a normal sexual life." Which statement by the nurse would be therapeutic? A. "Can you share with me some of the strategies you've been using?" B. "Do you want a normal sexual life? If you do, you will have one, I'm sure." C. "It almost seems that you're saying that you will never be able to love your fiancé." D. "You seem to be saying that you and your fiancé haven't been close, yet you found each another."

A. "Can you share with me some of the strategies you've been using?"

A client who was formerly a workaholic has lost his job and is being supported financially by his wife. The client says to the nurse, "I know that my wife is disappointed in me, but I can't seem to get a job doing what I've done for 25 years. Why should I take a low-level job when she's able to support us financially?" Which response by the nurse would be therapeutic? A. "Can you tell me a little more about this?" B. "I would dig ditches if it contributed to my family's well-being." C. "Sounds as if you're lucky to have your wife's job to fall back on." D. "I'm surprised that such a hardworking man is not able to find a job."

A. "Can you tell me a little more about this?"

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply. A. "Change positions slowly." Correct B. "Remove clutter from your home." Correct C. "Use public transportation as much as possible." D. "Drive your car only if you're not feeling dizzy." E. "Turn your head slowly when someone speaks to you."

A. "Change positions slowly." B. "Remove clutter from your home."

An older adult client who is dying says to the nurse, "My son is 40 years old, but he works in a very poorly paying job and is always borrowing money from me. I don't know how he's going to manage without me." Which response by the nurse would be therapeutic? A. "Could you share your feelings with your son just as you have with me?" B. "Sounds as if your son will never grow up and learn to take care of himself." C. "Goodness. At 22, I supported myself and never asked my mother for anything." D. "I wonder why you're so worried about your adult son when you need to concentrate on you?"

A. "Could you share your feelings with your son just as you have with me?"

Which of the following statements reflect the principles of sterile technique? Select all that apply. A. The edge of a sterile field and a border 1 inch inward is unsterile. B. If a package is not labeled as sterile, it should be considered unsterile. C. Sterile objects that come in contact with unsterile objects are to be considered contaminated. D. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched. E. When a sterile field becomes wet, it remains sterile as long as the items on the field are not touched. F. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.

A. The edge of a sterile field and a border 1 inch inward is unsterile. B. If a package is not labeled as sterile, it should be considered unsterile. C. Sterile objects that come in contact with unsterile objects are to be considered contaminated F. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.

The nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes? A. The health care provider was called to clarify the prescription for morphine sulfate. B. The health care provider made an error in the written prescription for morphine sulfate. C. The health care provider was called to correct an error in the dosage of morphine sulfate. D. An incorrect dosage of morphine sulfate was prescribed and the health care provider was notified.

A. The health care provider was called to clarify the prescription for morphine sulfate.

An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client's parents but is unsuccessful. In regard to informed consent for the surgery: A. The nurse understands that consent is not needed B. The nurse will contact the hospital clergy to provide informed consent C. The nurse will sign informed consent on behalf of the client and ask another nurse to witness the signature D. The nurse will prepare the client to undergo mechanical ventilation until the client's parents can be contacted

A. The nurse understands that consent is not needed

A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which? A. The tube is patent B. There is probably a kink in the tubing C. Suction should be added to the system D. The client is retaining airway secretions

A. The tube is patent

A client who has been taking lisinopril complains to the nurse of a persistent dry cough. What should the nurse tell the client? A. This is a side effect of therapy B. He probably has an upper respiratory infection C. He needs to have his blood counts checked D. A chest x-ray is required because the cough is a sign of heart failure

A. This is a side effect of therapy

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction? A. To increase the intake of legumes B. That seafood should be included in the diet C. That organ meats should be included in the diet D. To have at least one serving each day of a citrus fruit

A. To increase the intake of legumes

A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. What should the nurse tell the mother? A. To secure the infant in the middle of the back seat in a rear-facing infant safety seat B. To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant C. That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags D. That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car

A. To secure the infant in the middle of the back seat in a rear-facing infant safety seat

A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety? Select all that apply. A. Untacked rugs on the stairs B. Small rugs in the living room C. Carpet on stairs secured with tacks D. Clothes hamper at the end of the hallway E. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

A. Untacked rugs on the stairs B. Small rugs in the living room E. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's urinary output and laboratory values, anticipating which about the client? A. Urine output will be decreased B. Urine production will be increased C. Serum osmolality will be decreased D. Urine specific gravity will decreased

A. Urine output will be decreased

A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). What should the nurse tell the adolescent? A. Use of a latex condom can prevent transmission of STIs B. The only way to prevent transmission of STIs is abstinence C. Use of a latex condom is a good method for preventing pregnancy D. A spermicide needs to be used along with a condom to prevent transmission of STIs

A. Use of a latex condom can prevent transmission of STIs

A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A. Use the AED B. Stop the resuscitation efforts C. Perform CPR until emergency medical services arrives D. Check for a pulse for 30 seconds before continuing CPR

A. Use the AED

14. A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? • Most herbs are toxic or carcinogenic and should be used only when proven effective. • There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. • Herbs should be obtained from manufacturers with a history of quality control of their supplements. • Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

ANS - Herbs should be obtained from manufacturers with a history of quality control of their supplements. Rationale - The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading

25. A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? • May I ask your daughter to help you with your personal hygiene? • I will ask one of the female nurses to bathe you. Correct • A staff member on the next shift will help you. • I will keep you draped and hand you the supplies as you need them.

ANS - I will ask one of the female nurses to bathe you. Rationale - Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task (B). (A and D) are less respectful of the client's cultural and spiritual preferences. (C) delays the client's care.

19. An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? • Use a mechanical lift to transfer from the bed to a chair. • Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. • Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. • Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. Correct

ANS - Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. Rationale - A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams

After an earthquake, four groups of clients are given different tags in accordance with the disaster triage tag system. What is the correct order of treatment priority for each group? a. Red Tags b. Yellow Tags c. Green Tags d. Black Tags

ANS - RED, YELLOW, GREEN and BLACK tags in order for treatment.

9. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? • Check for a blood return. • Reposition the client's arm. Correct • Remove the IV site dressing. • Flush the lock with saline.

ANS - Reposition the client's arm. Rationale - If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion.

10. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? • Sensory pattern, area, intensity, and nature of the pain. Correct • Trigger points identified by palpation and manual pressure of painful areas. • Schedule and total dosages of drugs currently used for breakthrough pain. • Sympathetic responses consistent with onset of acute pain.

ANS - Sensory pattern, area, intensity, and nature of the pain. Rationale - The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A).

23. What is the most effective way to implement a teaching plan? • Teach the information that the client wants to learn first. • Streamline the teaching plan to include only essential information. • Present to the client all the information necessary to meet the objectives. • Provide the client with written material to review before teaching sessions.

ANS - Teach the information that the client wants to learn first. Rationale = Teaching is most effective when it responds to the learner's needs, and learning begins when a person identifies a need for knowing or acquiring an ability to do something (A). (B and C) provide widely varied amounts of content, each of which should consider an individual's learning styles, level of education, reading ability, culture, age, and readiness to learn. Providing written information (D) may or may not be the best way to teach when various learning styles and other client factors are considered. Category: Fundamentals

Nurses Lab Q17: All of the following characteristics would indicate to the nurse that an elder client might experience undesirable effects of medicines except: A. increased oxidative enzyme levels. B. alcohol taken with medication. C. medications containing magnesium. D decreased serum albumin.

ANSWER: A. increased oxidative enzyme levels. RATIONALE: Oxidative enzyme levels decrease in the elderly, which affects the disposition of medication and can alter the therapeutic effects of medication. Alcohol has a smaller water distribution level in the elderly, resulting in higher blood alcohol levels. Alcohol also interacts with various drugs to either potentate or interfere with their effects. Magnesium is contained in a lot of medications elder clients routinely obtain over the counter. Magnesium toxicity is a real concern. Albumin is the major drug-binding protein. Decreased levels of serum albumin mean that higher levels of the drug remain free and that there are less therapeutic effects and increased drug interactions.

1. The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? • The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. • The client tells the nurse that she does not have much of an appetite today. • The nurse notes that there are numerous scatter rugs throughout the house. • The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Ans 3 - The nurse notes that there are numerous scatter rugs throughout the house. Rationale - Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.).

A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first? A. Irrigate the catheter B. Reposition the client C. Check the system for kinks D. Hang the second exchange and continue to monitor the outflow

C. Check the system for kinks

An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? A. "It is caused by hereditary factors." B. "A loss of melanin occurs in the normal aging process." C. "The skin on the scalp becomes thin, causing moisture to escape." D. "The number of sweat glands and blood vessels decreases in the normal aging process."

B. "A loss of melanin occurs in the normal aging process."

A nurse is providing instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in one week. Which statement does the nurse make to the client? A. "If you are menstruating, use pads instead of a tampon." B. "Avoid intercourse for 24 hours before the scheduled examination." C. "Get a douching kit from the pharmacy and douche 2 hours before the examination." D. "If you are having a vaginal discharge, obtain a sample of the discharge for inspection."

B. "Avoid intercourse for 24 hours before the scheduled examination."

A 52-year-old client is admitted to the hospital for surgery to treat lung cancer. The client says to the nurse, "I was an alcoholic for 15 years, and now that I'm 25 years sober, I'm being punished." Which statement by the nurse would be therapeutic? A. "You started drinking at 12 years of age — is that why you feel that the cancer is retribution?" B. "Because you seem to be blaming yourself unnecessarily, perhaps we can talk about your illness and what you can expect after surgery." C. "Sounds like you feel that you're being punished for your drinking, yet you've been sober, so perhaps you're being rewarded by having a cancer that's curable." D. "You feel that you're being punished even though you've been sober for 25 years. Your doctor must have told you that the cancer is unrelated to alcohol."

B. "Because you seem to be blaming yourself unnecessarily, perhaps we can talk about your illness and what you can expect after surgery."

A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time? A. 48 units/L (0.816 μkat/L) B. 97 units/L (1.649 μkat/L) C. 150 units/L (2.55 μkat/L) D. 395 units/L (6.715 μkat/L)

D. 395 units/L (6.715 μkat/L)

The nurse reviewing a client's record sees that the following medications are prescribed. Which medication should the nurse plan to administer first? Client Medications 1. Atorvastatin (Lipitor) 10 mg orally 2. Zolpidem (Ambien) 5 mg orally daily 3. Ferrous sulfate (Feosol) 1 tablet orally 4. Levothyroxine (Synthroid) 137 mg orally A. 1 B. 2 C. 3 D. 4

D. 4

A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately: A. Documents the event B. Notifies the healthcare provider C. Checks the client's bladder for distention D. Checks to see whether the client has a prescription for an antihypertensive

C. Checks the client's bladder for distention

A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu? A. Spare ribs, rice, gelatin, tea B. Pasta, garlic bread, ginger ale C. Chicken breast, broccoli, strawberries, milk D. Peanut butter and jelly sandwich, chocolate cake, tea

C. Chicken breast, broccoli, strawberries, milk

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client's laboratory work that the client's hematocrit is normal? A. 10% ( 0.10) B. 22% ( 0.22) C. 30% ( 0.30) D. 43% ( 0.43)

D. 43% ( 0.43)

A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse? A. "You really need to ask your doctor about that." B. "That's hard to say. We won't know for a week or two." C. "Antibiotic therapy is usually prescribed and will cure the infection." D. "It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly."

C. "Antibiotic therapy is usually prescribed and will cure the infection."

The wife of a client who is dying says to the nurse, "I am able to take off the 6 months from work our doctor feels that my husband will live, but what if he lives beyond that time?" Which therapeutic response should the nurse make? A. "Only you and your husband can determine how you should best allocate your work leave." B. "Your husband has managed to be active up to now, so he could live longer than predicted, but his actual lifespan remains unclear." C. "Are there other options for you in taking work leave? Perhaps you could simply reduce your work hours at first so that you can extend your compassionate leave." D. "Why not write down the pros and cons of taking work leave all at once and any other options and then decide with your husband and family which would be most helpful?"

C. "Are there other options for you in taking work leave? Perhaps you could simply reduce your work hours at first so that you can extend your compassionate leave."

A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and states, "My priest assaulted me when I was an altar boy, and my dad just found out. He's got a gun, and he's driving over to the church rectory. I don't know what to do." Which response by the nurse is most appropriate initially? A. "How did your dad learn of your abuse by clergy?" B. "Call the police immediately and then call the priest to warn him that your dad has a gun." C. "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police." D. "You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened."

C. "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police."

A client who delivered a baby 4 weeks ago says, "I'm feeling as if I'm hanging on by a thread to keep my wits about me." Which statement by the nurse would be therapeutic? A. "Can your husband help you with the baby and your chores? Is he on paternity leave? B. "You have a beautiful new baby, and caring for her will help you feel better. Your hormones will be back in balance soon." C. "Can you share with me more specifically how you feel that you're hanging on by a thread? Are you having thoughts of hurting yourself?" D. "You seem to be experiencing postpartum depression. I suggest that you have someone take your baby for a while until your hormones level off."

C. "Can you share with me more specifically how you feel that you're hanging on by a thread? Are you having thoughts of hurting yourself?"

A 32-year-old married woman who recently gave birth to her first child by cesarean section says, "My husband and I worry about our baby all the time. We did everything right, yet he had so many problems at birth." Which statement by the nurse would be therapeutic? A. "I'd like to ask you a series of parenting questions to determine your fitness." B. "What's been happening since you all came home? As I understand it, the baby is thriving." C. "Can you tell me more about the worrying? What's been happening since you brought your baby home?" D. "Lots of women do everything right but wind up having cesarean sections. Why worry when it won't change anything?"

C. "Can you tell me more about the worrying? What's been happening since you brought your baby home?"

A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? A. "I can mix the food in the my infant's bottle if he won't eat it." B. "Fluoride supplementation is not necessary until permanent teeth come in." C. "Egg white should not be given to my infant because of the risk for an allergy." D "Meats are really important for iron, and I should start feeding meats to my infant right away."

C. "Egg white should not be given to my infant because of the risk for an allergy."

A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through." Which statement by the nurse would be most therapeutic? A. "The voices will disappear in a few weeks as your hormones stabilize." B. "This must be very distressing to you. Can you tell me more about the voices?" C. "It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices." D. "You will want to tell the health care provider about them when you visit him next week. He is very interested in these voices and will want to help you with them."

C. "It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices."

The client says to a nurse, "Do you know that after 24 years of marriage I still serve my husband breakfast in bed? After all I do for him, he still doesn't treat me well. He should treat me better." Which nursing response is appropriate? A. "You know, you could work and make money serving food to people." B. "I agree. If you can do all that for your husband, he should treat you better." C. "It seems that you feel that your husband could treat you well just as you treat him." D. "Ask your husband to do the things you'd like. If he doesn't, tell him you're leaving him."

C. "It seems that you feel that your husband could treat you well just as you treat him."

A client in skeletal traction says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me she had other patients besides me! I'm very sick, but the nurses don't care!" Which response by the nurse would be therapeutic? A. "You poor thing! I'm so sorry this happened to you. That nurse should be reported!" B. "I think you're being very impatient. The nurses work very hard and come as quickly as they can." C. "It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?" D. "I can hear your anger. That nurse had no right to speak to you that way. I will report her to the director. It won't happen again."

C. "It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?"

The young nurse has just completed postmortem care of a 16-year-old client who died of cancer. The nurse says to the nurse manager, "I never get sick, and this client kept telling me that he couldn't remember not being ill. I feel terrible and so bad for him and about what he went through." Which statement by the nurse manager would be therapeutic? A. "Next time, take someone else in with you for postmortem care, OK?" B. "Your feelings are normal and will go away after a good night's sleep." C. "Let's go for coffee and talk about this some more, shall we? We're both due for our coffee breaks." D. "I should never have assigned you someone so close to your own age. I'll be more careful in the future."

C. "Let's go for coffee and talk about this some more, shall we? We're both due for our coffee breaks."

As the nurse prepares to interview a client being admitted to the mental health unit, the client says, "I asked my family to bring me in here to talk to someone, but now I don't know where to begin." Which response by the nurse would be most helpful? A. "Why not just start talking and see where it takes you?" B. "If I were you, I'd begin with what you were doing this morning." C. "Perhaps you can start by sharing some of your most recent concerns." D. "Don't worry. Everyone who comes in here for the first time feels reluctant to talk."

C. "Perhaps you can start by sharing some of your most recent concerns."

A client says to the nurse, "I was cheating on my lover because I need the thrill of seeing someone new, and now my lover has left me to go live with this other woman. I know that this other woman wants more than friendship from my lover, and I can't make my lover see that I love her and that my affairs are meaningless. I don't want to lose her, but I can't stop cheating, because I need the thrill it brings." Which statement by the nurse would be therapeutic? A. "So she's left you for cheating on her. If you can't be monogamous, I guess you'll have to be content with one-night stands." B. "I'm confused. What is it that you've come to me for? It sounds like your lover refuses to share her lover with others, no matter how trivial the dalliances." C. "Perhaps your task is not to make your lover see that your dalliances are meaningless but to look at your own behavior and determine what you would like or not like to be different." D. "It sounds like you want to have your cake and eat it, too. If you can't have both things, which would you prefer — the thrills of one-night stands or the steady support of a loving relationship?"

C. "Perhaps your task is not to make your lover see that your dalliances are meaningless but to look at your own behavior and determine what you would like or not like to be different."

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding? A. "The care map is developed by a nurse and identifies nursing diagnoses." B. "The care map is a plan that is used only by the nurse to provide client care." C. "The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge." D. "The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis."

C. "The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge."

A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes this as an example of which speech pattern? A. Echolalia B. Tangential speech C. Clang associations D. Loosened associations

C. Clang associations

A schizophrenic client exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic? A. "Got it. The 'blinks' are 'taking over' the 'bumpers.'" B. "I can't understand what you're saying. You have to talk more clearly!" C. "This morning you are participating in the tree-decorating ceremony for the unit." D. "I can't understand you. Are you asking me to stay with you while you eat supper?"

C. "This morning you are participating in the tree-decorating ceremony for the unit."

A client in a retirement center rings the night alarm and says to the nurse, "Look at this old man! He keeps breaking into my apartment! You've got to get him to stay out of here so I can sleep." Which statement by the nurse would be most therapeutic? A. "Why not just throw him out yourself and lock up once and for all?" B. "Now, you know that you're always seeing things and people at night who aren't there." C. "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest." D. "I'm sure you're very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he'll leave your apartment."

C. "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest."

A client says to the nurse, "I came in to see you because I've been off my medication for 4 years but I feel as though I may be getting depressed again. I've been despondent again and thinking I should have ended it. That's why I'm here to get help." Which response by the nurse would be therapeutic? A. "Well, you really have had a good long drug-free time, but it sounds as if the health care provider needs to reorder your medication at once." B. "If you've been able to be drug free all this time, you probably don't need to restart the medicine. You probably just need some therapy to help you manage stress." C. "Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?" D. "Well, it's similar to when a client is battered — things have to boil over before the police can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before the health care provider can restart the medication."

C. "Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?"

Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. A. "When did you have your last full meal?" B. "Do you have a history of diabetes insipidus?" C. "When was your last drink of alcohol?" D. "Do you have a history of thyroid problems?" E. "Do you have a history of cancer in your family?"

C. "When was your last drink of alcohol?" D. "Do you have a history of thyroid problems?"

A client says to the nurse, "I have to do everything. My family can't plan or organize anything. My wife just wants to go out and socialize. My grown son and his wife live with us. They never do anything around the house but 'their' stuff, because they say they pay rent. We really need their rent money since I lost my job. My wife could work but she says 'it's too late to start over' for her. Well, that's what I'm doing—more work at far less money." Which response by the nurse would be therapeutic? A. "Do the terms 'divorce' and 'leave the nest' mean anything to you or your family?" B. "Would your family come in to see me so I can hear their version of the problems you cite?" C. "You seem to be going through quite a lot recently. I'd like to hear more from you about your concerns. Would your family come in and talk with us?" D. "You tell me that you do everything. You don't say what happens when you stop doing everything. Does your wife understand that you are not able to work as you once did and that you need her help?"

C. "You seem to be going through quite a lot recently. I'd like to hear more from you about your concerns. Would your family come in and talk with us?"

A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for the rest of my life." Which response by the nurse is therapeutic? A. "What are you saying? Sounds like you need to pull yourself together and go back to school." B. "Having faith in yourself is one thing, but looking at your alternatives realistically is another." C. "You seem to be saying that your choices are final and that you've lost any other opportunities." D. "Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get."

C. "You seem to be saying that your choices are final and that you've lost any other opportunities."

A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, "Well, I'm feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney." Which response by the nurse is most appropriate? A. "Good grief! You don't look organized to me." B. "Okay, what are you up to today? Your behavior is not appropriate." C. "You talk about getting organized. Are you thinking of killing yourself?" D. "If you keep behaving like this, you know that I'll have to tell the health care provider, and we'll have to seclude you."

C. "You talk about getting organized. Are you thinking of killing yourself?"

A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication." Which response by the nurse is appropriate? A. Telling the parents, "Medication noncompliance is the most frequent reason that people with this diagnosis relapse." B. Telling the parents, "Well, it's his decision to take his medicine, but it's yours to have him live with you if he stops the medication." C. Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?" D. Saying to the parents, "Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication."

C. Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?"

A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? A. Calling the nursing supervisor to obtain permission to accept the verbal prescription B. Changing the solution and rate of the IV fluid per the physician's verbal prescription C. Asking the health care provider to write the prescription in the client's record before leaving the nursing unit D. Telling the health care provider that the prescription will not be implemented until it is documented in the client's record

C. Asking the health care provider to write the prescription in the client's record before leaving the nursing unit

A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which action? A. Asking the client to take slow, deep breaths B. Removing the catheter and contacting the health care provider (HCP) C. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon D. Aspirating the fluid, withdrawing the catheter slightly, and reinflating the balloon

C. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). A. Clamp the chest tube B. Chang the drainage system C. Assess the system for an external air leak D. Reduce the degree of suction being applied E. Document assessment findings, actions taken, and client response

C. Assess the system for an external air leak

A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act to: A. Identify healthcare policies in her state B. Know how to perform certain procedures C. Be aware of the role of the professional nurse D. Be aware of hospital and long-term care facilities policies

C. Be aware of the role of the professional nurse

The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. What should the nurse tell the mother? A. Hepatitis B is a concern with body piercing B. Infection always occurs when body piercing is done C. Body piercing is generally harmless as long as it is performed under sterile conditions D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)

C. Body piercing is generally harmless as long as it is performed under sterile conditions

The wife of a client with angina pectoris calls the health care provider's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client's wife to: A. Have her husband rest and, if no relief is obtained, call back B. Discuss the situation with the doctor, who will call her as soon as he gets into the office C. Call Emergency Medical Services to take her husband to the emergency department (ED) immediately D. Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED

C. Call Emergency Medical Services to take her husband to the emergency department (ED) immediately

A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs the first action is to: A. Induce vomiting B. Call an ambulance C. Call the poison control center D. Bring the child to the emergency department (ED)

C. Call the poison control center

A nurse manager of an emergency department (ED) arrives at work and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services (EMS) has just called to report that several victims involved in a 10-car wreck on the interstate will be brought to the ED. The nurse manager initially manages this situation by: A. Telling EMS to take the victims to another hospital B. Closing the emergency department temporarily to incoming clients C. Calling the nursing supervisor to discuss activation of the disaster plan D. Demanding that the nurses from the night shift stay until all of the victims have been treated

C. Calling the nursing supervisor to discuss activation of the disaster plan

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. How should the nurse interpret this data? A. Is legally blind B. Has normal vision C. Can read at a distance of 20 feet what a client with normal vision can read at 80 feet D. Can read at a distance of 80 feet what a client with normal vision can read at 20 feet

C. Can read at a distance of 20 feet what a client with normal vision can read at 80 feet

A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? A. Call the health care provider B. Increase the rate of the IV infusion C. Check the client's overall intake and output record D. Administer a 250-mL bolus of normal saline solution (0.9%

C. Check the client's overall intake and output record

Before administering a prescribed dose of tetracycline, what serum lab test should the nurse monitor?

Creatine

Acute pancreatitis

Cullen's sign (periumbelical discoloration) and Turner's sign (blue flank)

Intussiception

Current jelly stool (blood and mucus) and sausage-shaped mass in RUQ

Skin tastes salty

Cystic fibrosis

During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client? A. "When was your last gynecological checkup?" B. "Have you been engaging in unprotected sexual intercourse?" C. "Don't worry about the discharge. Some vaginal discharge is normal." D. "I need some more information about the discharge. What color is it?"

D. "I need some more information about the discharge. What color is it?"

A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client? A. "Don't be concerned; any 2-year-old would welcome a newborn." B. "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." C. "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned." D. "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."

D. "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."

A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease? A. "Has he had any loss of appetite?" B. "Has he complained of a backache recently?" C. "Has he been excessively tired or lethargic?" D. "Has he had a sore throat in the last few months?"

D. "Has he had a sore throat in the last few months?"

A schizophrenic client attending a support group held by a clinic nurse says to the nurse and the group, "I've been laid off from my job at the factory, and so have 300 other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be most therapeutic at this time? A. "It seems that the stock market is responsible for mass unemployment in our factory-based city." B. "I'm sorry to hear that you've lost your job. Why not make an appointment to come in and talk with me this week?" C. "How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?" D. "Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."

D. "Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."

A nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm? A. "I need to reapply spermicidal cream with repeated intercourse." B. "The diaphragm needs to be filled with spermicidal cream before insertion." C. "The diaphragm can be inserted as long as 6 hours before intercourse." D. "I can leave the diaphragm in place as long as I want after intercourse."

D. "I can leave the diaphragm in place as long as I want after intercourse."

A client says to the nurse, "I'm really phobic about flying, so my husband and I always drove or took the train everywhere. Now he's been offered a big job in Europe, and if I don't get over this and fly with him, he says we're done. I'll be left to bring up our three children by myself." Which statement by the nurse would be therapeutic? A. "No problem. You can be hypnotized to sleep through your trip." B. "I'm interested that it took his threat of leaving you to motivate you to seek help." C. "You seem more anxious and afraid of raising three children alone than of flying." D. "I can teach you strategies to help master your panic. An anti-anxiety medicine would also help you."

D. "I can teach you strategies to help master your panic. An anti-anxiety medicine would also help you."

A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, "The voice in my head is telling me that you're cheating." Which response by the nurse is therapeutic? A. "Is the voice telling you to do anything?" B. "I don't believe that you are hearing voices." C. "It isn't possible for people to hear voices in their head." D. "I do not hear any voices. Has the voice said anything else?"

D. "I do not hear any voices. Has the voice said anything else?"

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager? A. "I'm not working overtime today." B. "You know how I hate to work overtime." C. "I will if you need me, but I am not happy about this." D. "I have plans after work and will not be able to work overtime."

D. "I have plans after work and will not be able to work overtime."

A manic client who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite.'" Which statement by the nurse would be most therapeutic? A. "When you can speak to me without yelling and being aggressive, I'll be happy to speak with you." B. "Just get your anger out with me, because we're not going to allow you be discharged until you calm down." C. "Do threats and name-calling usually work for you? Do people tend to listen to you and do as you order them to?" D. "I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."

D. "I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."

An alcoholic client who has been admitted to the mental health unit states to the nurse, "The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled me over in my car." Which statement by the nurse is most appropriate? A. "Did you ask the judge to clarify his decision to make you come here?" B. "This limit means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level." C. "Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don't you agree?" D. "This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."

D. "This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."

A 2-year-old child is a suspected victim of child abuse and the nurse is interviewing the child's parent. Which statement by the parent indicates the possibility of child abuse? A. "My child can't be expected to learn everything at once." B. "I can expect my child to talk using some words at this age." C. "I expect my child to try doing some things without my help." D. "When I tell my child to do something, I don't expect to have to repeat myself."

D. "When I tell my child to do something, I don't expect to have to repeat myself."

A young adult client says to the nurse, "All my friends are married and have children. I can't seem to meet anyone, and I know I'll never be happy until I meet someone I can care about enough to marry." Which statement by the nurse would assist the client in reframing the situation? A. "Sounds as if you're exaggerating your situation and looking only at the half-full glass." B. "It seems that you measure your life and what you need to do against the behaviors of others." C. "Aren't you a little young to be thinking in such negative terms? You do still have plenty of time before your biological clock winds down." D. "You can't seem to meet someone that you care about? You can still find enjoyment in friendships, work, books, and other things as well."

D. "You can't seem to meet someone that you care about? You can still find enjoyment in friendships, work, books, and other things as well."

A client who witnessed her husband being shot and killed in an incident of road rage says to the nurse, "It's been 3 months now, and I still can't drive my car without acting crazy. My sister says I grip the wheel like I'm glued to it. I can't merge with traffic until it's almost completely clear, and I'm parking a mile from in the mall when there's plenty of parking close to the building." Which statement by the nurse would be therapeutic? A. "I still grip the wheel when I merge with traffic, and I just wonder whether your sister needs to see me do it." B. "If I were you, I'd have trouble driving the car again. Driving a car and being the victim of road rage are two very different things, and you need therapy and time to heal." C. "Smart of you to take no chances. You should see the dents and dings on my car from mall parking. Does your sister depend on you for many things? It seems like she's pushing you too hard." D. "You're seeking help appropriately, and there are many things you can do to get comfortable behind the wheel again. You've returned to driving, but remember, you're still grieving. It's normal to still feel this way."

D. "You're seeking help appropriately, and there are many things you can do to get comfortable behind the wheel again. You've returned to driving, but remember, you're still grieving. It's normal to still feel this way."

A student calls the campus crisis hotline and tells the nurse, "I went out to a sorority party last week and drank too much. Someone raped me, but when I told my folks about it, they acted like it was my fault. I feel so dirty and used." Which statement by the nurse would be most therapeutic? A. "Would you come in to talk with me in the strictest confidence?" B. "I believe that you can feel a lot better about yourself. Won't you come in to see me tomorrow?" C. "Parents always feel that their daughters could never be raped. I could talk to them for you, if you'll let me." D. "You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"

D. "You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"

A client says to the nurse at the mental health clinic, "My husband and sister-in-law both have terminal illnesses, and my family thinks that because I'm a nurse I should be able to handle everything." Which nursing response would be therapeutic? A. "Are you saying you are overly involved and will need to emotionally distance yourself to be therapeutic for your family?" B. "Shame on them for expecting so much from you. Perhaps we need to schedule a family meeting so I can help you set them straight." C. "I'm sorry to hear that your loved ones are so ill. As a nurse, you should be able to assist them by using your professional expertise. Perhaps that's what your family expects from you." D. "You've seen your loved ones dealing with some troubling events recently. Sounds as if you feel that your family expects more from you than from others in the family because you're a nurse."

D. "You've seen your loved ones dealing with some troubling events recently. Sounds as if you feel that your family expects more from you than from others in the family because you're a nurse."

A client whose adolescent son committed suicide by hanging himself in the family's garage says to the nurse, "The coroner just informed us that our son had AIDS." Which response to the client by the nurse is appropriate? A. "You didn't know that he had AIDS? How did he see the family health care provider without your knowing?" B. "Your poor son. How troubled he must have been. It's a shame he couldn't talk to you and get some help." C. "Your son had an autopsy because he committed suicide, but the coroner didn't have to tell you that he was ill." D. "Your son was keeping a very troubling diagnosis to himself. I am so sorry. No matter how close and loving children are to their parents, some children just aren't able to confide in their parents."

D. "Your son was keeping a very troubling diagnosis to himself. I am so sorry. No matter how close and loving children are to their parents, some children just aren't able to confide in their parents."

A client's baseline vital signs are temperature 98° F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103° F. Which respiratory rate would the nurse anticipate as part of the body's response to the change in client status? A. 12 breaths/min B. 16 breaths/min C. 18 breaths/min D. 22 breaths/min

D. 22 breaths/min

A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client's headache D. Administration of a subcutaneous injection of epinephrine (Adrenalin)

D. Administration of a subcutaneous injection of epinephrine (Adrenalin)

A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves: A. Administering a local anesthetic to the fractured arm B. Soaking the left arm in a warm-water bath for 2 hours before cast application C. Debriding any open wounds and applying antibiotic ointment before the cast material is applied D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material

D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material

The nurse is teaching assertiveness training to a client with anger-management issues. Which instruction would the nurse give for helping the client assertively confront someone? A. Emphasize how much you like the person but insist that the other person make the changes you need. B. Tell the person that the behavior has become intolerable for you and that the behavior must be changed immediately. C. Demonstrate that you understand how the other person feels but state that you still expect the other person to make the changes you need. D. Ask for private time to talk and point out the facts without being accusatory, then determine areas of mutual misunderstanding and request the changes you need.

D. Ask for private time to talk and point out the facts without being accusatory, then determine areas of mutual misunderstanding and request the changes you need.

A nurse asks an unlicensed assistive personnel (UAP) to provide afternoon care to a client. The nurse expects that the UAP will take which action? A. Give the client a complete bed bath B. Ask the client whether he would like to wash his face C. Give the client a back massage and prepare the client for sleep D. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

D. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? A. Tape the tube in place B. Send the client for a chest x-ray C. Note how far the tube has been inserted D. Auscultate both lungs for the presence of breath sounds

D. Auscultate both lungs for the presence of breath sounds

The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? A. Initiative versus guilt B. Trust versus mistrust C. Industry versus inferiority D. Autonomy versus doubt and shame

D. Autonomy versus doubt and shame

A client requires a partial bed bath. The nurse, giving instructions to an unlicensed assistive personnel (UAP) about the bath, tells the UAP to take which action? A. Just wash the client's hands and face B. Provide mouth care and perineal care only C. Let the client decide what she wants washed D. Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

D. Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

A client requests the use of an alternative or complementary therapy to help control pain and asks about the use of guided imagery. The nurse responds by telling the client that in this technique, the clientwill experience which? A. Become totally unaware of pain B. Ignore the pain by focusing on the alternate activity C. Alter pain perception though the influence of positive suggestion D. Become less aware of pain by creating and then concentrating on a mental image

D. Become less aware of pain by creating and then concentrating on a mental image

A client tells the nurse that during the past 2 weeks her urine output has been greater than usual. The nurse, gathering subjective data from the client, should most appropriately ask the client about which? A. Has she been regularly exercising B. Has she been experiencing headaches C. Has she been having heavy menstrual cycles D. Has she been drinking an excessive amount of coffee

D. Has she been drinking an excessive amount of coffee

A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hyperemia, and explains to the client that this condition is caused by which? A. Contraction of the underlying blood vessels B. A reduced amount of bilirubin in the blood C. Diminished perfusion of the surrounding tissues D. Excess blood in the dilated superficial capillaries

D. Excess blood in the dilated superficial capillaries

A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will: A. Limit activity for 24 hours B. Take acetaminophen for discomfort C. Leave the eye patch in place until he has been seen by the health care provider D. Expect to experience pain, nausea, and vomiting after the procedure

D. Expect to experience pain, nausea, and vomiting after the procedure

A single mother whose only son died 2 months ago says to the nurse, "I've been bothered at work with thoughts of my son. Suddenly I'll think of something awful I said to him years ago or some punishment I gave him because he'd been bad." Which plan should the nurse include in caregiving? A. Scheduling the client for an appointment with the psychiatrist, because this is a pathological manifestation. B. Calling the health care provider to report that the client is a high risk for suicide and increasing the frequency of visits with the client. C. Seeking emergency certification for the psychiatric inpatient unit at the community hospital because of high lethality concerns and visiting the client daily. D. Explaining that bereaved persons often describe intrusive thoughts of negative experiences with the deceased and then increasing the frequency of nurse-client visits.

D. Explaining that bereaved persons often describe intrusive thoughts of negative experiences with the deceased and then increasing the frequency of nurse-client visits.

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? A. Loud music B. Use of power tools C. Occupational noise D. Exposure to cigarette smoke

D. Exposure to cigarette smoke

A nurse is providing instructions to an unlicensed assistive personnel (UAP) about effective measures for communicating with a hearing-impaired client. The nurse instructs the UAP to: A. Raise his voice when talking to the client B. Talk directly into the client's impaired ear C. Be cordial and smile when talking to the client D. Face the client when talking, keeping the hands away from the mouth

D. Face the client when talking, keeping the hands away from the mouth

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the: A. Second left interspace B. Second right interspace C. Left lower sternal border D. Fifth left interspace at the midclavicular line

D. Fifth left interspace at the midclavicular line

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after delegation of the tasks is: A. Documenting completion of each task B. Assigning any tasks that were not completed to the next nursing shift C. Allowing each staff member to make judgments when performing the tasks D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task.

D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task.

Betaxolol eye drops have been prescribed for the treatment of a client's glaucoma. The nurse tells the client to return to the clinic for follow-up for which purpose? A. To have weight checked B. To give a sample for urinalysis C. To have the blood glucose level checked D. For measurement of blood pressure and apical pulse

D. For measurement of blood pressure and apical pulse

A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? A. Recheck the score in 5 minutes B. Initiate cardiopulmonary resuscitation C. Provide no action except to support the infant's spontaneous efforts D. Gently stimulate the infant by rubbing his back while administering oxygen

D. Gently stimulate the infant by rubbing his back while administering oxygen

The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? A. Schedule an appointment with a dentist for a dental evaluation B. Rub the infant's gums with baby aspirin that has been dissolved in water C. Obtain an over-the-counter (OTC) topical medication for gum-pain relief D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast

D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast

A nurse notes documentation in a client's medical record indicating that the client is experiencing oliguria. On the basis of this notation, the nurse determines which about the client when planning care? A. Is unable to produce urine B. Is voiding large amounts of urine C. Has difficulty with leakage of urine D. Has a diminished capacity to form urine

D. Has a diminished capacity to form urine

A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse hould provide the clent with which information about a cold pack? A. Reduces muscle tension B. Dilates the blood vessels C. Promotes muscle relaxation D. Reduces blood flow to the extremity

D. Reduces blood flow to the extremity

A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures: A. Near vision B. Color vision C. Distant vision D. Peripheral vision

D. Peripheral vision

The nurse plans to wear this protective mask (see figure) when caring for clients with certain disorders. What are these disorders? Select all that apply. A. Scabies B. Hepatitis A C. Tuberculosis D. Pharyngeal diphtheria E. Streptococcal pharyngitis F. Meningococcal pneumonia

D. Pharyngeal diphtheria E. Streptococcal pharyngitis F. Meningococcal pneumonia

A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid? A. Lettuce B. Oranges C. Broccoli D. Pinto beans

D. Pinto beans

A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? A. Call the health care provider B. Check the hourly urine output C. Check the IV site for infiltration D. Place the client in a modified Trendelenburg position

D. Place the client in a modified Trendelenburg position

A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve? A. Asking the client to stick out his or her tongue and watching the client for tremors B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says "ah." D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention should the nurse implement? A. Placing the client in a private room and locking the client's closets and bathroom B. Placing the client in a private room and removing all knives and glass from the client's meal tray C. Allowing the client to go out on pass as long as the client is accompanied by a responsible adult D. Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times

D. Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times

A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which sign of DVT, the most common, does the nurse assess the client? A. Cough B. Hemoptysis C. Diaphoresis D. Pleuritic chest pain

D. Pleuritic chest pain

Which of the following situations is an example of the use of evidence-based practice in the delivery of client care? A. Encouraging a client who has had a stroke to consume thin liquids and foods B. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab C. Immediately picking up a dislodged radiation implant with gloved hands and placing it in a lead container D. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

D. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

A community health nurse is asked to assist in developing a community disaster plan. The nurse determines that this responsibility is a component of which disaster management phase identified by the Federal Emergency Management Agency (FEMA)? A. Response B. Recovery C. Mitigation D. Preparedness

D. Preparedness

A nurse is telling a pregnant client about the signs that must be reported to the health care provider or nurse-midwife. The nurse tells the client that the health care provider or nurse-midwife should be contacted if which occurs? A. Morning sickness B. Breast tenderness C.Urinary frequency D. Puffiness of the face

D. Puffiness of the face

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? A. Administering a sedative B. Encouraging fluid intake C. Administering an oral preparation of radiopaque dye D. Questioning the client about allergies to iodine or shellfish

D. Questioning the client about allergies to iodine or shellfish

A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of the: A. Capillaries B. Pedal pulses C. Femoral arteries D. Radial and ulnar arteries

D. Radial and ulnar arteries

A client has a prescription for short-term therapy with enoxaparin . The nurse explains to the client that this medication is being prescribed for which purpose? A. Prevent pain B. Relieve back spasms C. Increase the client's energy level D. Reduce the risk of deep vein thrombosis

D. Reduce the risk of deep vein thrombosis

Sex after MI

Okay when able to climb 2 flights of stairs without exertion (take Nitro prophylactically before sex)

Usually 3 phases

Oligouric, diuretic, recovery Monitor body wt, and I&O's

Pyloric stenosis

Olive-shaped mass (epigastric) and projectile vomiting

Large brain tumor resection

On non-operative side

An emergency room nurse is performing an assessment of a client who sustained circumferential burns of both legs. The nurse should assess which of the following first?

Peripheral pulses

Fluids are restricted for a 4year old boy with acute poststreptococcal glomerulonephritis. Which nursing intervention makes the fluid restriction less obvious to the child?

Play a game of tea party and serve the allowed amount of liquids in small medicine cups

61. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance

The correct answer is A: Avoid chocolate and cheese

14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness

The correct answer is A: Can predispose to dysrhythmias

Fibrinolytics

Streptokinase, Tenecteplase (TNKase)

NG tube removal

Take deep breath and hold it

Hyperkalemia

Tall T waves, prolonged PR interval, wide QRS

The charge nurse is implementing a quality assurance policy and accompanies a nurse while administering medications. The nurse identifies a male client by asking him to state his name prior to administering the medication. Which action should the charge nurse implement?

Tell the nurse in a private area that the identification was incomplete

B Rationale: This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

A nurse caring for a client with hypoparathyroidism evaluates achievement of the expected outcomes of the plan of care. Which of the following would be an appropriate expected outcome for this client?

The client verbalizes that therapy for hypocalcemia is lifelong.

A 65 year old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states that her pain has subsided. what is the legal status of the nurse?

The client would not be able to prove malpractice in court.

74. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client

The correct answer is A: A 79 year-old malnourished client on bed rest

94. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins

The correct answer is A: An infant who has been identified to have botulism

90. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity

The correct answer is A: Assess the severity and location of the pain

B Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive actions should be implemented first.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate.

D Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.

D Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.

D Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium

(Y) A nurse administers medications to the wrong client. During the investigation of the incident, it is determined that the nurse failed to check the client's identification bracelet before administering the medications. The nursing supervisor evaluates the situation and determines that the nurse can be guilty of negligence because negligence is:

defined as the failure to meet established standards of care

A male client with bipolar disease reports to the nurse that he has not taken his prescription medication, divalproex for the last 6 months.Assessment of which is most important for the nurse to obtain?

his mood

Blood sugar saying

hot and dry-sugar high (hyperglycemia) cold and clammy-need some candy (hypoglycemia)